This is absurd. Even in a country with liberal economics and "free choice" health system (however with universal care, and state regulation), the same stitches in a world-class private clinic in Santiago, Chile would cost 400 USD, before insurance. The clinics there are not the ones Americans imagine from a middle-income country, most of them have better infrastructure and doctors than the ones I know in Europe. And I don't even need to start talking about health services in Europe, where I live.
This is the kind of things that show how inviable is a market-led economy without proper regulation. Let the powerful profit from the weak and you'll see this kind of thing every time.
If you compare life expectancy in Chile and some other Latin-American countries with universal care[1], they are higher than in the US, despite being a more unequal and/or poorer.
Edit: Many commenters miss the point. The US leads the way in too many areas and at least I expect them to be an example of the benefits of free market economy. Some have mentioned that regulation is indeed the problem. I would say, that we need the right regulation so the right incentives are put in place, in benefit of the market and competition. So at best it would be better not to have the industry dictate the regulation.
The plastic surgery and vision correction industries work pretty well in the US. You see price competition and patients have the ability to shop around and make choices that are important to them (references from other patients, doctor personality, etc).
Now contrast that with going to a hospital for a procedure where you have time to shop around. Can you get a price? No. Can you easily get appointments with doctors to get their opinions on your case? Maybe. Can you get other patient references? Unlikely (but maybe).
What’s the difference? One insurance covers (thus the patients is cut out of price conversations) and one insurance doesn’t cover (this patient is the end payer). The big problem is more and more costs are being shifted to patients as deductibles and co-insurance, but hospitals treat it like it was 1990 and the patient pays some token amount so “who cares”?
And sure, an emergency doesn’t leave you much time to shop around, but something like 80% of healthcare procedures aren’t emergent.
The difference is that one is completely optional and you can spend as much time as you want comparing options, while the other you're forced to do on a whim at whatever place is closest. You can't shop around when you're bleeding out, as in the article. And such emergency health care constitutes most of these surprise bill situations.
Centralized hospital and clinics in certain locations. Don't allow building healthcare based on maximized spread. When there are multiple alternatives next to each other, it generates not just competition for customers (patients) but also doctors/nurses employments. Also build fully government subsidized hospitals in each of this location to force the private pricing not escalating. Then every hospital admins will need to undergo 6mths IRS audit. This force the job extremely undesirable and reduce the demand for it.
Really any healthcare procedure that is not typically covered by insurance has seen costs go down over time. Things like lasik eye surgery, or orthodontics are great examples in addition to the ones you've already mention. The service and technology gets better while the price continues to go down.
> Really any healthcare procedure that is not typically covered by insurance has seen costs go down over time.
Health "insurance" companies are incentivized to raise the cost of care. Why? Their profits are capped to a percentage of the cost of care. The only way for them to make more money is to have more revenue -- which they do by increasing the cost of care!
Let say you go and pick up a loaf of bread from the store. You don't pay, however. Instead, you have the bakery send a bill to your "buyer." Your buyer then negotiates the price. One thing about your buyer: the more revenue that flows through them, the more money they get to make. The bakery tells the buyer that the cost for the loaf of bread is $500. However, the buyer wants to keep you happy, so they reject the price, and come back with a lower price: $350. The bakery rejects the $350 price, and eventually, the two parties agree that the price should be $400. (Note, that other bakeries, where you buy directly, charge $4 for a loaf of bread.)
The buyer gets to say they negotiated. The baker doesn't have to look you in the eye when they gouge you.
It gets a little more complicated,though. Instead of just paying $400 for the loaf of bread, the buyer bundles the cost of all the purchases together, and then charges a monthly fee, based on the previous year's overall revenue. They then tack on 20%. So, it turns out, with that extra 20% you're actually paying almost $500 for the loaf of bread anyways.
The difference is that the customer pays 100% of the entire price. The industry doesn’t have a plan where you pay $0.10 for an eggs benedict brunch, or 10% a year after spending $100, and then get to charge your employer or your fellow citizens massive sums.
The uncertainty comes from not knowing exactly what services will be performed, who will be performing them, and how much the insurance company will cover (which has a ton of variables, many of which aren't known until everything is settled).
In my opinion, getting away from the fee for service model is one of the routes we ought to be taking to address healthcare spending in the US (if you're charging per service, you're incentivized to perform as many services as possible in a given encounter).
In other professions if you make a bid and fail to capture required work, you eat it generally speaking.
Contractors, many of whom are small businesses or individuals, do this all the time. They also give estimates like "If we find mold behind the wall, it will be an extra ten thousand".
Medicine is also odd in that you have to pay for the doctors mistake. If the doctor prescribes a less effective drug, it has no effect and then after doing your own research find a better drug and get the doctor to prescribe that instead. You still have to pay for the first visit. If a plumber decides to go from plastic to copper pipe mid job, he doesn't get paid for the work he ripped out.
Multi billion dollar hospital groups, full of highly educated professionals apparently can't pull this off but the guy who poops in a bucket on the job site can.
The most insane part are the out of network professionals. It's like you have a deal with the plumber to fix tout kitchen for $100. But in the middle of the fix, you hear a surprise ring in a front door and it's a helper of the plumber that comes an does something. And the next day the plumber notifies you that you must pay an additional $500 for the other guy.
The hospital is reimbursed on a fee for service basis. Most (all?) countries use a fee for service model, but most countries also don't have for-profit payers that are incentivized to drive up the cost of care.
Exactly the same situation is in rest of the world, no patient is shopping around. just goes usually to closest/biggest hospital. Yet we don't have this tragic mess US has. So its not about shopping around, rather some other reason like regulations, wrong dynamics between hospitals and insurances etc.
You don't have better equipment nor doctors in US compared to biggest hospitals in Switzerland for example. Yet we have fraction of the costs as patients, and its not due to low doctors/staff salaries. Equipment is also top notch everywhere, new machines in all departments.
I believe that "closest/biggest hospital" is a choice in emergency. Or when it's something unimportant. Otherwise people tend to choose a doctor and clinic based on reviews or recommendations, or maybe years of experience.
Even with a free healthcare you still have a paid private medicine and a free public one. And they have to compete which leads the price going down, because one side is always zero or close to it. Not like it's in the US where the direction is opposite as you don't have a zero side but only "unbelievable high price" side.
Even in relative emergencies. I'm in the UK. Years ago, my ex fell towards a glass door, and trust her arm through a thick glass pane, getting a nasty cut down her lower arm that exposed her tendons (I saw them... Not a pleasant anatomy lesson). After she was stabilised by the ER/A&E, she was told to come back in the morning (her arm was still open, but bandaged) to get properly patched up. Instead of going back to the nearest hospital, the following morning we went to the A&E of one an hour away with a good reputation for cosmetic surgery.
A&E can't turn you away. It gave her a few days of waiting in hospital (she was not a high risk patient, but they did want her available and under observation), but it gave her a leading specialist on hand surgery. And we walked out with no bill.
(and you're right - there'd still be the private options too, but in this case the NHS option had some of the best surgeons in the country in that field anyway)
I believe that in the end, it boils down to culture, with all the regulatory dysfunction and market dynamics acting as intermediary.
In the US getting wealthy seems to be almost implicitly well respected, no matter how you got there. At least if it's not obviously illegal. You found a tweak to squeeze more money from health insurances? Good for you, let them suffer for their apparent weakness. There's apparently still a threshold of where even success cannot vindicate the way to get there (that Oxycotin family comes to mind) but that threshold is super high. I believe that this threshold is much lower almost everywhere else on earth and that this has an influence on individual decisions on all levels. It doesn't even remotely make people elsewhere angels or something like that, but it's a little bit of friction in every decision towards "take what you can"
Dentistry is paid for by insurance and is relatively cheap either way. Healthcare in the US is expensive for several reasons. Excessive paperwork and bureaucracy, unpaid bills, required service, 24/7/365 services, complex diagnosis, lawsuits, medical school, regulatory capture, etc etc.
Changing any one of them isn’t going to fix pricing. We really need to change several pieces at the same time and the industry really doesn’t want lower prices as that reduces their income.
I’m pretty sure most of this is also what, say, EU has to deal with. They most certainly have bureaucracy, unpaid bills, 24/7/365 services, complex diasnosises…
Some big differences: Without the equivalent of AMA lobbying Europe has a lot more primary care doctors per capita than the US. No long history of trying to get everyone healthcare without using taxation resulting in a pile of Rude Goldberg regulations that nobody understands. Regular use of cost-benefit analysis in deciding what procedures or drugs to pay for, now that the FDA has approved aducanumab it's going to be available to people even though it probably doesn't work and is breathtakingly expensive.
Single payer largely avoids unpaid bills and a great deal of bureaucracy around billing. This is true even in the US, just look at the VA’s costs. The VA is serving a very expensive population and it does so relatively cheaply for the US. At least in terms of services rendered rather than just per person.
The 24/7 comment was in comparison to dentistry. It’s tempting to compare getting stitches to getting a filling but inherent overheads are associated with an ER which must be added to the bill.
The United States leads the way in treatments and medical tech, but this gives me the impression that the US society is not benefiting as it could from that.
As someone who used to work for a company trying to get insurance to pay for medical technology, the US was typically the easiest and fastest country to get coverage in for both private and public insurance.
This seems poignant. The cost/benefit analysis does not seem to be aligned with the market. I suspect it’s driven purely by lack of qualified practitioners.
It's not. Physician reimbursement has been going down year over year since the late 90s. Each unit of physician work (relative value units, RVUs) is worth 50% of what it was in 1998 for Medicare at least, and most insurers peg their reimbursement at a specific multiple of the Medicare rate. Sorry, the insurance companies, PBMs, and hospital administration is to blame for the high cost of care, not the physicians who don't control how much they are reimbursed for each office visit or procedure.
Medicare and Medicaid are at best 50% of reimbursable amounts in most sub industries.
Also, while $/CPT code can go down, you can see more patients/day or alter your staffing ratios and other operating metrics to more than compensate.
Healthcare has some of the most "woo woo" hand wave-ey financial metrics around. Do a private equity quality asseatment on quality of earnings on "gross earnings" in most health care settings. Other than the Enron consolidations there can't be a more bullshit financial metric (heck entire area) under US GAAP than gross earnings. With that level of obfuscation (purposefull or not) it's no wonder you have almost full opacity into the cost chain.
If that’s true then why have physicians wages continued to increase for most specialties? Some have stagnated, but I wouldn’t say physicians are underpaid.
Healthcare is rarely a good example of the free market. Medical decisions aren’t made by comparing costs between providers. And if you’re in rural America, you’re lucky if you have any provider. Price transparency would be nice, but maybe not as helpful as you’d like. Let’s say you’re in the middle of a rural area and the ER says you need stitches — but they cost $6000. What are you going to do about it? Are you really in a position to negotiate? Your choices might just be 1) get the treatment, or 2) go without.
Many things in rural areas cost more than they should. Usually on this forum we talk about the high cost of internet access and the lack of options, but medical is very similar in that regard. Services are hard to find, providers are covering a very large geographic area, and many costs are higher.
It’s not a good example of how a well functioning free market would work.
I’d go as far as to say the healthcare market in America is the opposite of a free market. Everything about it is anti-free, from the information asymmetry, to lack of local choices, down to an inability to even assent to participate in the transaction (due to incapacitation etc.).
It’s hard to even call this a market, let alone a free market. According to the Wikipedia entry on markets, “the usage of the price mechanism to convey information is the defining feature of the market”. It’s notable that in The American healthcare market, the price of your treatment is usually discovered after you’ve agreed to purchase the treatment (or it’s been administered without your consent). In fact, often it’s impossible to figure out what you will pay until after the fact due to how complicated answering that question is.
And even if it were a free market it’s debatable we wouldn’t want to keep it that way. In a commodity free-market of peas for example, a mismatch of supply price and demand price means that some people will pay a suboptimal price for peas while others will be priced out of the market entirely, and they will have to go without peas.
In a healthcare market, when someone is priced out they go without healthcare, which means worse and more expensive outcomes down the line. The old adage about how an irrational market can stay irrational longer than you can stay solvent comes to mind — a healthcare system motivated to maximize profit will price you out of the market longer than you can stay alive.
It's exactly what any rational person would expect from a corporate free-for-all designed for maximum extraction potential based on maximising political power differentials.
Good state-owned care smooths out the inequalities, so farmers in the middle of rural area will at least have affordable access to basic care, and more advanced care will be within easy travelling distance.
This ends up being far cheaper for everyone who needs medical care - which is basically everyone.
The only losers are profiteering shareholders.
Of course you still pay for it, but you don't pay as much. And you won't be bankrupted by bills for which you either have no cover at all, or limited insurance cover which still leaves you with a huge sum.
Healthcare is ripe with market failures - everything you are describing is well studied. Those who argue for a completely unregulated market, in my limited interactions, have not usually studied economics or the concept of market failures. Market failures are generally associated with public goods or government regulation.
To name a few with healthcare:
Information Asymmetry. It should be expected that a patient does not know what a Level IV emergency is and the complete ins and outs of how they are going to be charged. I'd argue that the industry has intentionally amplified this market failure. Furthermore, patients are often left with the final decision, but who is going to disagree with a trained professional on their required treatment? It's like going to a mechanic when you have no idea what's wrong with your car. You kind of are trusting the mechanic isn't taking advantage of you (and that is regulated). Or you have to reduce the asymmetry by learning about the basics of cars.
Medical research has the attributes of a public good: Non-excludability and non-rivalrous - when something is discovered it's generally known to everyone without dropping in supply and the information is available to everyone (yes the product which results is rivalrous and excludable in the same country, hence it works as a private good - but then that product has non-competitive markets).
Non-competitive markets with respect to rural areas are also mentioned in the article. Much like the issue with utility companies and broadband providers (the latter of which was shown to be a partial public good in the US with the infrastructure bill).
You've also got the Certificate of Need system, introduced in the Nixon years on the theory that if allowed hospitals to compete with each other it would lead to redundant capacity and thus higher costs.
And then there's the Medicaid reimbursement rates, decided by a committee using the labor theory of value rather than something sensible like cost benefit analysis and negotiation. And since it's illegal to charge someone else less than you charge Medicaid these tend to have a cascade effect.
Our healthcare system is a huge sequence of "make it so complicated that there are no obvious deficiencies" legal systems with layers of ad hoc patches its amazing it works as well as it does.
Normally I'm in favor of free markets but if nationalization is what it takes to clean up the current mess of a system we have then so be it.
The way Medicare is artificially restricted from driving down cost is atrocious. Medicare + Medicaid combined costs about as much per capita - NOT per patient - as the UK NHS. Except the UK NHS provides universal cover.
Now the NHS is an aberration and under severe pressure, but it is a good indication of just how inefficient Medicare and Medicaid are - and it's not that they can't do better, it's that they're legally prevented from using their market power.
My wife and her family are from Peru. It’s not uncommon for our relatives that are living in the U.S. to fly back to Peru and pay cash for procedures instead of doing it through their U.S. insurance.
The stitches are expensive mostly because of many regulatory factors that restrict the supply of medical services and drive costs up, with the "free market" component being in how much they can charge the patients. It's the worst of both worlds in the US.
I can tell you that you cannot freely open a clinic in Chile, and Doctors have the monopoly on many treatments that are delivered by nurses or other workers in Europe. Becoming a Doctor is not easy, and foreign Doctors must go through difficult tests before working for the public system.
Additionally, I remember that many supplies come from... the United States? So what regulations are you talking about?
There's three areas that I'm aware of. Certificates of Need, which some states require before you can offer certain services (like MRI/CT scanning). Supply contracts, where a hospital has a pre-set price for consumables like IV solutions, scalpels, and bandages with a supplier. And advertising.
The Certificate reduces competition because they impose geographical exclusivity. If you want to buy a MRI machine for your clinic, you cannot if the state determines if your area already has enough of them. And if you file a Certificate with the state intending to buy one, your nearby competitors are likely to place objections to your purchase. This is because the machines are expensive and the other clinics want to ensure their investment gets paid for. But this process also ensures they're expensive because the machines aren't able to be built in volumes large enough to result in a cost reduction.
The supply contracts make things easier for the hospital, as they only have to deal with one supplier for an item or class of item. The price is known up front for the duration of the contract. But this also means that the hospital cannot change suppliers if another one has a lower price for the same item midway through the contract period, reducing competition. They also restrict choice by the doctors at the hospital - doctors have strong preferences for items like gloves because of sizing & fit, and the way they transmit feeling through them (thinness, texture, etc). If a hospital changes suppliers to one that doesn't carry their favorite glove, they aren't able to perform as well. And they can't bring their own into the operating room because of liability.
I don't know how many advertisements you see in Chile for medicine, but here in the US I would guess that a quarter of advertisements on TV are for them. All those ads cost a lot of money, and they're not being targeted at doctors, but patients: "Ask your doctor if {brand} is right for you"
The certificate of need business seems bizarre. I live in London, and the place is so crowded with clinics offering cheap MRIs it's ridiculous, despite the fact you'll get them covered in the NHS I'd you actually need them (literally the very first ad I found for MRIs offered them for 200 pounds).
Well, I think then you'd agree with that we need the right regulation so the right incentives are put in place, and that at best would be better not to have the industry dictate the regulation, that in this case sounds absurd.
I was very surprised the first time I watched an open-tv US Channel seeing thousand of ads for prescription medicine. Which I believe are forbidden the countries I have lived in (CL, ES, DE)
WHen I stopped living in the USA, I realized that there is only one reason the USA is behind the rest of the developed world when it comes to healthcare, a social safety net and education. The USA likes it that way.
The American culture is one of rugged individualist pioneering cowboys who won't be told what to do, even if you're warning them that if they take another step they'll fall off a cliff.
I don’t think it’s the rugged individualism that’s at fault, so much as an emergent, insane incentive structure that has grown out of control. The confluence of big insurance, big hospitals/ practices, and regulatory capture have given us a completely warped system.
Definitely a common mindset, particularly of gen x and generations prior. I know I have it. Wouldn’t surprise me a bit if someone born and raised outside the us came away with this impression after living here for a while.
Honestly when I read the headline my first thought was “six stitches? Crazy glue is cheaper…”
>Honestly when I read the headline my first thought was “six stitches? Crazy glue is cheaper”
Unless you live across the street from the hospital it's just less hassle to do it that way. Any injury not worthy of an ambulance can be cleaned, glued and taped in the time it would take to sit in the waiting room while they serve all the people who are dying faster.
Not so sure for the impact of regulatory. Tons of other countries/areas have equivalent regulatories req, if not more strict, yet does not yield to absolutely insane prices.
Regulatory is there to prevent e.g. killing patients in a Therac-25 like events. When you have a too weak reg, you end up with things like 737-max situations.
Now maybe regulatory can also go too far in some niches, but the correct solution is not to blindly go in the other direction.
And anyway, absurd prices in cases of e.g. ER are most of the time explained not by the cost of medical supplies but by random attempts to purely extorts the patients: 6 stiches and a shot do not imply thousands of dollar of BOM, nor are physicians paid hundreds per minute. Look at the cost of covid vaccines if you want to know more realistic costs.
Exactly. What the US lacks is actually more liberal market in health. Less regulations and more competition.
When talking about regulations people usually mean regulating pricing and/or service quality but what actually needs to be tackled are the factors that limit competition, like:
- process for opening new clinics/hospitals should have little to none restrictions
- requirements for doctors (no doctors from outside can work in the US unless they complete $400k degree)
- Drugs from outside countries should be allowed to be imported without FDA's approval
The US is not a market-led economy in healthcare; I currently live in a country with universal healthcare and I make clear to people that when I disagree with universal healthcare it is not because I think it should be more like the US.
It is not uncommon in US going to the hospital and they giving you a list of options and prices. I don't know how to call that but definitely feels like a market.
BTW, I come from from a European country with universal healthcare and have been living in US for almost a decade and the feeling of someone making money of your health is at least weird. If I ever have some severe health issue no doubt I will go to treat myself to my country of origin.
EDIT: Also tired to hear about the problems of universal health care, specially with wait times. It is true that less important treatments could take some extra time but I have never seen a case where a fast intervention was needed and did not happen. I would say that common sense is something that works for universal healthcare. At least where I come from.
> EDIT: Also tired to hear about the problems of universal health care, specially with wait times. It is true that less important treatments could take some extra time but I have never seen a case where a fast intervention was needed and did not happen. I would say that common sense is something that works for universal healthcare. At least where I come from.
Almost all countries with universal care also have private options (Norway used to be an exception where offering private options for services available from the public healthcare system used to be practically impossible, but even Norway has relented on this though). Often the private options are also cheaper than the US.
E.g. for elective surgeries Americans might want to check London hospitals - many world-leading private hospitals for various conditions that are used to targeting foreign patients - especially wealthy ones - but still often charging much lower prices.
It's also not that unusual for those of us in the UK who can afford to go private to do so when we have some condition that the NHS certainly will treat but where there's a waiting list because it's not important.
And there are plenty of private insurers - only because the NHS offers a baseline, they're far cheaper than most US plans because almost all of them rely on the NHS as a first line and instead of picking up the bill for everything they only pick up the bill to accelerate care whenever there's a wait to see certain NHS specialists.
People need to consider the universal care to be the baseline. How much people are prepared to pay for the baseline over taxes will affect how fancy the baseline is, so if you want something better you'll need to pay. But at least it ensures everyone gets the baseline.
Meanwhile, Congress passed a bill that's supposed to help with surprise billing. The Biden administration has started to implement it, but doctors and their representatives (Democrats and Republicans alike) claim the administration is not implementing the bill as intended and they are favoring insurance companies over medical providers by trying to keep costs down.
> “The Administration’s recently proposed regulation to begin implementing the law does not uphold Congressional intent and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and potentially force small practices to close thus limiting patients access to care,” Rep. Larry Bucshon (R-Ind.), who is a doctor and helped spearhead a letter of complaint this month, said in a statement to KHN.
This shit makes my blood boil. Various vested interests, but mostly doctors, have stymied virtually all legislation (the ACA, Medicare and Medicaid being the notable exceptions) for a century.
Those greedy doctors trying to protect their livelihoods from a bill that gives insurers an easy path to drive down their reimbursement when an alternate method of doing the same thing (New York's law on surprise billing) exists that does not have that same feature. I for one know that software engineers would certainly support bills that would reduce their pay for the greater good! Physicians are the only group that everyone expects to work for less and less money. It may surprise you, but most software engineers will have an easy time outearning the majority of physicians. It's not the 80s anymore. Doctors aren't super rich. Doctors aren't the ones who made you sick, but they are the ones who trained for 7+ years to take care of the problem. Shame on them for wanting to earn a living.
In the states that use benchmarks similar to what doctors are suggesting HHS use instead of the agency's current proposal --such as New York and New Jersey — the report found costs rising. New York, for example, has a "baseball-style" system in which the arbiter chooses between the offers presented by the provider and the insurer, although the arbiter is told to consider the offer closest to the 80th percentile of charges. "Since the amount providers charge is typically much higher than the actual negotiated rate, this approach risks leading to significantly higher overall costs," the report finds. In New Jersey, billed charges or "usual and customary" rates are considered.
"When the arbitration process is wide open, no boundaries, at the end of the day health care costs go up, not down," Becerra says of the methods doctors prefer. "We want costs to go down. And so we want to set up a system that helps provide the guideposts to keep us efficient, transparent and cost-effective."
The system chosen by the Biden administration is expected to push insurance premiums down by 0.5% to 1%, the Congressional Budget Office estimates.
The US medical system is incredibly regulated and constricted by the government and the rules and regulations. It is NOT a free market. An English friend who moved to the Bay area for work at Genentech had a wife who was a doctor from the UK. She could NOT practice as a doctor in California. This is deliberate by design. The AMA restricts the number of doctors to prevent their incomes being reduced.
The third party payment system of medicine is both directly paid for by the government and subsidized by tax writeoffs for the private insurance industry (which is tied to employment).
And meanwhile during a pandemic majority of Americans supported Medicare for all. Yet the corporate politicians are against it. The performative art of the "squad" was at full display when they had a chance to force the "Medicare for all" vote and passed on it.
Yep, and the same shits go around telling everyone to get an ambulance instead of Uber to go to the hospital and go to the ER instead of urgent care for certain symptoms. Fix your fucking system first.
> This is the kind of things that show how inviable is a market-led economy without proper regulation.
The medical industry is highly regulated. I can't just go open up a practice giving people stiches. I would need a whole slew of certifications in order to do so. That's why this situation in the US is so absurd. The market is regulated to limit the competition at the expense of the consumer.
The ER is quite expensive to run, they’re designed to handle the riskiest kinds of situations.
Imagine how expensive a software dev team would be with 24/7 work, and full cycle scrum sprints every 72 hours to allow for constant pivoting, with injects from one to a bus load of product owners.
Okay, so a $200 surcharge every time they have to deal with butts. $100 for urine, $50 for vomit. Charge it to the insurance anyway, they're used to paying $40000 a day for a hospital bed, they can pay $200 for dealing with a butt.
Plumbers have to deal with the aftermath of butts MUCH more often and they don't have the luxury of someone's insurance they can just throw arbitrarily high charges to.
doctors are paid roughly equivalent, and the cost of healthcare is substantially lower in other companies, so I’m not really sure what you think you’re solving here, but I don’t see your plan ever working either.
Possibly upto a point, if you factor in that the physician has to contend with paying back $400K in loans and $1M+ in lost income from not working during earlier years in life.
Yes, and it would be even more expensive in Germany. But in both countries the insurance covers normally 50% of it, wherever you go. If not all. (Other sickness are covered normally 80% if not entirely whatever insurance you have)
What are you talking about? As long as you are not private insured - which is not difficult to do usally - if you have a job you are insured (a percentage of your pay is used for insurance, if you study you are insured (90 eur) or you can join on your own for 200eur/month depending on your income if you are working on your own.
You pay nothing for ER, 10eur/day for the hospital and a few eur for medication - but nothing even in the range for 50% or 80%
dental is also covered to a large degree but if you want state of the art you have to pay the difference yourself - but you can also add a private insureance for that for 100 to 300eur/year to have everything covered.
you can still fall through if you can't pay the monthly fee - but emergencies are also free even if you don't pay.
private insurance can be expensive but should usally cover also everything.
Did you actually read my comments in this conversation? Are you aware that in Germany clinics have different prices than the ones you pay after insurance? I have always talked about prices before insurance, which is what I'm arguing looks completely out of place.
I'm public insured in Germany and no, dental is not really covered, I had to pay my routine treatment last time at the praxis, and it was not cheap.
Do you know that if you don't have insurance (which is however mandatory in Germany) you get an actual bill for the medical services?
You do not need to pay extra for dental if you choose the most basic treatment. Most people like their dental work to look like their natural teeth which does not count as most basic. That is why you had to pay, but only the price difference to the basic treatment.
And, of course, the doc likes to sell you some extra treatment (say "professional tooth cleaning") which will make her/him some extra money.
Same for glasses. The most basic option is free. If you don't like the coke bottle bottoms then you will have to cover the difference yourself.
Would be much less in Taiwan for example. I don’t know exactly but I’d have to guess $50 USD? I’ve been to clinics that charged about $15-30 for a doctor visit (cash price as a foreigner—Taiwan has national healthcare but they can’t charge to that for me). ER would probably be double that.
It’s not like you’re taking up a hospital bed. It’s a sew up and show you the door operation.
@garmaine I'm talking about the one the most prestigious clinic in South America in Santiago [1], and that's before insurance. I never paid that myself, because it was covered by the insurance.
Free market works fine, unfortunately like tuition prices the government got involved and prevented what the free market is good at and driving down prices. Fortunately now there a new price transparency laws which the full the effects haven’t been felt yet and are a step in the right direction.
Free market brings prices down and quality up. The government tried to ‘help’ 50 years ago and now the prices have become so distorted that without government help you would need to be rich to go to school.
People like you think the government should solve a problem that they themselves created.
In theory, but in practice there are many markets where that simply doesn't work, mostly due to natural monopolies, such as any type of infrastructure, healthcare or education, where competition is impractical or impossible, equal access for everyone is extremely important, and costs are high.
I think free market could work with education. It is really a question how to verify the results. That is how should degrees be granted. Which is rather complicated issue as there is way too many ways to cheat.
Still, nothing really stops competing methods and prices for teaching to competing levels.
Our mostly private health care system is twice as expensive as the social systems in other developed countries because the government got involved?
By what fraction will the new set of tweaks have to shrink costs to pay for the last 30 years of the private health care market's failure to deliver on its "more efficient" promise? Remember, it has to cut them by 50% just to break even, and it'll have to go further to make this experiment worthwhile. A lot further.
Spoiler alert: it won't even get to 50%. It won't even get close to 50%.
There already is a massive public healthcare system in America called Medicare and Medicaid which is the root of distorted prices. The lack of price transparency adds fuel to the fire and allows those prices to stay high without any upfront awareness given to the end consumer.
A lack of price transparency is indeed deplorable, but it isn't the root of the problem. The root of the problem is that demand for emergency treatment is inelastic. Inelastic demand curves result in wildly volatile prices. And when the service is a basic human need rather than a luxury, to prioritize a free market solution is to prioritize the market over the human. Markets must operate for the good of people, not the other way around.
Price transparency is shifting deck chairs on the titanic. I actually do think the new chair arrangement is a notable improvement on the old one -- but in an industry with unaddressed tectonic issues, it's not going to right the ship.
I might be wrong. Maybe price transparency will lead to a 50% reduction in prices in the next few years. I doubt it, though.
When I got my tonsils removed my options were the $75k surgery at the private hospital, or waiting 3 months at the public hospital. I actually stopped consulting and took a job so that I could get insurance, and had the surgery two weeks later.
A few years back I broke my wrist while bicycling across England. I was patched up and casted a few hours later, I think the bill was about $200, as a foreign tourist. It wasn't even enough to cover my travel insurance deductible. This would have cost me about $5k in the USA.
I agree that the free market works fine, for those who run the market.
The free market didn’t make your operation 75k. The government giving a blank check to hospitals and the lack of price transparency did that. Both are as far from the ‘free market’ as you can get.
Sure, whatever. Shit doesn't happen in socialized countries. The only libertarian countries that ever exist are that short vacuum of power when a banana republic dictator fails and the new warlords haven't chosen a new dictator. But yeah, sure, can't criticize something that doesn't exist. Good argument strategy.
I lied to my doctor to an extent, and he lied to the insurance company to an extent.
All you have to do is ask a doctor "Please don't put any of this in a file until I have insurance next week". It doesn't mean anything to him to add the dates later. It's in his best interest, otherwise he won't get the cheddar.
Most of the time I restrict myself from this kind of comments, but here is what experience is typically like in Russia.
You are sick or even probably sick, like biten by tick and worry about it is infectious. You go to the neatest hospital, local ER, register yourself (no documents needed). Any time of day. You get triaged immediately, if your situation is not life-threatening, there is a queue. Waiting times are anywhere between nothing and two hours. Doctor sees you, you get medication, procedures, tests as needed. Everything is typically done in professional manner, quick and no bullshit. There are sometimes signs hospital is understaffed, like single nurse doing everything.
In Moscow, treatment is world-class. In rest of Russia, your milage may vary.
You typically leave diagnosed, fixed, with documents. Nobody ever asks you about payments or bills. What bills? The state-provided health care is free
This is the same in Canada. My wife is due to give birth in 3 months. The biggest bill we're concerned about is the parking lot. I think it's $20/day.
And if the parking fee was too much, I've heard that one can go talk to the reception desk and they'll open the gate for you.
I would rather pay very slightly higher taxes and let all of my fellow Canadians have this benefit than be very sightly richer and live in a society that doesn't have this.
Exactly! For me it is the peace of mind: not having to worry about deductibles... will it be covered? What hospital can I go to? Ambulance or uber... so much stress. On top of your ailment.
I prefer to pay 35-40% in taxes and not have to worry about that. I worry about my work and my systems. They pay me for that. I pay my money so that I dont have to worry.
Paying (a private insurer) to get additional worries? No thanks.
> I prefer to pay 35-40% in taxes and not have to worry about that
The biggest irony is that’s in line with the taxes we pay in the US (probably more if you’re in tech and live in CA or NY), so it’s not like you pay lower taxes in the Land of the Free anyway.
Same in the UK (except the hospital probably is understaffed!) - it's weird for me to think of a hospital as somewhere you might go to pay for a service, like Tight muscles? Go there, pay the masseuse; Bone sticking out? Go there, pay the doctor.
I'm asking since in Romania the public hospitals are still more miss than hit, even in big cities.
Hospital managers are politically appointed leading to terrible corruption and inefficiencies, meaning waiting times can be pretty long so the doctors who work there refer you to their private practices, and while conditions on the surface look good and everything is covered by the public insurance in theory, sometimes hospitals are short on supplies, asking you or your relatives to bring stuff from home, the food can be terrible, and you never know what corners some staff might have cut and you end up picking some dangerous hospital transmitted bacteria leaving you worse off than when you came in. And sometimes, if you're unlucky, you can end up in healthcare hell where you get bounced around between different hospitals if each judges you're not their problem to deal with.
Outside of big cities, you don't even want to go near any public hospital unless your situation is serious.
When my mom was admitted to the local hospital for infectious diseases around 2008ish, there were roaches and rats everywhere and this was in a big medical university city of the country. Pretty sure the roaches and rats are gone nowadays, but still that was unacceptable.
Yes, in Moscow public medicine gets better every year.
If you want to be operated, an MRI, or some expensive procedure, waiting queue might be quite a bit longer than that in commercial sector.
Military-serving hospitals are particularly good. There are certain cases of narrow specialists, where commercial medicine is actually worse than that is found in high-prestige public institutions.
I am speaking of Moscow and maybe few other big cities.
> Every time someone talks about free this or that in the Nordic countries an American will pop his head up and yell "It's paid for with your taxes" without fail.
Public money, that as you might know comes from a variety of sources, including taxes. But to say some taxpayer is paying your "free" treatments is a grotesque simplification.
Then, as someone who doesn't own property, why should I pay taxes that go in police funding just to protect your property? That means higher taxes which is very undesirable for someone who's already near poverty.
My daughter here in France had a bike accident two months ago which requires 14 stitches in her foot.
We received 3 follow-up visits from nurses to clean and redress her wounds --
We pay about 100€ a month for supplemental private insurance on top of the public health insurance here --
Total cost for us? about 40€. We would have had to pay about 100€ more for the nurses' visits, but the mutuelle covered it.
These are some of the reasons why my wife and I moved from the US to France -- she's French, I'm American; but I can't imagine returning to the nightmare complexity of billings and profiteering that the US system has become...
These are some of the reasons why my wife and I moved from the US to France -- she's French, I'm American; but I can't imagine returning to the nightmare complexity of billings and profiteering that the US system has become...
I'm American and live in Norway. I feel the same. My out of pocket here is around $300, after which a lot of things simply become free. I don't have to consider whether or not I can afford to take care of something, and I have trouble explaining how much lower my stress levels are because of it.
My taxes aren't higher than in the US: IN fact, they might be lower than taxes plus insurance premiums - and that doesn't even touch on the deductibles.
> My taxes aren't higher than in the US: IN fact, they might be lower than taxes plus insurance premiums - and that doesn't even touch on the deductibles.
I start to think that some people aren't really concerned by the amount they are paying. What they deplore is the idea that some "freeloader" could benefit from their taxes. Even if the net result is that they're spending less.
>What they deplore is the idea that some "freeloader" could benefit from their taxes.
But the ironic thing is that private insurance also works through "freeloading": you pay your premiums so that somebody else in the insurance pool can get treatment. It's just that some people prefer their intermediary be a private company which will also skim profits off top than their government.
Exorbitant health insurance premiums and healthcare bills was the primary reason our family of 3 (now 4) left the USA (we're all American citizens). It's such a relief knowing that we all have the option to go to the ER without emptying our bank accounts. My tax rate is higher here in Europe, but I'm actually saving significant money compared to the USA, when factoring in healthcare costs.
On the topic of Mutuelle - I'm still to find a reason to pay one, at all. Maybe you could explain, but the hospitalization costs after 31 days seem to be fully covered by the social security (Ameli), if you ever get to be so unlucky to get there, so some doctor visits and an incident requiring hospitalization may be better addressed by "paying yourself" insurance, e.g. saving $4k/year, in case you ever need it. It would be the HSA of the US, with the healthcare higher quality and lower cost of France.
Even with 'excellent insurance' (which I think I have as well), you still deal with deductibles, non-covered procedures, inability to choose and shop for prescriptions, limited choice of providers, HSAs, massively inflated prices... the list goes on. To the point of another commenter, just having to reason and think about the costs of necessary healthcare in one of the wealthiest countries in the world is a complete joke. Some people having OK experiences in the US still pales in comparison to the majority having good experiences in most other developed countries.
Edit: Also having your health tied to your employer is also a joke. I've read enough stories about people getting screwed by employers who know they need the insurance and get away with abusing employees.
Don’t forget your employer doesn’t ‘pay for your healthcare’, they have a budget set aside from your annual salary - if they didn’t have to pay as much for your healthcare they’d be able to pay you more (and capitalism suggests if a competing employer did and yours didn’t, the former would win long term).
And you get into an accident (fall in the bathtub/stairs) cannot work for few weeks, your boss fire you easily... Where you is excellent health insurance coming from now? COBRA? That will not be $750/year.
This is completely wrong for many people. In the US we have something called FMLA and then I also have short term disability and long term disability.
I have seen coworkers with cancer or even their family members with cancer and they take six months off with pay and come back like nothing happened.
Be a valued employee at a large company. It’s a completely different situation in the US. It’s actually really good from my experience and as you can tell by my username I’m actually pretty old.
It is impossible for everyone to "be a valued employee at a large company". We could all be 'valued residents/citizens of a large country', but we're not.
Your "great health insurance" is provided by an employer who is factoring the costs of that in to the price they're charging others for goods/services. Other people are bearing the cost of your privilege. I have little doubt that most folks in your position and companies like yours will generally shop for the lower cost services/products, which will necessarily mean those other companies you're buying from will not be able to provide the "great health insurance" and similar benefits you enjoy.
If everyone is a valued employee at a big company, who:
Handles trash
Landscapes
Makes our shit dissappear
Maintains society
Digs ditches,,makes roads
Prepares food
Etc...
Do those people just not deserve health care?
Reconsider your own life. Picture it with you, yourself doing those things. When I look at mine, the worth of those people is obvious and I am happy to have them doing what they do so I can do what I do and we all meet at the park and let our kids play together.
1) you’re right that social programs in EU is great but there’s a hidden cost. It’s all derived from centuries of imperialism/colonialism and the wealth accrued as a direct result. You’re effectively reaping the benefit (and this will likely persist for centuries more).
2) similarly, most drug developments and research are done in the US. EU is effectively leeching off of the US policies. I’d say even Japan by itself contributes more to that end, per capita and in aggregate, than EU as a whole.
3) whenever people marvel at quality of life in countries such as Denmark, Sweden, etc, you have to ask yourself how they got there. None of that is free and other people are indirectly paying for those privileges. In most cases, it’s third world countries that Europeans pillaged for centuries. And in modern times, it’s on the backs of American taxpayers and soldiers who fought to save EU on multiple occasions from their own selfish and inept policies.
I regularly travel back to Brazil when I need to do something more involved that’s not an emergency, because the healthcare I get there is MUCH better than what I get in the US (I pay $800/y to keep a health insurance plan there). That’s one of the Third World Countries for you.
I have friends who also live in the US, and went through chemo and surgeries there. I did LASIK myself. None of us paid a dollar on top of the annual insurance, for any of it.
I had a gout flareup while in Washington DC for work. It's happened before, last time (in the UK) I phoned up the freephone national number for advice, my wife drove me to the local hospital, I walked (hobbled) in, had a couple of tests, was given some tablets and a presecription, and left in 15 minutes. That cost about $1.50 in gas parking would have cost another $5, but it was the weekend and parking was free. The prescription was $12 (standard price in the UK for any prescription drug or drugs, no matter what it is)
In the US I phoned my insurance company, got an Uber down the road to the hospital, and walked in passed the (armed?) guards to sit in a crowded waiting room. Receptionists took my blood pressure twice, was unimpressed with my (international) insurance. 2 hours later I went into some form of casualty area and sat in a chair, had blood pressure taken a couple more times. Eventually someone came and gave me a tablet, then they wheeled in some computer trolley to take my credit card (about $900), and gave me a prescription. There was no informing me of prices up front, no choices (not that you have much of a choice when you're in hospital - for me it was a really minor thing so I actually would have had the choice to either pay or not pay).
A few weeks later at home I received another bill for $2k from the hospital. I believe the bill charged for each of the times they took my blood pressure, I was never asked "would you like your blood pressure taken for $200", I wasn't asked if I wanted to sit in the comfy chair rather than the plastic chair for an extra two slips of latinum, the price wasn't up for negotiation, it just was.
The difference between the two cases is night and day, the UK treatment is fast and free, the US will make you wait for hours and then charge you a fortune.
While we're noting, they are pretty good about telling you/charging you less if it's something that's available off prescription (and was prescribed just to record the advice, or particularly because non-standard dosage advised, etc.) so £12 too much.
Like paracetamol say, you'd need a pretty hefty prescription to be able to buy enough all at once that £12 was a good deal. (A standard box is I think 24x500mg, good for three days (4h spacing, but 4x1g max is advised, not 6x) at max standard dosage, can buy two off the shelf for about £1, so you'd need a prescription for almost three months' worth, or a correspondingly higher dose...)
Also, £12 is the one-off price, there are better subscription type rates for people with medium/long-term recurring prescriptions.
Anecdata: I just had a very mild infection a month ago, but it went to my heart so I went to the ER (thinking they'd give me antibiotics and send me on my way). They wanted to monitor me for 2 days so admitted me. I know I have the right to refuse (and very nearly did), but wanted to make sure my heart was all right. Long story short, they gave me nothing more than aspirin for that stint, did an echo and an EKG, and the billed amount is $130k. Completely ridiculous. I don't care if that's not the amount you pay, that's not right. The baby aspirin were $10 each!! Meanwhile they sent me home with an aspirin prescription for 120 (adult) pills that was about $5.
This is absolutely ridiculous. Lots of people who would need to be monitored will simply refuse to do so, afraid of the astronomical bills. Even 5k would be a lot but 130k?
Well, I haven't paid yet ;) but the adjusted amount charged to my insurance was about $12.5k. I have a highish deductible plan but I have an HSA so after meeting deductible and maxing out my out of pocket limit the HSA is going to cover much of what remains (it's been accruing for 5 years and I never have medical expenses).
But I think it's completely insane we have to play these games with healthcare. Why does it have to feel like gambling and bartering!?
What I find most insane in the USA system is the initial price and then some "adjusted" amount that can be nearly 90% discount... Why isn't there only one single price for everyone? Why isn't it mandated that you can only charge single price for everyone and you can't give discounts?
Somehow everybody in this system claims they're not the ones making bank on this swindling. The doctors say they're underpaid. The hospital admin says they're underpaid. The insurance companies say they're barely covering their payouts. So who is lying?
I had to go to the ER in Hong Kong and I got better service uninsured for $35 US than I've ever gotten in the United States fully insured. And no surprise bills afterwards whatsoever.
There you go. The insurance company is actually incentivized to not negotiate a lower price.
What if they refuse a ludicrous price? Their customers will complain -- what, what? go without MRIs?
Worse -- the insurance company gets to keep 20% of the costs as profit. For a $16,000 bill, that's $3,200. For a $3,000 bill, that's just $600.
So why, again, would they fight for a lower bill? No reason. Competition from other companies? Unfortunately, they're all playing the same game, and lower premiums are simply not happening.
The insurer did negotiate the price down - from $20,000, so a 20% discount.
But yes, UCSF just leverages their name and the desire for insurers to have them in network. Their attitude is basically “no, I won’t go lower, and you’ll pay anyways”.
No, insurance companies don’t keep 20% as profit. They can keep 20% in reserve, the rest has to be paid out as benefits that calendar year. United Healthcare’s profit margin is like 2-4%.
And of course they fight to lower their insurance premiums, that’s how they attract new customers.
> The insurer did negotiate the price down - from $20,000, so a 20% discount.
I've just got to point out that they're adding back 20% -- to keep in "reserve," as you say. So what's the advantage of insurance? The "premiums" force the scam pricing on everyone! (And not just the direct victims of this type of fraud.)
No one is lying. The system is filled with massive inefficiencies.
1) Insurance companies don’t pay sticker prices. They pay negotiated rates. At the same time, hospitals have to pick up a lot of ER costs that are never covered. They might be making money but reasonable amounts at best (also that’s probably not true either considering how many hospitals are shutting down in the US).
2) The negotiated rates insurance companies pay are still very high. They are probably making a good profit, but their margin is still probably a fraction of the margin of many other industries, and it’s not like they have no competition, so they do have market pressure to reduce prices.
3) Doctors pay a ton in education and liability insurance and delayed earnings due to the extensive education required. They can spend over a decade, and be into their 40s before their net worth turns positive.
So where is all the money going is an excellent question. No one is benefitting from this current system.
1 obvious destination for the money is the education system in the US. Higher Ed in the US is an increasingly growing money pit. Tuitions are exploding. Loans are exploding (and educational loans are unique in the US in that they cannot be canceled in a bankruptcy). Administrative salaries are blowing up. Ever fancier buildings are being built. Yet money for teachers, researchers and remasters/phds is plummeting. It’s a complete scam with the entire system paying ever more money to build fancy buildings, the vast majority of the cost of which is captured by corrupt contractors with connections to university presidents, etc.
Then you have the pharma industry, which unlike any other civilized society, needs to advertise to consumers in the US. This means they have pressure to constantly grow their sales and once popular enough they have parents, and once generic, brand value, to force hospitals and patients to buy overpriced drugs.
But the US can’t outlaw pharma ads like nearly every other civilized country has, because that will then destroy your Media and Tech industries, and where ads, and therefore pharma ads, make up a massive source of income.
And I’m sure the same dynamic probably applies to medical tech as we’ll.
So in honesty, the money is likely going to the places that are showing that they are receiving money. Not in the healthcare system, but rather to tech, media, and construction and real estate.
Distinctive thing I found in the US is that hospitals are always big and do everything under one roof. There are some smaller clinics run by chains in some states but they operate primarily only for insurance money and are not common. At the bottom of the chain, some doctors run their own operations from a strip mall like place but they again provide very minimal service.
Meanwhile, in developing countries, it's not that hard to find a decently qualified doctor running his own small clinic with couple of nurses in a busy street. And to the next level, there is always a small 20-bed hospital around with 3-4 doctors and a bunch of nurses. And options keeps increasing in size and cost from small to the big hospitals like you typically see in the US. Almost 95% of primary healthcare are met by these small-mid level operations and people go to the big hospitals only for complicated surgeries and intensive care.
In this example of just 6 stitches, it probably would have been administered by a nurse in a 20-bed hospital for fraction of the cost of a big hospital.
Germany is public-private healthcare insurance driven healthcare model compared to the pure play private insurance or out-of-pocket driven healthcare model in the US and other poor countries. Germany has statutory public insurance while the examples I’m quoting including the US don’t have any such. For a private driven healthcare system, it’s strange there are no smaller, cheaper and nimble competitors.
the US is not a poor country, it is an astonishingly rich country whose elites want poor (and working-class more generally) people insecure so as to maximize the degree to which they can be exploited via economic coercion.
Of course the US is not a poor country. Sorry if my sentence structure meant that way. The US is in a special cohort when it comes to healthcare where rest in the group are all developing or under developed countries.
Another big inefficiency is the margin of error allowed due to malpractice lawsuits. If a patient is at a 1 in a 10,000 risk for a problem, the Doctor will order a test to rule that problem out. Because if the Doctor doesn't order the test and the person ends up having the problem, the Doctor could be sued for malpractice. In other countries the Doctor would say this is very unlikely so I'm not going to run the test.
I don’t buy this. If this were true, Texas would have much better health outcomes than most other states, as med mal payments are capped and basically nonexistent relative to other states given the low cap/incentive for lawyers to pursue.
Instead of any kind of dramatic increase in patient results, this system instead protected truly terrible doctors like the murderer Dr. Christopher Duntsch.
You are actually proving my point. Incompetent doctors are incentivized to come to Texas because there is a low cap on malpractice. That makes healthcare worse. Also, the extra tests that are being run just to cover someone's liability in other states don't make outcomes better because they are overwhelmingly unnecessary. They just add extra cost to the medical system to avoid lawsuits outside of Texas.
Some people somewhere, with cigars, in $5,000 suits. "Look at all those schmucks! $400 per shot and $1,000 per stitch." The whole healthcare system needs to be regulated by the government end-to-end. All procurement must be transparent. Every cent traced. Pharma mafia dismantled - on a federal level.
They don’t exist. They’re the imagined scapegoat for what is actually just a much harder to comprehend creeping bureaucracy cost.
The human mind loves clear enemies but Hanlon’s Razor almost always applies. Almost no one ever actually has malicious intent, but our brain evolved to watch for enemies and loves seeing patterns where they aren’t.
The USA expenditure in healthcare per capita is, more or less, the double that the Netherlands (1) and doesn't cover all the population. Where the difference goes?
Sorry if some of us, in our biased minds, suspect that some of that money is spent in cigars and expensive suits.
So what you're saying is there is an horrendous creeping bueaucracy cost here.
Funny, because that's exactly what free market proponents argue is the cause of inefficiency in publicly managed healthcare systems, and the reason to move towards models based on the US system.
It’s you, to yourself. What we have is not by any stretch of the imagination a free market solution. It’s insane amounts of paper pushers created by the government. The whole insurance system we have is an impractical mess designed to fail. The free market would never have designed something so customer unfriendly, people would have gone elsewhere had competing solutions been allowed to exist. In a free market, you are free to go somewhere else.
Our health system is designed by the government, by way of outlawing everything else. If you want to talk free market, in the early 1900s it was common for large companies to keep a doctor on staff and offer their services to employees. That was essentially outlawed.
The rise of cash only flat rate doctors in current years is the closest thing we have to free market, and they’re great. Prices posted up front. No back and forth with insurance companies.
There can never be a free market solution as long as there is a need allocate resources between those who have and those who do not have, without letting the latter not die on the street.
I'd be interested in how the free market develops that solution. At the very least, regulation would be involved. And we all know how adept the free market is at getting around regulation.
Anyway. I'm off to go lie to myself some more. Cheers.
> They don’t exist. They’re the imagined scapegoat for what is actually just a much harder to comprehend creeping bureaucracy cost.
> The whole insurance system we have is an impractical mess designed to fail.
You shifted the boogeyman from corporate suits to politicians in the space of a few comments. If nobody has malicious intent then nothing was "designed to fail". It just doesn't work as expected or wanted by anyone involved.
The costs are more diffuse than this. First, the U.S. system costs twice as much as other systems because we have more people employed delivering care and they make higher salaries. Doctors, nurses, they all make more in the U.S. than in Europe. So more people, getting paid higher wage, results in double the costs.
But wait, the financing in the U.S. is quite predatory, so a lot of people pay nothing, and a few people are stuck with outrageous bills. It's like the infamous SF General Hospital that offered loads of free care to the poor and to immigrants and then refused to take any insurance so that normal people were regularly driven to bankruptcy if the ambulence took them there. The U.S. healthcare is one in which a half a million is spent on emergency care for an indigent person and 10 middle class families lose their life savings of 50K treating snakebites and broken arms.
Once you wrap your head around this, you'll understand we have a very similar problem in higher education, and for very similar reasons.
Ok, I'll take all of that at face value and as given. It just sounds completely broken over there and I'm not sure I will manage to wrap my head around it.
All I know is simpler systems around the world exist and work such that those 10 middle class families would never get stiffed like that, whilst also looking after the needy.
> It just sounds completely broken over there and I'm not sure I will manage to wrap my head around it.
Agreed. But that's the way it is, and it's important to understand why it's this way.
When Europe and Australia adopted national healthcare systems, the industry was ~3-5% of GDP. So at that point it wasn't politically strong enough to resist either nationalization or strict controls.
Then healthcare mushroomed in size, being ~10% of GDP in Europe and 20% of GDP in the U.S.
So now, when you try to do the politics that the europeans did, it doesn't work. The industry is too powerful. Merely blaming the US for not doing what Europe did misses this essential point.
There are millions of nurses, lab techs, administrators, and doctors, and they have money and they vote. So the left keeps looking for some villain -- greedy insurance executives, Wall Street, Evil Billionaires, etc. And basically refuses to understand that these are not the ones standing in the way of reform. It's the 13% of our labor force that earns 20% of national income, and these are not the same easy targets that the left can attack, because they are a large portion of the US middle class, and are core Democratic constituencies.
That's why healthcare reform in the U.S. always focuses on having the government pay some of the costs charged to consumers rather then reducing the costs of providing healthcare. E.g. more subsidies for this bloated industry, which only results in costs rising even more, and then calls for even more subsidies when people can't afford to pay the costs. When what we should do is fire 50% of the staff and cut the pay of those that remain by another 50%. That's the only way to get affordable healthcare.
Yes, the healthcare system is politically powerful in the US, but also we have a culture war that has existed since the founding of the country such that half the country considers is highest political priority avenging slights and punishing the other half. Any sufficiently powerful minority can leverage this state of low level war to prevent any legislation that might harm them. Someone wants to prevent hog waste runoff from CAFOs? Inflame the culture war! Medical pricing is out of control? Inflame the culture war! People are being destroyed by payday lending and someone wants to address this? Inflame the culture war! Someone wants to reduce our profits by forcing us to internalize the costs of methane leaks? Inflame the culture war! There are a bunch of people itching to beat up their neighbors. Tell them that the people who want to fix something are their enemies and away they go. That is why the Land of the Free is such a shitshow.
I think we can all agree the US healthcare system is broken. The above describes exactly why it can't just be "fixed"; only after taking those steps would moving to a universal solution make sense. No one, including healthcare workers, wants to be downsized or get a pay cut.
These people are rarely public, you don't even need to know they exist. They exist behind the figures we see on the TV. Where there is money and a chance of corruption, they definitely exist.
> The health insurance industry continued its tremendous growth
trend as it experienced a significant increase in net earnings to $31 billion
and an increase in the profit margin to 3.8% in 2020 compared to net
earnings of $22 billion and a profit margin of 3% in 2019.
My understanding is that the ER system is especially expensive because paying customers are subsidizing non-paying customers (homeless) who use the ER as primary care.
That said, I don't think this excludes the possibility that the insurance companies and the hospitals are also not telling the full truth.
I find it hard to believe the small non-paying contingent is unique to the US or even a significant % of daily patients, plenty of other countries have homeless who end up in ED's.
America somehow spends far more than any other country on healthcare and yet patients still have some of the highest out of pocket costs even when they have expensive private insurance schemes, something is clearly broken to anyone looking and it's not the homeless causing it.
The US's non-paying contingent doesn't need to be any different from any other countries in order to cause the problem. The issue is that the uninsured subsidize the non-payers alone. This is radically different from countries with universal health care where the costs are spread among the entire tax-paying population.
As for why the US spends more than any other country: it's due to an overabundance of caution among the comfortably insured. It's much easier to get a variety of expensive (and often unnecessary) tests and scans (such as MRI scans) in the US. In countries with universal health care these tests and scans are restricted only to those with demonstrable need and they may be subject to long waiting lists.
> As for why the US spends more than any other country: it's due to an overabundance of caution among the comfortably insured. It's much easier to get a variety of expensive (and often unnecessary) tests and scans (such as MRI scans) in the US.
Countries with universal healthcare also tend to have private health companies which can provide tests and scans at a higher speed, either on an insured or a pay-as-you use basis, typically at much lower costs than the US. Yet there doesn't seem to be the same "overabundance of caution" elsewhere. To the extent that precautionary procedures are responsible for high US spend, I don't think that can be decoupled from a system designed to ensure that primary healthcare providers are sales outlets for those procedures.
Do you have numbers for that? Even the comfortably insured in the US have to pay a fee when they visit a doctor, typically around $35 for GP and $100 or more for a specialist.
My last 5 insurers had copays between $0 and $20. Same price whether it's a specialist or primary care.
If it's an HMO, often it's just free entirely. PPO plans tend to have a small fee -- it's never been enough that I've given it a second thought -- and have wide coverage with few limits.
My wife and I never pay a fee to see our doctors. I pay $30 for sick visits for my kids. $100 seems really high. I’ve only had something like that for a test.
Imaging is used as a revenue center. Many states restrict CT and MRI machines based on the broken thought process that restricting capital spending will lead to lower overall prices. Of course in reality you also restrict investment and competition.
The issue is why it costs $6.5K to get the stitches rather than who pays for it.
I mean, it's clear that it's not sustainable to have a healthcare system in which stitches cost this much. Things are not made any better or less outrageous if these costs are transferred to someone else or if they are paid out of pocket.
The only thing that is particularly unusual about the US is that private insurance companies are probably not very efficient (admin costs are multiples of similar mixed healthcare systems).
But if you look at healthcare spending as a % of GDP: the US has the largest public healthcare system in the world, and it has a private healthcare system that invests very heavily in people's health (I think people get confused about this because US life expectancy isn't much higher but that is largely a function of things like obesity that, ultimately, aren't solvable without people eating less...the US does very well with quality of life and difficult to treat stuff like cancer, I am in the UK and a lot of cancers are treated properly, there is just no money to do so).
So, imo, the US is more expensive than similar systems like Germany. But incomes in the US are much higher, people are willing to spend more (particularly on quality of life stuff like joint replacements), and a lot of the additional cost is not in treatment but admin. Maybe moving to a public insurance system would help but look at France: public healthcare system, and doesn't spend that much less than the US (and in the US, public healthcare prices are cheaper than private but private does subsidise the public...and the gap isn't huge)...doctors don't work for free, medicine isn't free, nurses aren't free, you just pay the same but in taxes (btw, I think a public healthcare system would reduce costs by removing admin...would they like it when they couldn't get a knee replacement? No. Would they like it when a parent got cancer or their kid has a rare type of epilepsy and they can't get medicine? No...there are trade-offs, fully public healthcare systems generally do not perform as well as mixed systems like Germany or Netherlands...making insurers non-profit might be a good first step).
The US conducted the experiment to limit insurance companies' profits. A component of the ACA (Obamacare) was the 80/20 rule, where at least 80% of all premiums collected by health ins. companies had to be paid out for care. That was a failure. In the 10 years or so since that rule, premiums have increased dramatically.
Your reply is well-stated. There isn't one single 'bad guy' in the US system; it's more a function of a bunch of little factors that nobody wants to change: the US has the best, highly trained doctors (expensive), best equipment/hospitals (expensive), subsidizes much of the drug development for the rest of the world (for better or worse), and a weird public/private system where the private insurers make up for lower payments from public insurance like Medicaid/Medicare.
In talking with a number of physicians, my biggest concern is that they're starting to feel like most of the 'reforms' and changes the US is making are impacting them the most. None of my physician friends recommend their children go into the profession, and many are leaving poorly-run hospital systems to focus on boutique, private practice (catering to the rich.) We have a huge healthcare provider shortage coming, and I'm terrified the system is straining hard as I get older and will need to start relying on it.
They didn't stop increasing or go down, was my point. One would expect that if insurance company profits were a large component of the premium cost, limiting that to 20% would lead to some beneficial reduction in premiums.
I think it is more that prices are not transparent. Instead they are impredictable.
And you can't shop around for cheaper treatment. Partly because you are not in position to do so and partly because no one will tell you full price in advance.
I agree that those are problems with American healthcare. I'm describing why ER prices are specifically so much higher than care in other areas of the hospital.
Lol what? Insurers are hugely profitable— many are public companies and don’t hide that. And you can underpay plenty of people if you give them difficult to do bullshit jobs that don’t provide value. That doesn’t make “administrators” liars. Doctor salaries have declined over time with inflation— is hard to blame them for higher healthcare expenditures. My main point is outright calling people liars and playing a blame game isn’t going to get anywhere. The system is fubard.
Though in this case it is quite obvious that there are some parties making an obscene amount amount of money in healthcare, there are businesses where employees feel underpaid, owners lose money / break even, and customers believe they are overpaying, so no one is happy. Childcare is first example I can think of.
> The hospital admin says they're underpaid. The insurance companies say they're barely covering their payouts. So who is lying?
Insurance companies are definitely lying (their execs are paid tens of millions) though it should be noted that the US system greatly limits the ability to spread insurance payments on health populations, so it makes sense that the population using medical services is a larger share of the insured population, and thus has to pay more.
Anyway more generally the administrative overhead of US healthcare is absolutely enormous e.g. as of 2017[0] it was almost 35% of medical expenses, versus 17% in Canada (up from respectively 31 and 16.7 in 2003).
> [Administrative costs per capita in the US versus Canada are] $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs.
So the admin overhead in the US (v Canada) is:
- 5.78x on insurance
- 4.76x on hospitals
- 2.07x on nursing homes, home care, and hospices
- 5.34x on physicians
Importantly though you did not list drug companies in there.
Drug costs are completely out of control in the US (some generic and out of patent drugs have seen price increases of 80x in a decade), and AFAIK modern treatment regimens tend to include a lot more different drugs.
At the hospital level, aside from the administrative overhead above, as an other commenter notes there is also the issue that because it's not a single-payer public health system hospitals have to compensate for indigent ER clients by billing more to, well, people who can pay.
Then of course there's the issue that because all the incentives are fucked under the US system it's being used the least efficient way possible e.g. medical costs are sky-high, so people can't have a GP, so they can't take care of their conditions until those go south, at which point they go to the ER which is the most expensive and least efficient medical service center.
And then the ER's job is to stabilise them, but they still don't have any more money to pay for long-term treatment than they did before having to go to the ER (less, really), so they can't follow through, so they degrade again, and back to the ER.
The doctors likely aren't the ones coding the visit. That is often done by separate back-office staff (especially in case like this, where the physician is working for a medical staffing company).
Most medical practices employee (or outsource) medical "coders" whose job it is to take the notes written by the doctor and determine which procedure codes should be applied (which then determine what gets billed for)
I've had doctors in the ER bill directly out of their own practice several times. Out of network, but I've had no choice in the matter except to receive treatment or refuse treatment for life-threatening conditions.
The law here has changed since then to prohibit this kind of thing, though.
In the case where an ER doctor isn’t employed by the hospital, they are likely employed by a physicians’s group. These used to be ran by physicians, but now many of them have been bought up and consolidated by private equity.
The doctors likely have very little say in the pricing.
Yet they still charged roughly $2,000 for a single patient and that is something that did not take the whole day. If I was a physician I'd be happy if I could bill half that amount even if it took me the whole day to treat the patient
The hospital admins are lying. Doctors will go through a billing agency who can charge whatever they want. The doctor might not know, but would be naive to believe it’s not expensive.
Probably a lot of actors. You know that the hospitals who claimed that their prices were trade secrets when being forced to reveal them were telling porkies.
The American insurance system has inherent efficiency problems.
Hospitals are for profit corporations. Doctors are reviewed on how much revenue they generate per patient - usually by asking for more diagnosis and treatments - which is what patients want too.
Too much admin, too little doctors. Someone should get the admin to doctor ratios at hospitals, it is nuts. A lot of admin is there to handle the insane documentation requirements, software, machinery and dealing with insurance providers.
Insurance providers have their own army of admins, talking everyday to hospital admins.
On top of this, supplies providers know that insurance is going to foot any bill. So they charge more. Insurance tries to negotiate it down but there's only so much they can do - unless they buy stuff directly from China or somewhere else.
To add, each of these institutions has their own management ladder with fatter paychecks than the doctors themselves. These folks are nothing but leeches who just need the corporate ladder to exist.
Unfortunately, the only capitalist solution out of this is to allow massive production of doctors (blocked by AMA), allow doctors to unite and form their own hospitals
willy nilly (harder than you think because legal requirements are burdensome) and for insurance providers to compete in open market - as they do for cars. No more open enrollment.
> Hospitals are for profit corporations. Doctors are reviewed on how much revenue they generate per patient - usually by asking for more diagnosis and treatments - which is what patients want too.
FWIW lots of hospitals are non-profit (though I expect that changes are investors are moving more and more into the space).
That doesn't mean they don't focus on doctor's revenue, it only means there are no owners skimming off the top, but there are still execs being paid (a lot), as well as suppliers, etc... I'm not saying NFP hostpitals are worse (or even as bad as) FP, but they're hardly good.
* I paid $20 K out of pocket for a surgery that my insurance would not cover.
* A few weeks after surgery, I developed a complication that left me in HORRIFIC pain several hours / day.
* Almost immediately after development of complication, I got ANOTHER $20 K bill from the hospital.
* I read the fine print on my contract, "HOLY SHIT. THEY CAN DO THIS????"
* Meanwhile, horrific pain persists, day after day.
* Wife says, "You need to go to ER."
* Me: "NO WAY. You wanna get hit with ANOTHER $20K bill because I developed a complication due to a procedure that the insurance refused to cover from the get-go? I'll ride this out."
* Horrific pain persists. I cancel a lot of my work.
* A few weeks later, I have a follow-up visit with surgical group.
* I tell surgical group, "I got this $20 K bill ON TOP of the $20K I already paid."
* Surgical group: "Oh. That's a billing error."
* I explain very s-l-o-w-l-y that I did not deal with my horrific pain for WEEKS as a direct result of receiving an erroneous bill and that there may be a lawsuit coming someone's way.
* 15 minutes after leaving my follow-up visit, I got 3 phone calls from hospital admins and surgeon expressing profound regret for the error and assurances that the bill was "gone."
If I could leave the US, I would for this simple reason.
Even with my $0 deductible insurance that I paid several hundred a month for, I just got through a months long battle with my insurance over a $10,000 ER bill and additional $2,000 bill they deemed ‘not medically necessary’ — my partner was bleeding from their mouth and unable to eat or drink for more than 2 days after a surgery. It took multiple calls to the doctor and insurance and haggling with the billing department to get the final charges reduced to $0 and $100 respectively.
Even as a well paid software engineer, I’m strongly eying other countries where your life and death isn’t seen as a massive profit center for investors.
I'm in my mid 30s and have left fixing up some damaged teeth and my large wisdom teeth impacted for 17 years too long, this Monday I'm going to get them removed under general anaesthetic at a private hospital.
The Australian government covers hardly any dental unless your teeth have completely rotted through and are chasing other issues.
So far my costs are:
- $4500 in fillings and general dental.
- $1800 for a crown (gold).
- $350 consultation with surgeon (via zoom).
- $1100 for 30-40 minutes (max) of a theatre room for the initial operation.
- $4000 for the surgeon for 30-40 minutes.
- $450 for the anaesthetist.
- $0 for X-rays (covered under Medicare).
- $150 transport.
- $YTD medication post surgery.
- $YTD follow up dental work.
- $YTD additional surgery to cavities from the top teeth into the sinuses - this is only a maybe, it's a risk.
Total so far in the last 3 months has been over $12,000
What stand out for me is how can the surgeon charge $4000 for 30-40mins of active work, and I'm assuming a little paperwork.
Having said all that, I admitted myself to the ER earlier this year and spent the day there having a bunch of tests, didn't cost anything at all and no insurance required.
While healthcare in Australia is generally pretty decent,dental is significantly lagging behind and expensive.
My missus needed highly specialised but relatively quick and low-risk surgery. Maybe 3 surgeons in the whole country do this particular procedure. Think 30 minutes in the OR, a couple of hours to wake up from the anaesthesia, and then you go home.
$4,000.
And then the anaesthetist sent a separate bill.
What does Medicare + Private Hospital cover out of this? A grand total of $130.
It turns out that this particular procedure has no specific "code", so it's lumped in with a routine day surgery billing code. Which is something like $270, with $130 covered by Medicare.
Now, if you ask me, $270 is too low, $4K is a tad high, and 100% of both should be covered by Medicare.
I looked into it, and it turned out that the Medicare refunds are based on "fixed prices" determined by the government decades ago, and haven't changed since then. Private insurance "goes by the government pricing" because it lets them get away with paying you pennies on the dollar.
Realistically, you're not getting any kind of surgery with general anaesthesia for under $1K. Don't worry though, the government and your insurance company will give you maybe a bit over 10% of that back! They have you "covered".
I have no idea on the reasons or specifics but I needed pretty serious dental work here (AU), dental quotes were around $7-8k (“maybe more” they said), went to my GP and he wrote the referrals etc and it cost me $200 out of pocket, mostly for the prescriptions.
Sure you wait a while for our public health stuff if it’s not life threatening, and if you’ve got the cash available then private is faster/fancier,
but the public system does work.
Did you have to get major surgery under general anaesthetic?
This was after I had referrals from my dentist and a second opinion.
I do have some complications with a major nerve running about 1mm from one of the largest tooth's roots and I was told when there's some risk of damage to facial nerves you should make sure you get a good surgeon.
Travel during a global pandemic where we've had almost two years where we can't leave our houses for more than an hour I doubt that'd fly (no pun intended).
Ouch. Germany is pretty bad with dental for public health insurance, but at least necessary basics are covered. So you’d have had to pay for general anesthesia (only local is covered unless deemed necessary), and for the gold crowns (only some cheap and ugly material is covered, same for fillings)
I suffered a really bad motorcycle accident on Dec 2020 with fractures on both wrists, one arm, one shoulder and L4 vertebrae. Had to get arm and backbone stabilization surgeries and almost two months hospitalization plus rehabilitation. Total cost: zero. I later paid just a few dozen € to get the full medical documentation, tests results, etc. plus all the DVDs with the imaging, but that was my choice. I have neither insurance nor a job; if it wasn't for our healthcare, I really don't know what would have happened to me.
Actually I paid for it in advance with my taxes during my past jobs, and that's the whole point of universal healthcare: it's an investment for those who one day will need it, and a form of contribution for everyone else. Frankly I have never understood those who oppose it; are they so anally retentive wrt their money that they can't renounce to a fraction of their income to help others, and potentially themselves too?
In Switzerland the insurance system has various deductibles you can choose from per year, and then a monthly premium that varies per deductible. If you can't afford to pay this for genuine reasons, then the cantons will step in as part of the social insurance system. Once you have paid out of your deductible, insurance covers 90% up to a certain value and then everything.
Insurers under the LAMal system are restricted in what they charge for premiums too, and must negotiate this with the confederation.
There's still a lot of scope for private companies to make money here. LAMal covers what are deemed essential treatments, which is most things you need a doctor for. If you want 'alternative' medicine there are insurers you can pay more money to for that. Likewise, if when you go to hospital you want a guaranteed private room every time, then you can pay extra for that. And so on.
Even on the basic system, you have a choice between telephone doctor for all appointments except emergencies, family doctor for the same or the unrestricted system where you can ring up a specialist yourself without referral. Needless to say, the one where you ring the insurer first is cheaper, followed by the family doctor (similar to the UK: referrals are controlled via your GP).
I don't see any poor doctors here, or poor insurers either (insurance, behind banking, is a massive business here). So it is entirely possible to design a system that includes a large amount of private insurance that also doesn't randomly try to bankrupt people for getting stitches.
For one thing, healthcare is such a mess in the US that it actually might be easier to just nationalize it rather than trying to fix the private insurance system.
Also, in a country with both, the private system can't be any worse than the public system because it has to compete with it, so the fact that the UK has good private healthcare doesn't necessarily mean that it will be easy to fix the private system in the US without the existence of a nationalized system as well.
Washington Hospital in the Bay Area charged me $2,010 for a COVID test when I went to their ER. Later I was told I was stupid for having gone to the ER to do the test there. I just never suspected they would charge that much.
In this case it seems like the steep price is to prevent frivolously using the emergency room. You can get covid tests dirt cheap (or free) if you schedule and appointment at a hospital or one of the testing sites. Emergency room has to have capacity to take on actual life threatening emergencies.
It seems like you've done the research here: how do you know how you are supposed(?) to do the test in the US?
Here in my municipality in Norway the media keeps repeating how/where/when to get tested, and if anything important changes the municipality will literally send a SMS to all its citizens to ensure as many as possible are up to date.
From my admittedly limited experience with the US (NYC/tri-state area) I get the impression that information is often hard to find and hard to understand. This could of course be caused by cultural or lingual differences since I'm neither American nor a native English speaker.
It may be hard to find if you aren’t use to it. Normally you would call your doctor/clinic and schedule a test for the next day or so. A lot of times you can get into an office for a test same day (this is how you get sick notes for school) although it may not be with your preferred doctor and may just be a nurse giving the test. For covid, since it’s so widespread, there have been testing centers setup almost everywhere and a quick Google should give you a list of the closest ones. Again you can always go to a regular clinic for testing but they may not have same day service.
The emergency room is the last place you’d go for a simple test. The only reason you should go to the emergency for a test is if it’s heart related or you think you may die (an emergency.)
It is called "health care" and you are doing neither.
I live in a second world country called Poland and even here with all our failings and problems we are not afraid to go to ER when we need stitches.
Organizing medical help should be basic responsibility of a government the same way it should be to get its children to be educated and have good start for life.
Nation is a collection of people that work together so that they can prosper but, most importantly, fulfill their basic needs including a need for safety.
I can think of no large group of people that would say "Let's work together. But maybe let's decide we are not going to to deal with our life threatening problems that can hurt as sometimes completely at random.
When people talk about helping a third world country what are the first thing that are being mentioned? It is usually building schools and hospitals. Because educated and healthy people can take care of themselves. Why would USA decide to not provide free education and free healthcare is completely beyond me.
I always find interesting to read these stories because nowhere else but the US can you make over 300k USD a year as a senior engineer of some kind. In Europe, 200k EUR is already ridiculous, and most countries take away half your salary in taxes anyway so...
Would you rather make 300k and pay 4k for the occasional ER visit or make 50k after tax and pay 100 for the occasional ER visit?
I suppose this comment will get buried in downvotes, but do not ever forget that American engineers are the best paid workers in the entire world.
That's a great deal for the programmers. Not so much everyone else. Median household income for 2021* in the United States is $80k; which is a far cry from $300k.
Even the $300k doesn't go as far as you'd think given the costs of housing in the areas that pay that kind of salary.
Most tech companies offer great insurance on top of higher salaries, so this doesn't really effect highly paid employees. For example, my insurance premium is around $200/month for my family and I have a maximum out of pocket cost of $3k a year.
So the system works well for me at least, but I know it is much much worse for others
Eliminate all political donations from non-humans.
That is the biggest issue, thanks to Citizens United Ruling by Republican Supreme Court Appointees, people in the US votes have no power any more. As soon as someone gets elected the do not give a crap about the public. That is when money starts flowing to them in large amounts to push corporate agendas.
Republicans are very good at this game, notice how they are able to block even tiniest efforts are political reform.
> As soon as someone gets elected the do not give a crap about the public.
This goes too far. Believing it is impossible for politicians to do the right thing is a counsel of despair that harms those who are trying to do the right thing and gives advantage to those that aren't. If you believe it is impossible for democratic action to provide good governance, what is your alternative?
I wish I knew, but one thing that should be fixed in the US is the Electoral College. The limit of 435 Reps skews the numbers.
House of Representatives is suppose to be 1 Rep per a fixed number of people. But Congress put a hard limit of 435, that means Small States have more people per Rep than Large States.
For example, Wyoming has 1 Rep for 480900 people.
California has 1 rep per 736000 people. To be fair and agree with the original intent of the US Constitution, California should have about 82 Reps instead of 53.
Texas for that matter should really have 52 Reps instead of 36 has it as now. The way it is now it has one rep per 700279 people.
This will even out things a bit and hopefully get come changes through.
American emergency care is the exact opposite of a "free market". In a free market, you get to shop around, compare prices and most importantly, there is a supply and demand curve where if prices rise too much, you can choose not to consume the product. Works great with potato chips, not so much with bleeding wounds.
If I'm 'forced' to go to the nearest hospital because I may die if I don't, then that hospital should be 'forced' to bill me a fair rate. You can't have free market billing but captured service demand. They do the same with utility pricing - the power company can't decide to 10x the cost of a KW (sorry Texas), so the same should be for medical bills (especially emergency care).
We've 'socialized' firefighting, policing and the defense of our country. Why haven't we done the same with health care? I dunno, maybe not enough Americans have visited Europe or Canada and seen the liberating power of free health care.
From what I can see there is a cost breakdown in the article, but a deeper breakdown would help make sense of these things.
If the hospital has to pay for administrative staff, nurses, doctors, maintenance, electricity, etc. and then deliver a profit to the owner. Is this profiteering or just costs that are passed on to the patient? If it's the latter, then why are those costs high, and so on until something looks disproportionately expensive.
Is it that hospitals are pricing treatment because of having to comply with some expensive regulatory requirement? Or is it that doctors are paid an incredibly high wage compared to doctors in other parts of the world? Or is it that insurance paperwork requires a large administrative staff?
I suspect there is no single answer to these questions, and that there is some complex set of reasons why costs are high.
If it's just profiteering, then the solution is to get stitches from elsewhere. A vet or a nurse or EMT can probably do it freelance too.
Prices in medical care like anything else is a function of the maximum amount of money that can be extracted.
With the socialized Medicare/Medicaid already in place, hospitals charge as much as they can knowing the government has deep pockets, will pay, and will give minimal resistance.
Those high prices are then charged to insurance companies as well through closed door, complex negotiations on a case by case basis - super inefficient and expensive.
Also without consumers in the loop even caring what their insurance company is paying, and no price transparency in general, there is no pressure to decrease prices, improve quality or compete in general which are the cornerstones of free market economics.
Luckily price transparency laws were passed last year and are still working their way through the system so hopefully people will start to get a taste of what’s possible soon and decide to take those laws even further.
From personal experience, many states dont require workers compensation for independent contractors. Now there are protections still, but it isn't as robust as employee protections, and even then in some states (like Texas), the company doesn't have to have workers compensation insurance at all, but instead can use mediation and arbitration to "take care of" injured workers.
My sister is an orderly at a nursing home in Texas, and was attacked by a patient, she was was scraped up and had to get stitches, but they wouldn't allow her to fill out a work place injury form or reimburse her for medical expenses, and instead the onsite RN stitched her up at the request of management. The company (pretty large nursing home management company) does not carry workers compensation insurance and instead uses 3rd party arbitration to handle injury "disputes"... so if you are TRULY injured, you have no real recourse than to wait days and days without treatment waiting for this third party to say they will reimburse you.
I was charged 10,000 for rabies shots administered in the ER despite calling and getting pre-authed. Their billing dept fat-fingered my insurance companies address. Yes, that was the unique identifier - a physical address. I had to fix it myself.
Unrelated but I was also audited a similar amount due to clerical error by robinhood + irs. Unnecessarily complicated laws designed to screw 99% of us are working.
> But many facilities will require those who have insurance to use it — knowing they can bill higher prices that way.
And therein lies the problem.. It's been said over and over but there is still no getting around the fact that most people in the US literally can't afford to get sick or have an accident.
I'm not going to hold my breath. We seem to feel very clever for believing that any system will be made worse by government involvement. People are unironically worried that Biden will usher in an era of socialism. It's too stupid to make up.
Damn this is costly. I am an outsider from a developing nation in the east looking into this. Here that treatment wouldn't have costed more than 10$ in a very good hospital maybe. I have two questions for US citizens:
1. How are the prices so high(ELI5)?
2. What happens if someone doesn't pay the entire amount of the their medical bills?
Edit:
Another question I want to ask after reading some of the other comments.
3. Doesn't big companies in the US keep medical staff for basic medical emergencies like this? That would be free of cost for the employees if things are similar to how it is here.
For Americans that question why some other country has certain polinices or government that seem extremely crappy (say, Mexico crime struggle, Venezuela failed economic policy), healthcare is a good local example of a country's broken system which most citizens hate but that just cannot be reformed.
For a lot of these abuses, shit needs to hit the fan in some way like what happened in Egypt during the Arab risings. Otherwise it's a gradual decades process to move away from the status quo.
This is insane. I live in Iceland. I recently fell off my bike, got a bad cut on my forearm and needed stitches and extensive cleaning of the wound. I visited my local clinic where a nurse cleaned the wound and a doctor applied 5 stitches. The whole process took about 90 minutes with wait. For this visit I paid 500 Icelandic Kronas, about $3.75. Afterwards the wound got infected which required another $3.75 visit and antibiotics treatment costing about 10.000 ISK,rougly $75.
This reminds me of the ESS surgery I took last Sunday. The bill came at approximately $4,900, and approximately 60% goes to the physician. I didn't have insurance, so I have to pay them in full.
Although I enrolled in the universal healthcare scheme (which allowed me to pay up to $1 for treatment), my sinusitis is more serious such that I don't think UHS will properly cure me, causing me to pursue special clinic at public hospitals (where more experienced physicians are available).
There's no free market in healthcare. Same thing in Singapore (highest free market in the world) would cost 0 due the cheapest healthcare plan is around 16 dollars.
I am in the UK.
My father-in-law has just been treated for almost cutting a finger off with a chainsaw (the safety gear was sitting on the floor next to him).
He went to the emergency dept (saturday) for initial checks and xray and then to a plastic surgeon today (sunday) who operated on his finger.
Total cost to him was £0.
Why is it that poor, third-world countries can afford a single-payer health system that treats all patients equally and economically, and the so-called richest country on Earth makes sure its citizens get bankrupted for the most minor medical issues?
I had triple-bypass in 2005. Cost to me? Zilch! If I lived in the US, I'd be dead for the last 16 years.
The market for healthcare needs to be completely unregulated and open to competition. The licensure barriers to providing drugs, medical devices, and medical services leads to far less innovation toward more efficient ways of producing medical products/services than there otherwise would be.
A colleagues son was in a motorcycle accident, and needed some emergency surgery to fix his leg. He was talking about how he was really dreading the hospital bill. I got to go through the joy of explaining to him that because we're in Australia, it's free.
The American healthcare system seems completely nuts from here.
My wife’s last ambulance ride was $1200 to take her to the hospital 4 miles away. They didn’t even do anything for her, just drover her there. I wish she had called an Uber — something like this makes me not want to call an ambulance ever again.
That is not the problem, IMHO. I would suggest that the problem is that the consumer, i.e. the patient, is doubly removed from price considerations.
Firstly, insurance shields the patient from the direct cost of healthcare. Second, many people are shielded from the cost of their insurance as it is chosen and paid for by their employer.
Just my 2 cents. I live and work in Germany and am insured in one of the many public insurances.
My monthly contribution is 350 Euro, my employer has to pay 350 Euro per month, too. Hence, I am paying approx. 7500 Euro for my insurance per year. Assuming I work 35 years plus some inflation, then I will pay over 300.000 Euro for my insurance. This excludes contribution before 25 (where my parents paid for me) and my contribution after I retire.
What I want to say: public insurance is NOT free, but also comes with high cost.
I also should add that dental treatment is only covered when you get the most basic things. When you have bad teeth, you are f"""ed as you will have to pay the lion-share for your dentures.
But dont worry, there are insurances for that, too. The good ones cost you another 300-400 Euro per year. This makes another 30.000-50.000 Euro on top of what I already pay.
I'm fairly certain the indicator they cite there is Current expenditure on health
by general government and compulsory schemes, i.e. includes the public health insurances, but it appears it's not in the current WHO database anymore and thus can't 100% verify that.
£715 (approximately $950) for 4 doses, almost a month's worth with 1 dose per week coming out around $1k/month.
Even ignoring the fact that patients here don't pay, just having NICE and a system which will fight drug companies over costs appears to massively bring down the costs of these medications.
Question from a welfare country and complete ignorance: what exactly are the steps necessary to change this and why is it so difficult for the USA to take them?
This is not that bad because he ended with a negotiated rate and paid 1,000 or so. I’ve seen much worse
One cause is political. One place I worked govt would only pay a % of the billable rate - this was so politically they could say program was saving money.
So the ‘rack’ rate went through the roof. The irony? We’d have preferred to charge less to cash payors (this was a nonprofit) because they were much less painful to deal with if they paid when service delivered - but instead it was so costly no one could afford cash payments
Having to go through the process of negotiating it down is proof that the system is a failure, because that’s very obviously difficult for the majority of people to do. You simply shouldn’t have to do that in the first place.
Yes you can negotiate the prices with insurance, but that means there's always a risk that insurance doesn't cover as much as you hoped for. This means every emergency becomes a risk assessment of estimated cost / probability of negotiation / network coverage / hassle. This is so broken.
When I'm headed to the ER, I'm looking for immediate medical attention. I don't want to be shopping around for hidden hospital price estimates, verifying network coverage and deciding if I should Uber, ambulance or drive while I'm half dead. After all that we still got slapped with a $30k bill for half an hour. Cleared the HDHP deductible real fast. Thanks WEC Hospital for the wonderful hours long wait to pay you jacked up prices.
When we had our first kid, we had to repeatedly call the hospital and insurance to make sure it's within network and that the midwives were going to be covered. Then we got slapped with a $15k bill because one of the nurses is outsourced and not within network. After 5 separate hour long conversations on the phone with Aetna we finally managed to get the clinic to lower the bill to $3000 which Aetna then covered. And then 10 days later I received a $15k bill payment reminder.
I think the whole healthcare discussion in the US seems way too distracted with figuring out how to refactor a code base written by clowns, instead of just building a new system ground up. With 50 different states to pander to, I guess that's the logical result.
Pretty glad I left the US, my mind is now cleared of lots of unnecessary baggage.
This is why you want to go to ConvenientMD or similar urgent care centers for anything not acutely life-threatening. It's usually faster than being seen at an ER, and costs an order of magnitude or more less - my insurance has a baseline fee of only $50 vs $600 for the ER.
I don't get this. I live in Kerala, India. And for most things that doesn't involve a surgery, I can visit a government hospital nearby and it would cost me absolutely nothing. The medicines are free. Vaccines, TT shots and injections are free.
Americans have to watch their health more these days. Companies are now ONLY offering high deductible plans. You HAVE to invest in your HSA for things to be sane.
You cannot afford to be overweight or t2 diabetic in America, not anymore. The biggest money makers are cardiovascular surgery. These are bankruptcy makers.
Get your teeth checked out and clean. Get physicals - keep your cholesterol low. Get the vaccines and booster. Try to get as healthy a weight as possible. Watch your higher risk behaviors. Avoid cigarettes and alcohol.
This is definitely a problem but the problem is not high deductible plans, its price transparency which distorts supply and demand and steers people to high cost emergency room medical care while unfairly shifting costs to those who choose more price transparent plans. And the article's charge calculation is dishonest, ignoring premium savings and insurance discounts in order to get a bigger headline grabbing number.
I had a high deductible plan and got snagged with a similar charge but not as large. Same deal, a walk-in by a family member to an emergency room cost over $2, 000, no treatment, simple 15 minute consult. They classified it as a level 4. I understand this is intended to offset overhead and also to discourage unnecessary walk-ins but really ? I argued with the hospital on the level 4 classification and the fact they never informed my family member how much it would cost them prior to (or even after) treatment. They would not budge and I held out until they threatened to send to collection at which point I gave in because it was easier to pay.Also I figured I saved as much on my high deductible plan and it was a lesson learned both to me and my family.
The article is not being up front with the cost calculation.
First, the family in the article likely saved thousands of dollars from their high deductible plan ( for example at the time I was saving at least $300 a month on my plan v lower deductible plan, a savings of $3600 a year in premium). I didn't see anywhere in the article where the premium savings was calculated and it certainly was not deducted from the headline number.
Second, included in the headline number is the unnegotiated undiscounted retail cost. No insured person pays that number. Buried in the article they note the true discounted cost, the "you pay" number which was negotiated by the insurance company as part of their deal with the hospital and passed on to the insured. Granted the discounted price is still outrageous, but it's much lower than the headline.
Third I believe the article fails to mention those with high deductible plans are able to put away the thousands they save on premiums (and more if they choose) in a health savings plan (similar tax advantages to a 529 for education or a 401k roth and similar investment choices of mutual funds, stocks, bonds, cash, etc. ) which is only available for those with high deductible plans and which can grow over a lifetime (this NOT forfeited each year like the medical savings accounts most people are familiar with).
In addition, most areas, and I would bet even in this rural area, there are private stand alone clinics that would have treated him for around $200 . The mistake is to walk in to a hospital emergency room for non-life or death situations, a problem that most people who are on low deductible plans do all the time, driving up artificial demand and real costs for everyone. Hospital emergency rooms are equipped with the most expensive personnel and equipment, they should not be used for non-life threatening problems.
One of the main problems with the American system ( other than government intervention which has royally misallocated resources, screwed with normal market driven supply and demand, and micromanaged health care production, supply, and delivery) is that no one knows how much it will cost given the complexity of the insurance.
Hospital emergency rooms need a simple menu-like sign at the door giving the out-of-pocket cost for common treatments and encouraging people to call their insurance company first and/or go to other clinics for non life threatening issues.
The price transparency law that was passed a few years ago did little as it resulted in long lists of obscurely named procedures, usually in a pdf buried in the website.
And/or they should give a reasonable estimate to high deductibles and charge them a r$1000 or so in order to walk through the door, refunding any difference when they walk out.
In addition the low co-pay plans for emergency visits are obscuring the true cost to the hospital, encouraging unnecessary emergency room visits, and pushing these costs onto cash only and high deductible plans. High deductible plans should be encouraged legislatively, rather than demonized.
Also, instead of fighting the tendency of people to run to hospital emergency rooms, hospitals should run lower overhead, lower cost 24 hour clinics adjacent to the emergency rooms and informing people of cost/benefits of each.
While I appreciate this article pointing out the problem of emergency room costs, high deductible plans, are not the problem but one of the solutions to high medical costs. They can regularize supply and demand and increase price transparency.
This is the kind of things that show how inviable is a market-led economy without proper regulation. Let the powerful profit from the weak and you'll see this kind of thing every time.
If you compare life expectancy in Chile and some other Latin-American countries with universal care[1], they are higher than in the US, despite being a more unequal and/or poorer.
[1] https://ourworldindata.org/grapher/life-expectancy?tab=chart...
Edit: Many commenters miss the point. The US leads the way in too many areas and at least I expect them to be an example of the benefits of free market economy. Some have mentioned that regulation is indeed the problem. I would say, that we need the right regulation so the right incentives are put in place, in benefit of the market and competition. So at best it would be better not to have the industry dictate the regulation.