Medicare might not technically be a monopsony, but it acts like one, and all the rest of us working folks end up paying the gap that rounds out the rest of the costs.
We have a few generations that have had easy lives, where they had easy access to homes, to higher education, to wealth building, and decided to cut off access to the same as soon as they got it, while still living off the labor of current working people that are not even allowed to build new apartments next to these wealthy people while they pay for all their health care.
The economy is a massive multiple player rpg with a point system economy that's fixed by federal and state laws, and it's been rigged both at the health care level and at every level to extract wealth for those that had it easy in the past.
That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Another part of the problem is the bloated administrative bureaucracy of hospitals in the US, we well as the fact that you aren't allowed to build a new hospital (and yes, this is actually true) unless you can prove that a hospital is needed in a particular community.
With no competitive market for healthcare providers, nor a competitive market for places where they work, why shouldn't they extract as much as they can from the rest of us?
They get away with it, too, because "medical doctor" is one of the highest trusted and most reputable professions. It's badthink to discuss these things in polite company.
Until we fix those things, it simply doesn't matter how the insurance/payment system works. Every time I hear that we need to get rid of private insurers, nobody can seem to explain how doing that will save more than 10-15% despite the fact that insurance companies have a statutorily-limited profit margin.
I agree that certificate of need laws should be repealed to increase competition between healthcare facilities. That only impacts some states, not the whole country.
https://nashp.org/state-tracker/50-state-scan-of-state-certi...
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
While many specialties are fully filled, we need pediatricians, family medicine, and internal medicine docs. They're generalists and where the largest shortage is. There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
You lost me...from your cite[1]:
| Specialty | Positions | Applicants | Matches | App/Pos | Deficit |
|-------------------|-----------|------------|---------|---------|---------|
| Pediatrics | 3,135 | 3,998 | 2,988 | 128% | 4.7% |
| Family Medicine | 5,357 | 7,337 | 4,552 | 137% | 15.0% |
| Internal Medicine | 10,941 | 17,131 | 10,584 | 157% | 3.3% |
Aren't a lot of these shortages scattered around rural areas where young doctors really don't want to move to? I understand from a buddy who is currently in med school that there are all sorts of incentive carrots being deployed to attract doctors to these underserved communities.
[1] https://www.nrmp.org/wp-content/uploads/2025/05/Main_Match_R...
https://www.nrmp.org/intro-to-the-match/how-matching-algorit...
Basically, you interview at a bunch of programs and then rank them. The programs (hospitals) rank applicants and then the algorithm does its magic to "match" applicants to programs. Now, if one doesn't match with any of them, there's something called the scramble where a med student works with their program to match into a program somewhere in some specialty that has room. This is non-ideal, but can work out.
Generally speaking, the match algorithm is setup to guarantee all U.S. medical school graduates a match somewhere in something. In may not be what you want, but you will have a job. Then, preference is given to things like the island schools (affiliated medical schools in the Carribean, which are very expensive, but somewhat easier to get into), and then to other international medical schools. Somewhere in there are also foreign physicians who want to work in the U.S., but are forced to redo residency.
I don't know everything about how it works, but that's the general idea. To that end, I don't fully understand the stats you pulled from the reference. That doesn't mean they're not valid, but I don't know.
And, yes, often times, there are open slots at some program in the middle of nowhere. As much as there can be incentives such some debt relief by working in rural hospitals, the jobs are not a good fit for a lot (most) people. I mean, someone just worked extremely hard for 10 years or more and you want them to go live in a town of 10k people. It's not that it's not important, but you can't force people to do it and it takes a particular personality to be happy there. A lot of highly educated people want to live in urban centers with amenities. Not all, but probably most.
Places like Canada use their foreign docs to fill this rural gap. A not small number of the rural docs are foreign born and trained and they essentially work this crappy jobs until they have permanent residency and then they move to more desirable markets. It's a trade, I guess, but there's not a small amount of resentment about it.
I very much agree that pay is a barrier to entering specialties like family medicine. Though it depends on the market, I normally see family medicine at around $200k/year and that's not great if one needs to take something like $750k debt to get there along with eight years of training after a bachelors. If we want to fix that, then we need to make the value proposition better and reduce the medical school debt, improve working conditions, and/or increase pay.
So, yes, if one wants to maximize their earning potential, then they need to enter one of the specialty residencies and fellowships. Those are currently filled. However, that's not where the biggest need is and I contend that's not why there's a physician shortage.
Odd how the most popular programs in the US, social security + medicare, are the ones with zero means testing.
Maybe let's not blame one of the few only noble professions left in our greed fueled world.
Blame the hospital administrators or pharmaceutical reps before you start blaming doctors.
Health insurance companies have profit margins around 5% or less. Hospitals are half that. A Subway franchise has a higher profit margin. That’s just not where your healthcare dollars are going.
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
That is not to say the adjudication process is done well. In fact, it is hugely wasteful, either intentionally or unintentionally, and the problem is that the government does not audit the insurance companies often enough, nor does it levy penalties sufficient to incentivize proper and efficient adjudication.
The government should be doing constant random checks on claims to see if they were processed and adjudicated in a timely and efficient manner with a sufficiently low error rate on behalf of the adjudicators, and the government is basically doing none of that.
Who gets more and who gets less depends on who has political power (that's why the old and non working get subsidized by the young and working), and in a democracy, this question ultimately comes back to the voters.
Bottom line is due to demographics and restrictions in the credentialing process (including for medicine itself, one of the costliest components of healthcare), there is nowhere near enough supply of healthcare relative to demand, AND due to the enormous damages awarded in lawsuits in the US, the cost of liability protection is sky-high and increases prices for every step of the healthcare chain.
We need way more healthcare providers, and tort reform, and publicly funded medicinal trials, and without that we will continue to limp on with this bureaucratic maze to essentially reduce demand to manageable levels.
>hundreds of billions in profit that health insurance companies extract
yet no request for evidence?
Here's data for medical loss ratios:
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
Here are the sub 5% profit margins for the publicly listed insurers. On the same website, clicking on the "Revenue & Profit" tab will show you that all of the health insurers, combined, earn less than $50B of profit per year, and most of that is probably not even insurance related since a large portion comes from UNH's enormous healthcare provider business.
https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...
https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...
https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro...
https://www.macrotrends.net/stocks/charts/ELV/elevance-healt...
https://www.macrotrends.net/stocks/charts/HUM/humana/profit-...
https://www.macrotrends.net/stocks/charts/CNC/centene/profit...
https://www.macrotrends.net/stocks/charts/MOH/molina-healthc...
The above obviously does not include the many millions of Americans covered by non profit insurers, such as Kaiser Permanence, Providence, Cambia, and the various Blue Cross plans.
Here are the 5 year returns for the above businesses compared to SP500:
https://i.imgur.com/S8bNSM2.png
Suffice to say, you would not want to be a shareholder of a health insurer.
Doubt.
> That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Now explain this trend[1].
Physician pay depends on specialty, but it can range from the low $100kish mark for pediatricians to $500-750k for certain kinds of surgeons. Family medicine tends to be around $200k. However, this amount ranges vastly by market and top pay often goes to those willing to work in more rural hospitals because no one wants to. For example, pay in NYC for physicians is appalling low compared to the rest of the U.S. market. In addition, certain systems have hard caps. For example, the VA hospitals cap physician pay inclusive of bonus at $400k. This is documented and you can in fact just look up a random doc at the VA with one of the many federal pay search tools.
While some doctors can make more, it typically because they own a practice and that increased pay comes from good old fashioned capitalism. Meaning, they tax the amount their nurses, NPs, medical assistants, etc. make just like all businesses make money per head on their employees. Whether you believe this is right or wrong is up to you. However, this is not any different that someone who runs, for example, a yard care business. More accurate pay can be found by those who work directly for large hospitals.
Next, the cost of medical education in the United States is vastly higher than other countries. Right now, medical school will cost you somewhere from $400-600k. This is in addition to whatever debt accrued during undergraduate. Further, medical school applications are highly competitive, so students often accrue additional debt by completing a masters in something like public health prior to entry to medical school. This means that someone may have upwards of $750k of debt when they finish medical school, but they still have somewhere between 3-10 years of residency and fellowship before they make attending money. During this time, the debt accrues interest and balloons.
Now, once you become an attending, you're still not good and expenses are vast. Shift work can vary from something like 7 12-hour shifts in a row for intensivists to 14 shifts in a row for hospitalists. Note, just because it says its a 12-hour shift doesn't mean you work 12 hours. They still need to chart and bill and if it's busy, that may be another few hours after the shift is over. In some remote clinics, an ER physican may work 7 24-hour shifts in a row. That may sound absurd and unsafe and it likely is, but it's the reality of the work. If someone is working that schedule, they have increased expenses to just, frankly, live. On the low end, it's very difficult to cook in that environment, so you have to buy a lot of premade food. On a more expensive end, having children on this schedule is extremely difficult. You either require a spouse that doesn't work or you need something like a night nanny. If you're working 12 hour shifts, you must sleep at night and you can't be up to take care of a baby otherwise you run the risk of killing someone the next day. Unless you're paying someone under the table, current nanny rates in large markets are about $20-25/hour. Insurance rates are also high. I don't mean malpractice either. Generally speaking, one needs to carry disability insurance because if one gets into a car accident and breaks their magic hands, there's no way to pay back that debt otherwise. These policies are thousands a year. That's just the start. They pay a large amount of money to buy their time back because they don't have it.
Next, there's a myth about limiting residency slots in order to increase pay, at least recently. I will not defend the AMA and some of they took, especially in the 1990s. Here's the 2025 residency match data:
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
The number of offered and filled slots is on page 2 (or 13 depending on how you count). Some specialties filled all of their slots. Where the U.S. vastly lacks is pediatricians, family medicine, internal medicine (who can work like family medicine if need be.) Pediatricians had 147 unfilled slots. Family medicine had 805 unfilled spots. Internal medicine had 357 unfilled spots. These spots can be filled by people who graduated from U.S. medical schools, island medical schools, Mexican medical schools, or a vast array of other foreign medical schools. However, they're not filled because they don't have the applicants. That's not medical school collusion. That's the hard reality that medical school is extremely expensive and the training is extremely long.
Now, how do other countries handle things? One, their medical school is not as crushingly expensive. Two, places like Europe cap the number of hours a physican can work. If you want to pay American physicians less, you'd need to blow out their medical school debt, reduce their hours, and offer better benefits. Until then, no, really, they're not overpaid.
If you want to start pointing fingers, try the vertical integration of insurance companies, pharmacy benefit managers, and hospitals. I don't have the numbers readily available, so I'll stop here. But, really, it's not the docs.
State Medicaid and Workers Compensation funds were already insolvent before the 2024 election, and as such most states lack the fiscal overhead needed to fully support a fully funded single payer program today.
It would end up the same way the NHS has in the UK.
Vast swathes of the US are deeply fiscally troubled due to the impact of the COVID pandemic, and if that is not solved then we cannot even start to contemplate single payer.
This should not be used to justify austerity which is not the answer and does more harm than good, but points out that a reckoning is needed. From my personal experience dealing with the current crop of state and local politicos, it's looking dicey in portions of the US.
Edit: can't reply
> Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever
Yes. But you need capital to build an insurance fund. And a large portion of that is going to service existing liabilities.
The core issue is it suddenly destroys a large number of companies and removes millions of unnecessary jobs from the economy. That’s a great deal of wealth and a great number of voters who don’t want you to save hundreds per month by making them redundant.
I'm also skeptical about putting the federal government in charge of establishing standards of care. We already see that some medical conditions have been heavily politicized by certain patient interest groups. And while evidence-based medicine is great, we still have nowhere near enough data to establish clear clinical practice guidelines for medically complex patients.
Utilities have had complete regulatory capture of most states' Public Utilities Commissions. It's blatant and obvious in places like Arizona that have open corruption in their elections and commission decisions. But in places like California it's far more hidden: the massive increase in cost of utilities is mostly from increased costs for the transmission and distribution grid, but CPUC has basically zero information for the public to understand why they keep on handing over more money to the big utilities. There definitely seems to be massive corruption but where is it and what is the actual mechanism? It's so well hidden and sophisticated that if there is corruption nobody understands what the F is going on.
How do you replace a state-sponsored monopoly like a utility into something competitive? I don't know, when I learned econ 101 utilities were given as the example of a "natural" monopoly. But clearly that's not working out... maybe it just needs to be "state" rather than "state sponsored monopoly." The only other state sponsored monopoly we really have is the state itself. What does the public gain by allowing monopoly utilities that giving away the public's money to investors? The incentives are all off.
Between ghost networks, death panels that deny you treatment, and the nature of deductibles, you have no fucking idea what you're buying, and whether or not you're getting ripped off.
> "The largest increase by a wide margin was for employee health insurance, which saw an average increase of 14.2 percent among manufacturers and 12.9 percent for service firms"
> "The next largest cost increase was for utilities, which climbed by 8.5 percent over the past year for both types of firms, with about 15 percent of all respondents reporting increases of 20 percent or more"
> "Business insurance—which includes liability, property, auto, and workers’ compensation, among other things—climbed by about 7 percent, on average, for service firms and by 7.5 percent for manufacturers"
I alluded to this before on HN [0] - much of the insurance woes faced are the legacy of the COVID pandemic, as a large portion of workers compensation funds are insolvent and healthcare pools are heavily stressed, leading to perverse incentives.
My car insurance went up 30%, in one year. Tried pricing around and it's not much better. Took an online "safety class" and got an 8% discount.
Edit: can't reply
> This started decades before COVID, and has been summarily ignored for the entire time. We’re still insuring properties in areas we known sea level rise and climate change make uninsurable
It's not property insurance that's causing the issue as I as well as the article pointed out.
The market isn’t going to correct itself now that we have enough data to know where to squeeze next, and how hard it can go. The only way to unwind this disaster is meaningful regulations and wholesale reforms.
* Stop tying healthcare to private insurers and employers. State-level single-payer models by default via fixed payroll deductions per employee, and let the government dictate or negotiate costs.
* Re-work incentives for efficient utility usage. Incentivize self-generation for power through lower electric rates if a certain percentage of your consumption is generated on-site, for instance. Also, stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
* Those insurance rates keep going up because healthcare continues rising and repair costs are increasingly more expensive or on par with replacement costs. Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
* Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher (along with costs to replace those wages from injury or loss via insurance schemes) until and unless we actually address the underlying crises. This means lowering housing costs, lowering rent, lowering transit costs (either through cheaper cars or expanded public transport, ideally both), lowering food costs, lowering utility costs, lowering healthcare costs, lowering childcare costs (universal childcare or incentives for more single-earner/single-income households), etc.
This report hits the highlights, but this is a huge issue that’s only going to get worse if we don’t start seriously addressing the myriad of root causes.
Most state-run workers compensation and Medicaid funds are already insolvent. Until that gets resolved, no attempt at creating a single payer fund is possible.
> stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
Most DC projects in the US have already integrated renewable and battery storage systems thanks to Biden-era subsidizes and capacity building.
Utilities are using data centers as a scapegoat - the reality is most are stuck with fiscal liabilities due to COVID along with insurance and raising prices as a result.
> Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
I support right-to-repair at a personal level as a tinkerer, but that wouldn't move the needle for the insurance problem.
The big issue is the COVID pandemic era liabilities that continue to require to be paid out to this day.
It's the same for workers comp as most workers comp funds are already insolvent.
> Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher...
Becuase that's not something that dramatically impacts the bottom line in most industries - most businesses can afford increasing salaries a couple dollars an hour by reducing capex next year, reducing hours for existing employees, or moving employees to the salaried bucket.
But if my insurance premiums are constantly increase by 7-20% YoY it becomes difficult to manage.
Edit: can't reply
> What do you (sic) proscribe as a solution then?
F#ck if I know.
This is a polycrisis, and each state will have to solve stuff individually because of the federal nature of the US. The pandemic was brutal and we're still facing feeling it's reverberations to this day.
[0] - https://oui.doleta.gov/unemploy/docs/trustFundSolvReport2025...
This hits TFA's culprits, rising insurance and utilities costs. They're just the symptoms, not the source.
Until the early 2000s, things were built to last, solid build, simple.
Now, even fridge has AI in it like what the actual f!!! Cars are tablets on wheels, Tesla and others, rather than just being cars.
And this weird desire to please modern audience costing movies, products, videos games billions of dollars, closing studios thousands of jobs lost unable to make the investment back as consequences and yet, companies seem to do not read the room.
Narrow banking now.
This is something the Federal Reserve can actually fix. Give every single US person (I am not a lawyer and I can't define what counts as a US person) a fee-free bank account with the Federal Reserve. Cut out the middle men of commercial banks. I think that alone will go a long way to drive down business costs.
What you said, fee free banking + KYC + free instant transacting is something we definitely need, even if it hurts JP Morgan Chase a little bit.
Never, ever going to happen.
