Comment by drawkbox | Hacker News Reader

Comment by drawkbox | Hacker News Reader

Health pricing is a weird fixed pricing with all sides in insurance companies, medical suppliers and doctors holding the cards to get the highest prices within the gamed rules with the consumer left out in the cold and each bill a random output that is rarely known beforehand.

Part of the problem is healthcare provided through work that skews pricing for large companies over individuals/small/medium businesses and entrepreneurs.

If we can't get healthcare removed from employers and have both a private and public option based on Medicare for all. We AT LEAST need legislation to bring in CLEAR pricing for insurance cost and non-insurance rates, similar to the CFPB mortgage Loan Estimate and Closing Disclosure that show all pricing clearly in one sheet of paper both the estimate and the final mortgage.

What other product do we buy that the price is not known until after the product/service is rendered? At least some idea of an estimate is even hard to get as each part of the medical pricing matrix scam (insurance companies, medical services/suppliers, doctors, pharmaceuticals) try to keep pricing shrouded to stick it to people wherever they can.

The consumer healthcare experience is horrible in the US healthcare system and employers being the insurance companies main customers is a major part of this problem but pricing can be helped with clear regulations and needs to be now.

I don’t disagree with your sentiment, but a major problem is that the US healthcare system’s function (or lack thereof) is based on price discrimination e.g. the list price for a doctor visit might be $150, the doctor gets reimbursed $15 for a Medicaid patient, $60 for a Medicare patient, $90 for privately insured patient, and a $135 for a cash pay patient.

It’s a lot like college tuition - there is a sticker price - but very few student’s actually “pay” the sticker amount, or the same price for that matter

At the end of the day the core problem is that price transparency and price discrimination are at odds with each other...people don’t like being told they have to pay more for something because of “who they are”

I think the reason meds are expensive are completely different why doctors or hospitals are expensive in the states. While all of those things happen because the system has no desire to be cheap and free market forces do not happen they are all different and need to be fixed individually.

> I don’t disagree with your sentiment, but a major problem is that the US healthcare system’s function (or lack thereof) is based on price discrimination e.g. the list price for a doctor visit might be $150, the doctor gets reimbursed $15 for a Medicaid patient, $60 for a Medicare patient, $90 for privately insured patient, and a $135 for a cash pay patient.

But all of this price discrimination is bad -- it's hurting everybody. Medicaid and Medicare patients paying less causes more doctors to not accept them. Privately insured and uninsured patients paying more imposes costs on working people and small businesses who have to subsidize a government program, not through taxes in proportion to their revenue or wealth, but through higher insurance premiums in proportion to their number of employees regardless of how much the employees make.

Eliminating that sort of price discrimination would solve a significant portion of the problem by itself, by eliminating that cross-subsidy and requiring government benefits to be funded overly and by the people who can afford to pay rather than covertly through higher private insurance premiums on people who can't.

In my view, understanding the flow of money in the health care system will be impossible until the system is wholly owned by the government. This may be the primary reason why health care in most civilized countries costs half of what it does here. Until then, everybody who's gouging us accuses everybody else of being the ones who are gouging us.

You should consider the possibility that you have the direction of causality reversed there.

Considering ... done. Comparison with other countries says: Not reversed.

Trying to parse your suggested reversal. Do you mean "health care in most civilized countries costs half of what it does here system is the reason it is government-owned in those places"?

Leaving aside from the fact that very few countries have wholly-government owned health care - this formulation doesn't make sense.

Or is it the line about gouging you are referring to?

Can you explain a bit more clearly what your point is? I haven't woken up enough yet to decipher your comment.

Certainly, and I apologize if my brief wording wasn't clear.

> This may be the primary reason why health care in most civilized countries costs half of what it does here.

There is a common conception that simply adopting one of the many different systems used in these other countries would immediately solve the cost problems in US healthcare by way of single payer price negotiating, but the problem that addresses doesn't tell the whole story of high healthcare cost in the US.

It's not just US healthcare costs that are abnormally high but healthcare consumption - due in part somewhat to the defensive posture of medicine towards a tort heavy society, but also because healthcare consumers in the US simply demand more healthcare than consumers in other countries; (call it the Super Size Me effect?)

So it's not necessarily the case that any kind of single payer system is going to change that culture of consumption. The systems used in other countries are largely possible due to different levels and modes of consumption.

Mind you, I generally support some kind of single payer system for the US (preferably modeled after some combination of elements from Canada, France and Australia). But I'm bothered by these panacea arguments when it doesn't seem at all clear that such statements of causality can be convincingly made.

The most frustrating issue with the Bernie Sanders single payer campaign is that they flat out lie saying that the reason why healthcare is expensive is because it is private.

Healthcare hasnt been so expensive forever, it was actually very cheap decades ago, when it was still private. The efficiency issues are not public vs private. Its mostly regulatory burdens.

As someone who lives in a country where the regulatory burdens are higher and healthcare is cheaper, you are very wrong.

Share your country and I will be very much able to show you why the burden of regulation is worse in the us, at least in terms of price. And lets add one more thing: we can compare the US to itself, to 50 years ago, and show that 50 years ago healthcare was super cheap, and still private.

Yes regulatory burdens like actually being forced to cover people with pre-existing conditions, not being able to drop people once they use thier insurance and not being able to exclude certain conditions....

I'd be very curious as to what country you live in. I wasn't aware of any country with more rules around the provision of healthcare than the US has.

Most other countries have government run healthcare. By definition, they all have more government involvement.

Thats not how you measure the effect of regulatory burden on price. If the us government turned into single-payer, the doctors are still private, but the government is the insurance.

Almost all doctors in the UK work for the NHS. Most countries with single payer also negotiate drug prices and reimbursement rates. So how would you have the government setting prices and reimbursement rates and not have a higher "regulatory burden"?

How could that possibly be a free market system/.

> Most countries with single payer also negotiate drug prices and reimbursement rates

The government itself barred Medicare from negotiating drug prices. If it is incapable of overturning such a policy, why should it be entrusted with 10x more patients?

> So how would you have the government setting prices and reimbursement rates and not have a higher "regulatory burden"?

You could have the government give a health-stipend for insurance for all americans, so its government funded, kind of like school vouchers. Today medicare instituted fee-for-service, which means you have to document every procedure you do and you get reimbursed based on that, which I believe is the core reason why there is so much red-tape in Healthcare.

This would allow all patients to choose which insurance fits best, and unleash major competitive forces on price.

> The government itself barred Medicare from negotiating drug prices. If it is incapable of overturning such a policy, why should it be entrusted with 10x more patients?

The political faction which opposed and supports the policy you point to does so for precisely the same reason it is opposed to the faction proposing single payer; people voting for the faction that supports single payer would also vote out the faction supporting that policy. So, you are literally conflating two opposing things as the same thing.

> You could have the government give a health-stipend for insurance for all americans, so its government funded, kind of like school vouchers

Yes, and if you also have the government provide a default fully-public-funded option just like with school vouchers, you will have almost exactly recreated what Medicare already does for it's covered population (Medicare Parts A & B are the public option, Medicare Advantage plans are the private options to which public “voucher” subsidies can be applied in place of the default public option.)

> The political faction which opposed and supports the policy you point to does so for precisely the same reason it is opposed to the faction proposing single payer; people voting for the faction that supports single payer would also vote out the faction supporting that policy. So, you are literally conflating two opposing things as the same thing.

I disagree, but regardless of that appreciation the problem exists today when its smaller, if you had single-payer it will be a harder problem to fix.

> Yes, and if you also have the government provide a default fully-public-funded option just like with school vouchers, you will have almost exactly recreated what Medicare already does for it's covered population

It was an example to show how high government participation can lead to low regulatory burden, not an actual intended recipe for the US and its current or proposed system.

That's an excellent example of how even government provision of healthcare can be more or less regulated. The law doesn't allow the agency running Medicare to not buy certain drugs which is the other side of the coin in terms of them not negotiating. By contrast the NIH is legally allowed not to buy a drug and uses that fact to negotiate lower prices.

Ok, that's our miscommunication. I'd say that government ownership is certainly government involvement but it's not at all the same as government regulation. Even when the government has an agency running all the hospitals you can still have a more or less regulated healthcare system depending on how many rules parliament has passed about where you can build hospitals, how you can hire or fire doctors, etc. In the US hospitals are private but possibly because of that we have a ton of rules about who can become a doctor, how medicines are made, how close you can build one hospital to another, etc that are in excess of what you see in other countries.

Also, while most countries have healthcare that is payed for by the government having the government run healthcare is also fairly uncommon. I know Canada, the UK, and Singapore have public provision but most countries have public payment and private provision.

More like burdens like limiting the amount of doctors available, not allowing the importation of foreign drugs, tying healthcare to the employer, etc.

You can manage the problem of pre-existing conditions in an insurance system with a subsidy, instead of a mandate that forces a 20 year old minimum wage person to work part time, because the employer cannot afford to pay healthcare for him.

More like burdens like limiting the amount of doctors available,

There has never been a law in the US limiting the number of doctors available.

tying healthcare to the employer, etc.

There was never a law tying healthcare to the employer. Before the ACA, if you had a preexisting condition, that was the only way that you could get insurance - by being part of a covered group. The insurance company wouldn’t cover you.

You can manage the problem of pre-existing conditions in an insurance system with a subsidy, instead of a mandate that forces a 20 year old minimum wage person to work part time, because the employer cannot afford to pay healthcare for him.

So we need universal coverage like the rest of the civilized world....

> There has never been a law in the US limiting the number of doctors available.

My understanding is that the supply of doctors is limited by the amount of residency slots and that is limited somehow by whatever professional association licenses doctors.

> There has never been a law in the US limiting the number of doctors available.

There is at least one such limits to about 1/4 of 65.000. And even within that limit they have an irrational amount of extra requirements.

> There was never a law tying healthcare to the employer.

Sorry but in the US, health insurance is provided by the employer because it is a tax-exempt expenditure. Tax it and see wages diminish considerably once employers pass the cost to the employees.

> So we need universal coverage like the rest of the civilized world....

The uncivilized world also has universal coverage. That should be a red flag, shouldn't it?

Sorry but in the US, health insurance is provided by the employer because it is a tax-exempt expenditure. Tax it and see wages diminish considerably once employers pass the cost to the employees.

Employers already pass the cost to employees through lower wages.

The uncivilized world also has universal coverage. That should be a red flag, shouldn't it? reply

Yes, that in this regard the US is worst than a third world country...

They don’t pass to the employee the marginal tax rate pf the health benefit, which by the way is a very regressive policy.

And you would be very wrong to believe healthcare in the us is worse than in third world socialized medicine countries. You will find horror stories galore as well as all other kinds of trade offs you wouldn’t accept.

This is demonstrably untrue in pretty much any other developed western democracy.

Please make the demonstration

"The efficiency issues are not public vs private. Its mostly regulatory burdens."

The phrase 'doubling down' comes to mind here.

I agree: going single-payer is absolutely doubling down. Medicare itself, today, has more patients than most national health programs like Canada, and it is also more expensive than them. We already know medicare is not cheaper than other countries health systems. And do you believe that expanding medicare 10x will make it more or less efficient? Because I believe it will do worse, a lot worse.

Rhetoric that is mostly correct.

>> In my view, understanding the flow of money in the health care system will be impossible until the system is wholly owned by the government.

To judge the correctness of your statement, just look at what has happened to other industries that the US Federal Government controls: costs rise, service times increase, quality suffers, accountability disappears, etc.

You might want to compare the cost and service from VA to the private medical system. It’s not pretty for the private sector.

Agreed. I would have no problem with the Canadian government owning US healthcare since they already own and operate Canadian heath-care and do an ok job at it. Everything the US government owns seems to eventually slide toward being a lot like the DMV.

This seems to be because people in the US don't want to actually give their government control of anything. And thus anything that is government run seems to have clauses that allow private industries control things. The worst of both worlds!

I don't think it's so much the goverment but the industry that tells the government what to do. You don't bite the hand that feed you.

If Americans really believed in the superiority and effectiveness of the private system, they'd use it for their military. Troops should have a choice of Medevac service providers!

Another hypocrisy is the insurance congress critters grant themselves while denying anything comparable to the hoi polloi.

As far as prescription drug cost, even the part of the health care system that is government control - Medicare - prescription drug prices are whatever the company sets. When Bush signed the law making prescription drug coverage part of Medicare, part of the law was that the government could not negotiate prices.

I.e. Bush gimped any controls on drug costs.

> until the system is wholly owned by the government

The thing is that single payer healthcare systems in Canada and Europe aren't necessarily owned by the government. In Canada, each province's healthcare is run as a government owned insurance company, with the requirement that everyone have health insurance. Some provinces bill this out to each insured person on a sliding scale of income, with a cut off for the low income.

> This may be the primary reason why health care in most civilized countries costs half of what it does here.

It's not, because other countries with mixed public/private systems don't have notably higher costs than the full- or primarily-public ones.

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