When the social norm hardens around "don't charge what it's worth, charge what you can get" this is the result. I once asked a hospital billing agent how they could justify a $10k ER bill for 4 hours of waiting and 1 hour treatment, and they responded, "How much is your life worth?"
One place that gets it right is Germany: an inexpensive public option that gets you competent medical care almost anywhere. Bring your card, no deductibles, no paperwork, no complex calculation and a minimum of paperwork (which is a rarity in Germany). This is how it should be here.
Germany has a major doctor shortage and it can’t just attract foreign doctors like Anglo countries due to language requirements. This issue will continue to get worse as the population ages.
It's not better here. Just seeing my GP takes weeks, and he's overwhelmed.
I remember a few years ago, I noticed a mole on my arm suddenly looking very irregular. I kind of panicked, thinking it was potentially skin cancer. I have decent PPO insurance, no worries, I can go call up and schedule an appointment with a dermatologist directly. I live in one of the largest metro areas in the US, tons of doctors, should be a breeze to get it checked out.
I load up the find a doctor website on my insurance company's website. There's like 30 dermatologists within an hour or so drive from me, awesome. I start calling. Not taking new patients right now. Can't be seen for 6 months, 8 months, we could get you in next year. Next year, when I might have quickly growing skin cancer?
Luckily when I finally talked to my wife about it, she reminded me she had poked my arm with a permanent marker. Some solvent, and my mole looks normal again. I still make sure to keep my dermatologist appointments, just so I don't have to deal with the new patient issues and the "we're not taking anyone new these days".
I had a different issue with extreme nystagmus come upon me. Bedridden for days, I couldn't even open my eyes without having extreme vertigo. Calling ENTs to try and get help, none would be able to see me for weeks. Luckily a friend who works with ENTs managed to get a doctor to see me but if it wasn't for that I probably would have just had to suffer at home with no answers as to what was happening.
I now know that unless I'm practically about to die, seeing a doctor that will do more than run extremely basic labs and very basic healthcare is weeks away in the US even if you have decent insurance.
In both examples, just getting an MRI would have told me practically nothing. Maybe for the nystagmus, it would have told me if there was significant brain cancer. Maybe a blood test would have told me something about cancer, but there's a good chance it would have been inconclusive, I needed a biopsy (or, in hindsight, a bit of rubbing alcohol).
This was in an actual city. Things can be even worse out in the sticks, where hospitals are much farther apart and often offer only some of the services you expect from a big-city hospital.
Lots of these plans also only cover a small geographical area, except for ER visits (which I think they have to cover). So don't get sick in a way that gets you discharged from the ER into a regular hospital bed, but still unable to get home, while traveling within your own country, if you don't want to go bankrupt.
Like it truly wouldn't have been crazy for someone on one of those plans to get some kind of travel insurance while traveling in the US. That's how fucked up our healthcare system is.
> Guess what, when you price shop, the price they tell you has no relevance to the final price.
I've found they often can't realistically give any kind of useful quote. I remember getting a total cost estimate from the hospital when my second child was born, anywhere from $20k to $160k before insurance, please sign here.
We can't even scale out broadband to the entire US.
I had Kaiser Permanente when I was in the US. Now that I'm in BC, Canada, it is very similar. I walk into any hospital in the province and every doctor and specialist in the building are part of the same system (technically they are broken up into three geographic subunits, but to the patient it basically doesn't matter). If I need some sort of treatment that hospital doesn't offer, they can immediately refer me to the correct hospital. For emergency cases the provincial ambulance service will transport you to another hospital by road or air at no cost.
There are still independent specialists and doctors outside of the hospital system, but they have access to the same records systems and the billing is so seamless that I suspect that most people don't realize it is happening since it never involves the patient outside of providing your ID.
Of course the approach works, we can see it work at various scales. I think what prevents it from working is that it works best when it is the only option. I don't think we could support 5 kaiser permanentes. And that feeds into insurance - there are a lot of insurance plans, and each of them would likely only support their specific kaisers
So ideally there is one insurance, with one provider that has vertical integration everywhere and then indies outside the network you can go out of pocket for, and oops I invented single payer
That is a serious and real obstacle. German has a well-deserved reputation for being difficult to learn. I'm pretty good at learning languages but German is extremely difficult to speak properly unless you are raised in it.
German public health insurances are concerned right now about their unusually high deficits. Because many millions refugees are not working they only get paid a reduced amount towards the mandatory health insurance but have the same full service. Bringing the already substituted public health insurance into insubstantial deficits and now they are increasing the rates for the working class and probably they will need additional tax money too.
Even with an active infection, that could have cost her her jaw or her life if it had been left unchecked, it took months to get anyone to even make an appointment for an initial consultation. We were very fortunate that the oral surgeon we were finally able to talk to was able to fit her in for surgery within a short time after that, due to a cancellation.
People talk dismissively about the "long wait times" you get with some public healthcare systems, but always oh-so-conveniently ignore the fact that there are long wait times here too. Sometimes catastrophically so.
Almost universally, when you dig into it, the "long wait times" that exist in those systems fall into one of two categories: either they are wait times for elective procedures, where your long-term health is not at risk, or they are caused by shortages that are symptoms of unrelated problems.
They can't exactly pause the surgery and get you to consent to an extra few thousand dollars' worth of work.
This is another example of why healthcare really, genuinely is best left as a single-payer government-funded service. People can get the care they need to be healthy, without ever needing to worry about the uncertainty inherent in the price of such a service.
There's plenty of actual data on this. Relying on what "nearly every Canadian you know grumbles about" when the topic is "are single-payer systems, on average, better than the clusterfuck the US has", isn't sound reasoning.
> "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces"
Blaming insurers and drug companies is fashionable -- and employers is a new twist, I suppose -- but it feels like a desperate search for a facile answer. Nobody wants to hear the hard truth, which is that if you had to pay for it, you'd suddenly become a lot more picky about the health care you purchase.
You don't see the prices, so you don't care, and you can't shop around. I'm not saying there aren't a ton of other negative incentives in the system, but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.
I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything.
I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance.
Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here.
From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
That’s basically my plan. I work for a FAANG, and have a low 2k/year max out of pocket for in-network, which is almost everything I encounter. I just book specialists when I want, and I see them as many times as I need. I can do PT 365 times per year, so as long as I don’t go more than once a day (which would be silly), I consume as much as I want. I recently chose to go to the Mayo Clinic — out of state, no referral, and everything is covered. I keep getting estimates from them of $0 since I hit my max out of pocket. The only thing I’ve been denied for is Botox for TMJ which they say is not medically proven (seems to be the opposite, but I understand why they’re wary).
I’ve never had a medication, procedure, or doctor visit denied.
You cannot consume as much and whatever type of healthcare. You have to consume from the pre-approved list of doctors that have negotiated rates with your insurer. I also do not believe for a second that if you found a doctor willing to give -for example - daily electrolyte IVs for your post workout recovery, that the insurer would touch that claim. Same thing with cosmetic or elective surgery. Will your insurer cover a facelift? Will they cover Ozempic for vanity reasons? Will they cover the full cost of all name brand drugs after your deductible is spent? And you still have to pay $2k before any of that is in effect.
Mind you, your extreme outlier reality is one that is essentially never experienced by >95% of people, and it still has constraints.
I’ve never found a doctor who would do anything daily, but if there was a medical need, I’d expect it to be covered.
Where in the world is a facelift covered? No healthcare system covers that. What a silly thing to point out.
If a doctor is willing to rx ozempic I’m sure they’d cover. I already get a glp-1 covered.
Brand name drugs are covered fully.
Yes I have to pay my $500 deductible and co-insurance until I hit my 2k max.
What constraints?
When I was a kid, everyone no matter economic level had pretty much the same pediatric doctor group. Now the working class people around me don't really have a pediatrician, but an overworked 'nurse practitioner'.
These do not apply to me. I cannot be the only one. In fact when I was a 2 person startup things weren’t so terribly different from my current situation as well. No need to accuse me of classism when I’m simply refuting the premise with my own data and lived experience.
The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am.
You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service.
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.
This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.
"the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good."
I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?
Much of the rest of the developed world doesn't ever even see a dollar amount.
Thus, the "knowing costs drops spending" theory doesn't hold up.
Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.
Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping". So if you want to call that system price transparency, then all I can do is shrug and walk away.
I mean, go visit any Reddit thread discussing an American healthcare explanation of benefits bill. The Americans go "yup, it's expensive here"; the Europeans tend to go "I literally just paid $6 for parking for childbirth".
> Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping".
If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?
Again, people on high-deductible plans know very intimately how much everything is costing them.
No. The next one could be more, it could be less. There could be other fees. You have no idea, because there is no price transparency.
You obviously know this is true, or you wouldn't have used the words "likely to cost". You're just arguing to argue.
Go to the grocery store. There are no prices posted, you just take your cart to the register, and the cashier charges you $20, then sends you a bill in the mail for a random amount -- trust us, we'll figure it out! Oh, that can of tomatoes really was $50. Sorry. At least you know for next time, right? (Unless the price changes.)
Do you see the problem now? Would you really call this system price transparency?
Americans know intimately that doctors visits are going to hit them in the pocketbook. Far more than someone from a single-payer system does, where there's a good chance they will never receive a bill with a dollar amount on it.
Yet, we're the big outlier on medical costs. Knowing "this is gonna cost me, ooof" does not seem to have any impact on the costliness of the system.
There's no way the cost difference (often literally 10x+) in private healthcare with the US can be explained by anything other than "US prices are actually total bullshit".
It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
This isn't cosmetic surgery comparison shopping. This is "this Doctor has experience with my rare neurological condition, has published papers on it, and has shown success in designing care plans for people like me."
Except...you absolutely should, and it isn't weird at all. If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it? [1]
Maybe you would, maybe you wouldn't, but the choice exists, and someone is making it.
[1] You can make it more complex and human, of course: most medical interventions not only cost money, but also carry serious risks. Maybe you would choose to spend an enormous amount of money, but would you also choose to take a treatment that will leave you deathly ill for the remainder of your life in exchange for 1 extra day?
This isn't theoretical. People do exactly this. https://www.newsweek.com/doctor-sold-fake-miracle-cures-near...
They are simply not avoidable unless you have literally (literally literally, not figuratively literally) an unlimited budget. No country or system has unlimited resources.
But all countries do that cost-benefit analysis all the time.
Not every procedure or medication will be administered to the patient, even when those procedures and medications have been approved for use in a particular country.
But, whoever decided to start marketing things like low deductibles and out-of-pocket costs as a premium service, that person bears a lot of blame. They are the one that decided customers shouldn’t see most of their healthcare costs.
The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups.
Mixing in employer insurance also caused a skew, because it makes people see their employer insurance as a perk. A perk should be something you actually experience. Employers should dump money into your HSA, and subsidize a gym/healthy snacks for their campus instead (some do, of course).
Well, that's just silly. The whole point of insurance is to cover tail cases: Catastrophic costs with low probability. If there is no cap, why have insurance at all?
And always they're like YOU MUST PAY THIS IMMEDIATELY or be sent to collections even though they take their sweet fucking time getting them to you, and also make it a pain in the ass to question any of it (and some of them are serious, in two cases we had trivial-amount ones slip through the cracks of the 50+ billing and EOB and blah blah blah letters we received, and go to collections right at 30 days, not even a follow-up "hey you may have missed this, you're overdue" letter)
I wouldn't be surprised if there are a bunch of scam artists out there sending fraudulent small bills to patients with recent major procedures (guaranteed to have a mountain of confusing bills coming in for months) whose info they got from our massive privatized spy network, and having almost all of them get paid. Like, compared to some other stuff that goes on, that seems like a no-brainer of a scam to run, with likely a very high success rate (am I going to burn potentially half of a day per bill to figure out if one of these fifteen $10-$200 invoices is fraudulent? No, no I am not)
At what point in your story were you able to comparison shop for a cheaper option? I know you said you chose a more expensive option, which is always your prerogative, but how many other providers did you evaluate before you made that decision?
I mean, in this case I actually was able to depend on the numbers, it's just I can't depend on my insurance but then that's also a fact of insurance markets. Take away the insurance, I doubt my total cost would've been lower, even accounting for my insurance premiums and whatever my employer pays as part of that.
There's a market here, I would prefer it were more regulated, not less. A less regulated market would not help me. A less regulated market would make it easier for prices to change at random.
There are certainly acute situations that are unpredictable -- go to the ER with a gunshot wound, and nobody can tell you what it's going to cost. That's fine.
But most of the time, you're wrong. Health care moves slowly, and there's lots of time to think and plan. The costs of pretty much any procedure is pre-negotiated by the insurer and the provider, so they actually do know what it's going to cost. They just don't tell you.
There's no fundamental reason you couldn't have been quoted an accurate price in the scenario you described.
I received an itemized bill with the exact cost and what would be covered listed, then it changed after the fact. It is certainly the case that for some procedures you can't get this, but for procedures where you know the cost will be hundreds you can easily obtain such a bill. Such bills always involve guesswork though. Even absent insurance this would be true, complications happen.
Most people in the US never see a doctor outside of emergency care because it's too expensive to do so. Price shopping doesn't do shit for the majority because the people that do get healthcare get it from their job and don't have a choice anyways which doctors they can see or not.
The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can.
This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year (and more like $1.5k for her parents, being tenant farmers) and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore, let alone a HCMC or Hanoi where the jobs are actually located.
Similar story for my cousin in India as well - he's attending a T5 AIIMS and is looking at 10 years of medical education (an MBBS doesn't cut it in 2025 anymore - you need an MD as well now) in order to get a $15k starting salary, but he is also lucky that his parents are both doctors. If he was not from that background he would have probably attempted the USMLE as well and leave.
Both India and Vietnam are seeing a significant medical exodus, as is the UK, South Korea, and other countries where this kind of penny pinching sentiment is rife.
HNers harp about layoffs and offshoring, but seem to only care about stagnating wages for themselves in high wage industries with no barriers to entry, relatively chill work cultures, and no risk of legal liablity.
What do you guys want? Barefoot doctors and aryuvedic treatment?
People already have plenty of incentive to become doctors. We just don't let them. Medical schools collude to limit the number of medical students each year (under the guise of preventing having "too many" doctors). Medical schools have ridiculous selection criteria, like picking the candidates who earned an "A" in physics instead of a "B", or who came from a rich enough family that they could perform many hours of volunteer community work (mostly because the low quotas make it otherwise impossible to select candidates without literally rolling dice).
You know what? I think tech workers aren't paid enough. There isn't enough incentive to become a tech worker. We should limit how many people can study CS each year with strict quotas. It should be illegal for a person to program a computer unless they have a CS degree from an accredited school (one in on the quota system) and have passed an exam. Practicing programming without a license (or practicing from a foreign country with a local license) should be illegal, punishable by time in jail. Finally, programmers should have access to computer tools (like encryption) which will be illegal for the rest of the population to possess, and be given the benefit of the doubt if/when they misuse them.
Do you see how ridiculous this sounds?
If a patient faces a complication or (god forbid) passes away, you as a medical practitioner are held legally liable and can lose your license and potentially even your freedom.
I mean, people in the US pay $250k+ tuition, median income $65k/year, work $35k/year for a while, and eventually make something like that $250k/year. A house in many US markets is $300-500k.
It's pretty much the same balance between each item, just more zeroes on the end of each number.
You cannot compare the poverty or material condition between the two.
Personal access to tap water, personal bathrooms, not having to pay a bribe to get ID, public services, school meals, public schools the actually have some sort of services, and other stuff Americans take for granted are not available to the vast majority of Vietnamese, Indians, and others in the developing world.
My SO literally had to pay a $5k bribe/speed money to get her diploma from her university otherwise she'd have to work as an unlicensed doctor for 2 years.
The rent for an illegal 1 bedroom hovel in D3 in Saigon with a tap water connection and personal bathroom goes for $250-550/mo - that's literally the monthly wage for most residents in Saigon
You really cannot compare even the worst life in the US with the life the silent majority faces in developing countries
Sure, but your example cites someone who expects to be making the median annual salary every month within a few years, right? In both places, there's a hefty up-front investment for a much-better-than-average earning employment opportunity.
No.
This is someone who spent $50k in debt just to end up earning the same salary ($700-800/mo) if she worked in a factory sowing clothes (which give free dormitory housing vs paying $200-400/mo in rent like non factory workers do), working in the unregulated vice industry in Singapore, UAE, of Korea, or doing nails under the table while overstaying their B2 visa in East San Jose - like a number of my SO's peers who didn't make it into a degree program that leads to you becoming a doctor, dentist, bureaucrat, or engineer.
Spending 8-10 years of education just to end up earning a similar amount as a factory worker makes people who devoted so much time and effort angry, and why you see a significant exodus of medical professionals in developing countries to developed countries, becuase they are not remunerated enough.
Remunerating people less only exacerbates brain drains.
And note how this is specifically medical professionals - other white collar roles pay less and are much more competitive or difficult to land a job in VN
Saying the median American has a life comparable to the median Vietnamese is TRULY out of touch.
I'm still not seeing the bad investment here.
To make an investment you need capital.
A $6k a year tuition is double the median household salary for most Vietnamese. And unlike in developed counties, student loans are essentially non-existent for the majority of the population. To get a loan, it means going to a tattooed snaggle tooth guy wearing a flower shirt who exchanges gold and foreign exchange, and getting a double digit monthly loan. Best case, you are lucky and have land you can mortgage or family abroad you can beg for remittances. Additionally, tuition is paid up-front - not monthly payment plans. Additionally, the universities didn't provide half of the materials needed like scalpels or gauze - that came out of pocket at US prices.
Additionally, for someone from the bottom half of society, like my SO's family, social security and public services are non-existent, so they are dependent on their children sending them $150-200/mo while their kids are paying $250/mo in rent and $100-150/mo in incidentals on best case a $700-800/mo salary.
If you are a woman from the bottom half of society, like my SO and her peers - it is almost impossible to afford 8-10 years of no cash flow. If you are an 18 year old woman in the Central Highlands or the Mekong Delta, immediately working in a factory with a subsidized dormitory and food means you can immediately start sending cash to family to help them out. Alternatively, earning $15k-$20k working in the "unregulated vice industry" in Singapore, South Korea, the UAE, and others starts looking extremely lucrative (usually referred to work there by that snaggle tooth guy I mentioned). Best case, you get an arranged marriage with someone in the diaspora in the US or become a "Viet Bu" in Malaysia or Singapore.
My SO was literally the only person from her social class at her medical school (Vietnam's equivalent of Harvard Med) - everyone else were the children of doctors, bureaucrats, diaspora Vietnamese, businessmen, MPS officers, and other crème-a-la-creme of Viet society.
For people in my SO's case who somehow even make it to medical school, they all try to leave to practice in Japan (which my SO did), Taiwan, South Korea, or the US as soon as possible becuase it is the only way they can even recoup the cost. And this is exacerbating the medical health crisis in much of Vietnam, because a rural government doctor in a village like my SO's (if they are lucky enough to even get a doctor) would earn a $100-200/mo government salary that is almost always late.
Like, there are massive issues in the US, but to even compare the that to those faced by the bottom half of a developing country is legitimately out of touch and actually insulting as it trivializes the pains billions of people face across developing countries.
I will spare you the ethical and moral reasons, and give you a practical one.
Private healthcare, being a business, cannot afford the investments of public one. Instead it operates following the Pareto principle where 20% of services and treatments cover 90%+ of patient needs.
Now this works with much joy over most of your life, but there are just too many edge cases over a life time where this will screw you.
E.g. A close friend of mine gave birth in a private clinic. The most luxurious one with almost a dozen people following her.
All of this: pointless. Her child had complications minutes after birth, and no single private hospital in our country has a pediatric intensive care unit, or, to label it more correctly a pediatric _reanimation_ unit.
The only private hospitals that do? University ones, as they operate on slightly different financial basis and incentives.
This goes beyond this example I have. It doesn't matter if you're in a country with good private healthcare (e.g. Switzerland) or a crap one, public healthcare is accepted to be a money loser for the greater good and will cover more services. Always.
Mind you, I'm not saying that a single public hospital will offer everything and private is bad, just stating that there's many situations where it's easier to find the service offered in public rather than private health care.
The only ones that do are all university hospitals and they only do so because they operate on a very different financial non-profit model.
And I'm talking about Switzerland.
PICU isn't just an example of service and treatments where even very very rich countries with quality healthcare are relatively uncovered compared to much poorer countries with public health care.
It's not even the happiest one, because PICU is still "relatively" common, so I don't want to focus on it.
Other examples of treatments that are relatively common in public health care are organ transplants, ICU for infective diseases, post trauma (stroke-like) rehabilitation are just some of the examples of treatments you're gonna find in many public hospitals in a country but extremely rarely in neighboring countries with excellent private healthcare.
I understand medicine is slightly different but my hunch is that any sufficiently smart person can do well enough as a doctor after 1-2 years of theory.
This might anger a lot of people because there’s a trend where we elevate medicine and doctors to a godly level.
Thankfully with the internet and AI, knowledge is not gatekept as much now.
I wish we allow more people to become doctors and intelligent people to become doctors. The type of people who choose to become doctors are not problem solvers, at least from my experience.
Of course my argument doesn’t work exactly for surgeons but I think we should not artificially reduce their numbers.
The far left Democrats have consistently blocked such proposals, usually without so much as a hearing.
Forget other countries, they won’t even let health professionals from the United States practice. I believe this is true of several large state Democratic parties.
There should be a good career ladder for nurses to become actual doctors if they perform well on the job. No need to gatekeep now that we have AI and internet.
The numbers don't back this up. https://www.cms.gov/files/document/nations-health-dollar-whe...
> There should be a good career ladder for nurses to become actual doctors if they perform well on the job.
Again, that's most frequently called becoming a nurse practitioner.
Look at the buckets: Things like Dental Services, Home Health Care, Nursing Care Facilities... This tells you about healthcare spending at the macro level, but doesn't explain why a particular doctor visit cost so much (I don't use any "nursing care facilities" or "dental services" when I visit the doctor for a sprained ankle, for example).
When you go to the doctor for a sprained ankle, where does that money go? By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan). Where does the other 85% go? Certainly some it is the cost of running a clinic (staff, rent, equipment, etc), but what about the rest?
Then look at doctor's income. Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more. Where do you think that money comes from?
That's quite a bit to a middleman.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6179628/
"According to Reinhardt, “doctors’ net take-home pay (that is income minus expenses) amounts to only about 10% of overall health care spending."
It's also a big incentive for the insurer to increase prices. If they want more revenues, and more profits, they have to get overall spending to go up.
> Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more.
Good. They should.
I'm aware of two huge exceptions that are large enough to make this basically not-true.
1) This doesn't apply when they're administering a self-funded plan, like most plans provided by large companies. This represents a giant chunk of US health insurance.
2) This doesn't apply to new plans (I believe in the first two years of operation). I admit I've not looked into it, but I'd be shocked if this isn't being gamed such that a fairly high proportion of plans that aren't excluded by #1, are always "new" and so not subject to those limits.
Personally, I would always rather see a physician due to how much more training/experience they have. A physician who's out of residency will have gotten at least 3 years of on the job training (after medical school). A nurse practitioner may have just gotten their BSN and then gone straight into an NP program without ever working a single day as a nurse.
But yes, you're right, this person is absolutely describing NPs.
There's a very good chance, if you're seeing a NP, that the NP has a lot more experience with that sort of condition than the docs. After all, the practice is sending those sorts of issues to the NP. My dad's a radiologist, but they haven't assessed a minor break in decades, because they're very subspecialized.
If it's unusual or complex, the NP is probably the first to say "we'll need to make an appt with Dr. So and So".
The first chart includes "private healthcare insurance" as an input, so I'm pretty sure you're wrong.
The $4.9 trillion detailed in this chart is "the official [estimate] of total health care spending in the United States". https://www.cms.gov/data-research/statistics-trends-and-repo...
Unfortunately, right now, it is difficult for doctors to do so much as move to and start practicing in a different state. But if you want medical costs to actually come down and to ensure availability, you need to multiply the number of doctors available to treat people.
It matters how much they add to the cost.
Typically, "margins" means the profit they make over and above expenses. For insurance companies, the salaries of all the people they employ, and the rent/mortgage/upkeep on their buildings & grounds, would all be classified as expenses that would not generally be included in their margins.
But in a single-payer system, none of that cost would even exist. We have to pay for all of that through our premiums, and we get nothing out of it.
2. Single-payer systems still have administrative costs. The administrative cost of running England's NHS is not zero. But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.
3. Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
Which means, of course, that their main option to increase profit is to increase overall spending on healthcare. Reducing cost is directly against their interests.
UnitedHealthcare buys up physician practices, and pays theirs higher rates. That's part of the 85% bucket, but they're profiting off it. https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...
> Single-payer systems still have administrative costs.
https://www.healthaffairs.org/do/10.1377/forefront.20110920....
"According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue. Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower."
> Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
I mean, that's a start.
If you chart the US against the rest of the OECD, we're doing something bafflingly expensive versus everyone else. It is certain to be multi-factorial, but our insurance setup absolutely plays a role. https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
This is only true if you assume that health insurance companies have no influence on the cost of care. That is, however, patently false.
We create these roles and gradually give them more and more autonomy precisely because we can't agree to produce (or import) more MDs. MDs actually see the writing on the wall, too. Their lobbying organizations are strenuously opposed to expanding NP and PA roles.
And how many people are at risk of dying if you screw up at your job? My guess is exactly 0.
I can’t prove this but my intuition says that you don’t need this high of a barrier.
I think you're vastly underestimating the complexity of the human body and the amount of education necessary to do a good job as a physician.
Medical schools care whether you got an A or B in your undergrad physics-for-life-sciences lab (I know this because I had to deal with annoying grade-grubbing pre-meds as a TA for that class). I would feel 100% comfortable with being treated by a physician who "only" earned a B in my undergraduate physics.
Medical schools also care about how many hours of volunteer community service you do. So, I guess all the applicants who had to work a job through undergrad can just go fuck themselves.
You might start by asking why medical schools care about such silly things. It's such a strange metric! The answer is that medical school collude to limit the number of doctors (so that we don't have "too many"!). Since the quota is so low, they have an enormous ratio of qualified applicants to seats. , So, they need objective criteria to pick some people over others. A or B in undergrad physics (or number of hours of community service) is an objective, quantitative way to cull the herd of overqualified applicants.
Personally, I always thought a better solution would be to have med school applicants roll a die. While I would be 100% comfortable being treated by someone who earn a "B" in my physics class, I'm not sure I want an unlucky surgeon operating on me.
I don’t think having to study for 10-15 years to become an MD reflects in the marginal benefits. A couple of years is probably all you need.
That said, I think that a RN -> NP career track with some kind of "executive NP" program (analogous to "executive MBA"), followed by supervision under an MD and eventually graduating to full autonomy, is an interesting idea.
I think this sentence shows that you don't really understand the difference between the two jobs. Nurses and physicians have wildly different training/education. There are things about the body that any first year medical student could tell you, that nurses never learn even after decades of experience (because they don't need to).
I spoke to to the eye surgeon's billing department and the same happened. How the F* can it be like this? To top it off, I just got a bill for $300 after paying $1300.
The system is completely broken.
A poor, uninterested, or other valued[1] person would only sacrifice $N to improve their health beyond "still alive". A rich person, or highly interested, or other valued[2] person would sacrifice potentially many multiples of $N.
Take Bryan Johnson[3] for example is willing to spend on many improvements to his life. For example, in Canada he'd be basically unable to do what he wants to do with his own money.
As one such person I am happy to pay more for more. What I really think is needed here is improvements in contracts and transparency. For example, there should be a contractually binding price agreement (of which the prices themselves are publicly available to all including competitors) for any non-emergency non-urgent procedure. (If time is of the essence then we need to prioritize that, naturally)
As an example of being willing to pay more, my insurance isn't willing to pay for the exploratory labs, and software platform, that function health built and provides for $499 a year. I'm willing to pay it, it has benefitted me over the standard annual physical, and to me it was worth $499. It also likely will save my insurance $1000s maybe $10000s over my life time too. (We discovered something concerning...)
[1] - (eg a father who prioritizes spending on their kids) [2] - (eg a father who prioritizes being there for their kids later in their life) [3] - https://youtu.be/pfSFnFWb8X4
Yeah, nice headline!
In the US, a majority of large employers don't buy insurance in the strict actuarial sense. They self-fund health benefits under ERISA, paying claims directly and hiring insurers only as administrators (ASOs). The plan may contract with an insurer (e.g. UnitedHealthcare, Aetna, Cigna) to process claims and run the network, but for most employees at large firms, the insurer is not actually insuring anything. Self-funded ERISA plans are regulated by the US Department of Labor, not state insurance commissioners.
The system is beyond silly in pricing.
Another prescription had a 10$ copay since it was just a generic drug. Again I requested please don’t run through insurance and the rx price was 4$.
I did a deep dive into understanding how prescription pricing works in the US, long story short it is insanely way too complex and for profit private health care insurance is not good for the health of the population.
* https://archive.is/https://www.noahpinion.blog/p/insurance-c...
Occasionally, you get situation like Nvidia which has huge margins because their competitors don't know how to make a decent product.
They (easily) found someone who will see them out of pocket. It's not a supply issue in this country, it's an incentives issue.
I think we can assume that no matter what your political persuasion, in some sense the government is ultimately at fault, either for overregulating or for allowing for the existence of privatized healthcare. As such, it needn't be said, and we can focus the conversation on the proximal rather than ultimate cause.
2. Repeal the ACA mandates and enact interstate laws which permits low-deductible, low mandate policies along with reintroducing catastrophic insurance. The current status quo forces young people to pay for old people and those less responsible with their health. What we have now is prepaid medical care, not insureance. This also removes the insurance monopolies states and companies have created together.
We have the worst of all possible systems at present.
Mark Cuban had an interesting proposal to this effect. https://x.com/mcuban/status/1934834421225672999 . A combination of tax subsidies and debt forgiveness that cuts out insurance companies altogether.
I was half expecting there to be something in here about the average that employers were spending going down to justify the headline but that was nowhere to be found.
> "It's kind of hidden, because [premium deductions are] coming out of your paycheck and if you're not paying close attention, it may not be obvious,
I have to ask, who the hell is not looking at the amount that is coming out of their paycheck when it comes to open enrollment? Sure you may just accept it since what is your choice, but I think the systems I use generally show how much it is going to change.
Am I just becoming more sensitive to clickbait that outright lies or are headlines getting worse? Nothing in this article justifies any blame to your employer.
Multiple discussions this week:
Health Insurance Costs for Businesses to Rise by Most in 15 Years
https://news.ycombinator.com/item?id=45212976
Americans face biggest increase in health insurance costs in 15 years
There are two sides to this. The first is, hospitals are owned by investors, and have to increase profits. The typical playbook of trying to acquire at least a local monopoly to price-fix is in play everywhere.
The other side is: to achieve high profit margins chase wealthy customers and cater to their preferences. Headhunt star staff with increased salaries. Build shiny new hospitals and prioritize private rooms (HIPAA provided a great excuse here). To woo investors turn administrator into a CEO position with commensurate pay.
None of this incentivizes providing quality health care to non-wealthy people at a fair price. It incentivizes trying to get rid of lower income patients as quickly as possible to make room for high income or well insured patients who can be billed more.
Same as housing, this issue is everywhere in the western world. We can try to tackle it by itself (transparent pricing would probably help a great deal), but the root issue is bigger: the rich are getting what they want on both sides of the equation. They don’t want affordable healthcare.
Saddens me to think about, but imagine if American healthcare and innovation was nearly as "free market" as smart phones, LLMs, etc.
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
> Saddens me to think about, but imagine if American healthcare and innovation was nearly as "free market" as smart phones, LLMs, etc.
That sounds horrid.
Cheaper, universally accessible, and same outcomes seems more efficient, yes?
That said: https://cepr.net/publications/can-we-just-admit-were-wasting...
> Traditional Medicare has significantly lower administrative costs than private insurance with 1.1 percent of spending in 2024 going towards administration compared to between roughly 12-18 percent for private insurers in previous years. Coincidentally, the bloated administrative spending of American health care is one of the factors contributing to why the United States spends around twice as much per person compared to other developed nations even though we have worse health outcomes.
The food system is basically a free market (with some weak safety regulations). The apparent end-state of this free market that America has arrived at is tragic. Sure, people like me are free to select healthy, nutritious food at reasonable prices, but at a population level, 70% are overweight and 30% are obese, with all the risk and disease that comes with that.
This is where free markets (in necessary goods) tend to end up. Perfect for ensuring the concentration of capital, disastrous for the average consumer (and never mind the “externalities“…)
> That's because employers will be paying a lot more
> Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care
> more people are going to the doctor or other providers. But that surge in demand has also led to a surge in prices.
> Last year, the average U.S. employer spent more than $19,000 per employee to provide family coverage while the employee kicked in $6,000,
Why should health care ever get cheaper? Americans treat our bodies like garbage bins for sugar and fat. Old people spend 100ks just to die in a hospital 3 months later. The narrative is always that some rich dude did it to you though?
But they don't seem to do that.
Even this isn't so simple. Foods in America are engineered explicitly to increase consumption, often (but not exclusively) by increasing fat, sugar, and salt. A good example of this is bread, as most breads sold in the US would be classified as cake in other countries due to the added sugar.
The only way to avoid this is to make your own food by scratch, which simply isn't viable for a large population living paycheck to paycheck.
