Health insurers just published close to a trillion hospital prices | Hacker News Reader

Health insurers just published close to a trillion hospital prices

dolthub.com

901 pointssl-dolt526 comments

I'm the author. A question I have is: how did so many prices ever get negotiated in the first place? What kind of systems are in place to do this kind of micro-negotiation?

Super curious about this, too.

Also! What did they do before they could store 100TB of pricing data? How has pricing (and care quality) changed as a result of being able to do this type of thing?

Possibly the original data is logically compressed. E.g. payer A pays 110% of our standard rates, payer B pays 85% of our standard rates. Those two rows could translate into thousands of CSV lines depending on the number of procedures.

Maybe you have a couple one off negotiations for high volume procedures, but even still the source data could be several orders of magnitude smaller than the dumps.

They are obviously not computing pricing this way. Their pricing system applies rules. But they are dumping every possible combination.

this would be a great social study. cases where technology has enabled the racketeering and price gouging by corporations with almost no gains in efficiency or output or quality or any metric of value.

Any time you can convert a problem from an `N x K` problem to an `N + K` problem, there's some asshole administrator trying to turn an `N + K` problem into an `N x K` problem. It wouldn't surprise me if there's huge amounts of redundant information in there.

> In the newly-released data, each "negotiated rate" (or simply "price") is associated with a lot of metadata, but it boils down to: who's paying, who's getting paid, what they're getting paid for, plus some extra fluff to keep track of versioning. The hundreds of billions of prices in the dataset (probably over a trillion) result from all the possible combinations of these things.

They basically denormalized all the dimensions.

Imagine you have a function which takes 5 arguments and returns one value. You could give me the source code and let me run this function. Or you could give me a mapping of every possible combination of the 5 inputs to the returned value. The former could be quite small, but the latter would be a massive number of rows.

> You could give me the source code and let me run this function

If I understand correctly, in this case, that function's source is highly distributed in wetware. It's about as closed-source as it gets; nobody has anywhere near the full source. Each hospital is its own fiefdom!

Yeah this is part of the problem.

But even if you had like 10M rows of pricing and then gave a 2% discount to entity A, 3% discount to entity B, 4% discount to C, etc.

You could publish these discount rules.

Or you could just multiply the 10M rows by the number of different entities giving 10*n M rows.

And then let the consumer of the data try to figure out the rules from the output...?

It would be interesting to see whether it's possible to reconstruct the rules by comparing the negotiated prices to a baseline like Medicare price, and doing classification into discount buckets to recover the categories insurers negotiated.

The next question would be 'how long did the average negotiation take' followed by 'how much were the average people on each side of the negotiation paid?" (or are most of these negotiations the result of computers talking to each other? Either way with a few assumptions one could make an estimate of the smallest amount these different prices cost the system. Might be huge

They aren't negotiated individually. They are negotiated categorically. They generate individual prices based on some discount rate off of a negotiated max.

The US healthcare system is wildly complicated and inefficient because it is a double-bureaucracy; pubic and private. The government bureaucracy makes a bunch of rules and also provide healthcare through Medicare/Medicaid. The private bureaucracy compete with each other, and hospitals, and pharma companies, ect.

Many of the private health providers are for-profit and lobby against rule changes that would reduce complexity and save the system money. It know this may sound glib, but if you are trying to understand the US healthcare system and something seems strange, usually it's because it makes someone money and they'll fight hard to keep it that way.

> Many of the private health providers are for-profit and lobby against rule changes that would reduce complexity and save the system money.

This is almost certainly an anti-competitive move. By keeping many rules and regulations, you need more staff to deal with them - and smaller insurers have fewer patients to amortize those salaries over.

"usually it's because it makes someone money and they'll fight hard to keep it that way"

And it's not just some money but very BIG money they make.

Canada is the only country I know of that has only one system - public.

So your claim of public + private being the issue makes no sense when almost every country has that.

Also Cuba and North Korea.

The Canadian system is a mix of private and public, with a mix of national and provincial funding, some national standards (tied to funding), and provincial jurisdiction.

For procedures covered by provincial health programs, doctors in private practice (GPs, at least some surgeons) give the service to the patient and then bill the government for that amount. For services that aren't covered by provincial health programs, GPs/surgeons bill the patient.

Provincial health care programs cover anything medically necessary. My general understanding is that you cannot pay to have a service done which is covered by a provincial health program. The intent is to prevent the establishment of a two-tier health care system.

It's probably less complicated than the US system, but it's still complicated.

My understanding (not an expert by any means) is that we basically have two tiers of negotiation - the fed. govt. has way more leverage but also some amount of corruption that goes into pricing, then afterwards individual hospitals and "networks" of providers will negotiate with the insurer - sometimes after the procedure has already happened - to figure out the final price.

The end result is that you might end up with an individual doctor having to work with the insurance company for pricing, so the same procedure can cost vastly different amounts at hospitals down the road from each other providing the same level of care. To make it worse we also have laws preventing healthcare providers from providing prices upfront, out of a fear that people will forego necessary care they can't afford.

Edit: seems like this changed 01-01-2021, now we do have some price transparency laws - https://www.cms.gov/hospital-price-transparency

> To make it worse we also have laws preventing healthcare providers from providing prices upfront, out of a fear that people will forego necessary care they can't afford.

What are these laws? This seems so backwards - I know personally I have put off medical care in my past because I had high deductible insurance, and no guarantee that the bill I'd get wouldn't wipe me out, and no way to price shop. Paralysis of unknown.

Ah thanks for making me look this up! Seems like it did change recently (Jan 1, 2021)

https://www.cms.gov/hospital-price-transparency

Now assuming the hospital is compliant the information should be available. To be fair my understanding of the argument for the old law was that you didn't want a hospital with a big sign out front saying "Broken arm repair: $10k" and having people not go in for it when there might be some financial aid they could get afterwards

I'm sure the real reason is that the hospital up the road will set up a sign "Broken arm repair: $9k" to compete and that isn't something the lobbyists want.

What I see around here are billboards with the current emergency room wait time on them in digital LEDs.

Which often struck me as kind of weird - the rooms with shortest wait time are probably most expens

It’s not the case. The No Surprises Act requires a good faith estimation for most procedures. Although IIRC it doesn’t apply to people who don’t have insurance, which seems kind of backwards as those people would likely be the most price-sensitive and have the least amount of bargaining power in the market. I guess they also tend to have the least amount of political power, too...

Are we sure they negotiated unique prices with each provider? I wouldn't be surprised if they have a dozen of templates that get replicated every time a new entity accept preexisting price sheet. Basically they have dumped a denormalized data set.

I would assume these get negotiated as a large list with each payer so if you have 500 services, and 4 payers, you probably and up with 1k-2k unique prices?

Today in Massachusetts, physicians cannot get paid unless they belong to an organization that negotiates their rates with the insurers. These negotiating entities are like unions but not really. If the insurer and the organization disagree, the insurer simply goes to a different organization to make a contract. Prices were not publicly available so each negotiation resulted in a different fee schedule. On top of that, insurers invent different 'products' with different amounts of 'coverage' for different premiums. Each of these 'products' had their own negotiation, their contracts, and their own subset of physicians who chose to participate. So what do these organizations do for the cut that they take? They reduce the burden of the insurers so they dont have to negotiate with each individual provider.

Hospitals are an entirely different system. They have much more negotiating power and if an insurer has a customer that goes to a hospital emergency room outside of their contract, the insurer has to pay outlandish rates. So it is in the insurer's interest to make a deal. They achieve this by inventing different 'products' with different amounts of 'coverage' for different premiums. Each of these 'products' had their own negotiation and their contracts.

Price transparency is the first good thing that has been mandated. However, this misses the mark. The focus is the patient, not the insurer, the hospital or the physician. Accordingly, patients should be allowed to submit their explanation of benefits and their bills-this is the data that reflects the true cost of healthcare. All of the numbers provided by hospitals, insurers and physicians has been massaged and buried in a forest of minutiae.

What was negotiated was probably more blanket style discounts like "10% off your published medicare rate for procedures in categories a/b/c" for one customer and "15% off retail price for all categories other than x/y/z but only in these geographic areas" for another customer, and so on.

But, when publishing, they omit the context and just dump every negotiated rate. Because it's technically compliant, but keeps things opaque.

This is probably the data as they have it and instead the people responsible for inputting things in to whatever system this data came from just have a little print out taped next to their screen reminding them customer XPN305 has a 10% discount on codes that start with FJR and so on.

It's an entire pipeline of billing to extract the tax benefit of insurance.

The real economy has way many more prices than this one - from each store of anything in the country that negotiates from straws to bread. The difference is that these ones happen in a system that has a paper trail from the doctor, to the insurance, and this admin burden is only (apparently) worth it because the vast majority of money in healthcare goes through tax-advantaged insurance.

Cash based payment should suffice for 50~70% of healthcare expenditues and it would have more prices and not have expensive and abusive billing processes.

There are hundreds of regional networks across the Country. Heck how many Blue Cross Blue Shields are there?

And I, as an Australian citizen, am wondering why we don't have this mess. Afaik in our system, each insurer just has one flat price for how much they cover of each procedure. And each provider has a flat price for how much the procedure costs. No individual negotiations between providers and insurers.

There is not a universal practice. Predominantly just excel, a lot of emails, conference calls and meetings. Different institutions have distinct personalities and that reflects in how things are done between them. Some people still have actual mainframes involved.

When it comes to large parties, multi-practice groups, health systems, etc, an overall fee schedule or charge master for an existing institution is typically not renegotitated line by line every year but as incremental changes from the previous. Many/most of the parties involved have been working together for decades, some even longer.

Many plans administered by familiar names like Anthem are actually funded and controlled by the large employers the plan services. In those cases the employer plays a role in defining what will and will not be covered and what will be paid and the insurer is a middleman (acting as a third party administrator).

I'm author of Hacking Healthcare for O'Reilly, 20 year health system executive, blah, blah.

It's very easy for people to forget the scale of the US "health system", we are talking 1/5, maybe more, of the entire US economy. If US healthcare spending were a country, it would have the third largest GDP in the world. Accidents of history and the massive federal beauracracy created the crazy monster of ICD/CPT codes that results in the very clumsy way of pricing healthcare services that results in this massive matrix of data.

As pointed out elsewhere there is a tremendous amount of cost distribution that goes into the code matrix and this plays a large role in negotiations with health insurers as well. Ground is given in one set of procedures and lost in others.

This is a big step in shining light into areas that need it to improve the system overall.

Do you consider the amount that the US spends per capita on healthcare relative to other countries for the same standard of care a "failure" of the healthcare industry? Or is there some other reason healthcare "just costs more" here?

Also wondering what you think a solution is - single-payer for better and simpler price negotiations, or some other approach?

My main concern is if we're spending 20% of GDP on something other countries accomplish with 10%, then that's a huge waste, especially in a country with a larger total GDP pool.

Healthcare is such a base layer of the economy, I find comparisons to be extraordinaly difficult between countries. On the most basic level our pathway to becoming a healthcare provider of all sorts is dramatically more expensive and limited than other countries, what healthcare providers are paid is dramatically more than other countries, we invest many times per capita what other countries put into basic medical research, the way are population is taxed is very different than other countries, our patient population is very different from other countries, our expectations are very different from other countries, our scale is dramatically different than other countries, and so on. The US is a singular animal politically in that it is a compact of individual states that especially in regards to healthcare, the federal goverments powers (though it may not seem so at times) are actually quite limited. It's all but impossible to come up with reasonable numerators and denominators for comparison.

> Healthcare is such a base layer of the economy

Academically this sounds enlightening, but it only takes one cursory walk around a supermarket in the US to see this is unequivocally false. Healthcare is an externality, not a base of anything. From the average customer to the product in the aisle to the marketing - everything is 100% not a direct cost benefit function in terms of healthcare.

And add on top the oft-repeated that “health insurance is healthcare.” That’s how you obfuscate a whole of things.

I'm not sure what that proves, given that you went to a grocery store instead of a pharmacy.

I'm guessing parent was saying that most medical spending is payback for terrible US American eating habits?

I hope his view isn’t so myopic/“boot straps” but I guess it’s possible.

Thanks for the benefit of doubt, 'hoo!

After you criticized the comment as only “sounding enlightening” I was eager to hear your thoughts.

Unfortunately I think your comment is even less enlightening.

I mean, not all healthcare problems are caused by lifestyle. So clearly healthcare is a base layer - there is no situation where it wouldn’t exist.

I'll concede that the comment was vague and relied too heavily on a shared intuition. Though I will admit, the reward became well played dry comedy throughout your sibling comments.

So I'll break down my reasoning a bit. It requires a full blog post to get out, so please forgive the abridged version.

Healthcare is a catch all for all the other problems of society. The top costly conditions in the US are (in order of this barely sourced article): Mental Disorders, Heart Conditions, Trauma-Related Injuries, Diabetes, Cancer, COPD and Asthma.

Every single one of these is plainly racking up unneeded costs by the daily actions of all of us. My quip on the supermarket was a remark on the total view of health (from mental to reproductive care to basic carcinogens to ...).

How many people are mindlessly scrolling on Instagram while performing another task, how many people smell of cigarettes, the marketing of 'sinful goods' (depending on the state), the near impossibility to avoid added sugar in every packaged foodstuff, the number of 'alcohol noses' you can see down a 50ft isle, the parenting of children, the smell of fossil fuel exhaust from the parking lot, the gait of the elderly, injured, or soon-to-be, the accommodations (or lack thereof) for those in wheelchairs and with living assistance, and still the primary food at checkout - And to include everyone in the conversation: think of the anyone working two jobs and has 0 time to prepare fresh food for themselves or anyone else, the eventual cost is in the habitual behaviors made in the constraints of under-compensated labor.... I could keep going and I've left out other observations contributing to other conditions but I think you understand.

The thing I'm trying to say is that there are interventions all over the place - however, the up-front costs (ignoring all else) of a 'double blind randomized trial' for every single one of them to earn the proper authority to define its relative utility to cost is unrealistic at the moment (also most governments do not allow for risk based price of care) - an economic externality.

Couple this externality behavior with a market of near perfect inelasticity for good health (and before someone comments, yes, suicide / assisted euthanasia may not be inelastic in price on this metric) - and you can't say "Healthcare is such a base layer of the economy" - an alternative analysis is "Healthcare is an externality that is priced in a government controlled market"

[Edit] I completely left out the externality of the high reward litigation industry on malpractice and all of the above conditions as evidence of harm - adding pressure on compensation to the highest paid professionals.

The workers who are not allowed to sit their entire shifts, a uniquely American cruelty

It is offset at all by all the workers who are forced to sit their entire shifts? It's probably better on our bodies to stand than to sit for 6 hours at a time, but it starts in schools and ends at desk work. Standing desks are nice, and can help, but not everyone has access to them.

One of the nice things about working from home is that it allows people to escape that kind of environment to a point, but it just enables other types of obsessive micromanagement like "Why hasn't your mouse moved for 15 minutes!" or keeping cameras pointed at you all day long.

What we really need is less micromanaging and an expectation that not everyone is going to be at their desk every minute of the day, but that's a very hard sell in some environments.

Why job punishes a sitting worker for standing momentarily within a shift? And what do you mean by one cruelty offsetting another?

> It's probably better on our bodies to stand than to sit for 6 hours at a time, but it starts in schools and ends at desk work.

It definitely isn't, standing puts enormous strains on our bodies. Walking for 6h is much easier and better, but sitting out lying down are much better than just standing.

They're also talking about a population of workers - this includes elderly people with bad hips, bunions, handicapped people who aren't always given proper accommodations, etc.

Yes, most governments do not allow pricing according to ricks; but, whether insurance will take that risk group and insure them does in fact act as pricing according to risk. An example is diabetes. As if you are not with an elite insurance carrier via elite high income job you have actually not having insurance and dying from diabetes due not being able to afford insulin shots.

Walk around the supermarket that you drive to, hopefully not being maimed or maiming someone else on the way. A ludicrous expenditure of energy to avoid physical activity so that you can buy products to help alleviate the symptoms of the energy expenditure and laziness. Can’t walk, or bike, or take the non-existent public transit. That’s for sure.

I don't think driving is merely to avoid physical expenditure. Driving is a result of rural and suburban living as well as poor urban planning. Lots more people would walk or bike if it was reasonably feasible.

I suspect it's a bit of a chicken/egg problem (based on my opservations from visiting the US). Even in suburban areas there seems to be roads everywhere, often very hard to cross without a car.

Where I live in Europe, the expectation is that the kids will walk or take the bike to school. 95% of the paths they need to travel is covered by walkways (usually separated from the roads, and in many cases with dedicated bike lanes). Everywhere the kids need to cross, there are crosswalks, and every morning before school a team of parents is organized to safeguard these crosswalks.

Meanwhile, driving is slowed down significantly by the efforts above. The roads are underfunded and lines tend to form around the school (some parents still do drive their kids, up to about half when the weather is really bad). But with parents blocking the crosswalk every time a kid is near, bottlenecks do form. Basically, if you're in a car, you're treated as a 2nd rate citizen. :)

Oh, and I suppose one benefit of all this walking is that hospital bills go down. Mostly because of the exercise, but also to some extent due reduction in air polution (which is helped further by most of the remaining cars being electric, most of which, ironically, are of a certain American brand).

Where i live in the suburbs we don't even have sidewalks ffs. I live about 3 blocks from my kids' school, yet they are driven or take the bus to school because kids are not allowed to bike or walk to elementary or middle school, unfortunately.

wow, didn't realize so much of EU can afford electric vehicles. They are more expensive over here in the U.S. - especially compared to a decent used car. Is this a function of the cost of fuel being much higher over there? Or are there subsidies for purchasing electric or something else?

> wow, didn't realize so much of EU can afford electric vehicles. They are more expensive over here in the U.S. - especially compared to a decent used car.

I don't live in the EU, though. You need to move a bit further north and west.

And it's not that electric cars are cheaper here than in the US, rather other cars are taxed at +100% or so (more for "luxery" cars), while electric cars have had low to zero taxes.

Also, fuel has an extra tax of about $1/liter ($3.8/gallon) on top of the normal price (and 25% VAT even on that), meaning even before the current boom, fuel was typically priced around $1.5-$/l (around $5-$7/gallon), and has been approaching $2.5-$3/l (up to about $10/gallon) recently.

Another difference compared to the US is that we have about 25% fewer cars per capita here, despite having about 20% higher nominal GDP per capita than the US (purchasing power of households are lower than in the US, due to taxes and tariffs ). Partly because of car-hostile taxes (except for electric cars) and partly because other means of transportation are subsidized. More of the money is put into buses, trains and sidewalks and less into cars, roads and parking lots.

It's a confusopoly!

They're most obvious with "basic" products like energy and comms - in theory what is delivered is mostly undifferentiated kWh or GB but through the magic of "confusing plans", marketers have succeeded in making comparisons very difficult for regular people.

(You can do it, but you need OCD, a year of billing data and a spreadsheet - which greatly exceeds the cognitive effort most people will invest in choosing a mobile or energy provider).

The US healthcare sector seems to be the largest, most intricate and most successful (in terms of gdp extraction) confusopoly in history.

Huh? I look on a comparison website for price per kWh.

...because the healthcare corporations get congress to sell out citizens. $3.5 BILLION flow through lobbyists every year (all industries). Healthcare being a huge part of that. Congress sells out US citizens & corporations fuel it

That's a pretty good deal considering US federal spending alone amounts to 7.3 trillion dollars.

Lobbying American reps has the highest ROI of any investment in human history.

Ted Cruz would probably cosign a bill to 'throw all puppies off a mountain' for an all inclusive trip to Tulum

This is an underrated joke.

To be fair, energy isn't just kWh. A Joule delivered during times of peak demand costs more to produce (or has a larger opportunity cost) than a Joule during a lull.

Also a marginal Joule that you can demand at will is different from one that you committed to months in advance.

Similarly for data.

Of course, in practice most plans don't reflect this 'essential' complexity, but are full of accidental complexity to confuse people.

Off-topic but "confusopoly" maybe Scott Adams true contribution to human understanding. IIRR he wrote a comic management book and dropped in a throwaway line and invented the term.

I understand you're the relative expert here, but even so I must disagree with your general thrust.

I've been hospitalized in four different countries. The least sane was America. The sanest was a private hospital in England, but the public hospital in England was fine too. My home country of Canada is sane, reliable, and reliably slow and mediocre bordering on subpar. Cyprus lacked toilet seats, but at least the food was fantastic.

America's healthcare system is bananas. Even trying to come up with a metaphor here is difficult. It's $5k a day stays with Wonderbread, tuna, and bad not-actually-mayo-mayo for lunch. It's well groomed, well respected, monied indentured second and third opinion servants. It's Moloch's own mediation on Moloch[0] sold on the discount rack of the bookstore pharmacy downstairs.

You can think Americans are different. They are not. They move to Canada all the time and we service their bum knees just fine.

You can think Americans do all the medical research in the world. They don't. Plenty comes out of Europe, China, and elsewhere.

You can think your tax code is unique. Ok this one I kinda agree with. It's almost as bananas as your medical system. But it doesn't change the fact that Americans put up with absolute bananaspants insanity for a healthcare system when they're perfectly capable of funding their libraries and roads.

China beats you on scale. And so on.

The basic fact is that Americans have what is essentially a psychopathic medical system at the best of times. One can negotiate with a psychopath, but Kafka returns your offer with a can of stale soup and doesn't even laugh.

[0] https://slatestarcodex.com/2014/07/30/meditations-on-moloch/

You're coping. Americans are responsible for about half of the world's medical research.

That's factually untrue. China and Japan alone match the USA, and when adjusting for percent of GDP the USA isn't even in the top five countries.

https://en.wikipedia.org/wiki/List_of_countries_by_research_...

Why would you adjust this value instead of using absolute terms?

If you mean PPP, then the reason is simple. How much a janitor is paid to clean a research lab's washroom doesn't materially affect the quality of the research produced. There are other measures that look at things like papers cited or page rank like algorithms, and on those USA does even worse if I recall correctly.

At the end of the day, though, this is a distraction from the core argument. A valid defence of US healthcare policy is not "but we're good at research." Imagine if China was trying to defend their overbudget and under-effective military by talking up how much they've done for global aeronautical research.

Grandma lost her house because she got kidney stones, but, butterfingers, at least we research stuff! Oh and often times our pharma kills more people than it saves and true justice is never metered out ala opioid epidemic.

Keep shouting #1, #1, #1 until you believe it.

> e invest many times per capita what other countries put into basic medical research

This is a big thing. I'm in the UK, where healthcare is very socialised, but I very much appreciate the fact that the US invests in making and productionising the next generation of healthcare, which we can then buy in bulk at a discount.

> our patient population is very different from other countries > our expectations are very different from other countries > our scale is dramatically different than other countries > the way are population is taxed is very different than other countries

do you have evidence to support these claims? what makes the US patient population or their expectations or the US taxation system unique in the world?

Not the OP, but Americans as a whole are very unhealthy (with 42% of the population being obese and over two-thirds being overweight) and culturally have very high expectations of what medicine can do for them, as opposed to making difficult changes to their lifestyle.

A part of the latter is based on the actual superiority of the quality of medical care in this country -- due to the high levels of wealth produced by this (mostly market-oriented) economy and advanced medical technology, doctors can in fact perform miracles here that they cannot elsewhere.

A part of the latter is based on the actual superiority of the quality of medical care in this country...

How is it superior? Sure, some countries fare worse. But folks aren't getting the healthcare they need because of cost, and the results aren't exactly the best in the world. I'm not convinced that "culturally" folks have high expectations either, and sure, you might want to change your lifestyle to lose weight - but at the same time, you might just need medical oversight to do so. Not to mention that a bunch of things medicine helps are not things that lifestyle just fixes.

Yes, folks are being priced out of healthcare, but the healthcare that is being provided is of superior quality than can be found in other countries -- even first world countries with socialized healthcare. I mean it in that narrow sense, that the service that is being delivered is of higher quality.

It sounds like your point is that wider delivery of healthcare would be superior overall. That's fine, but I contend that the best way to achieve that is by increasing the supply of healthcare providers, instead of applying a price ceiling, which leads to shortages (as seen elsewhere on this thread[0]) and quality deterioration.

[0]: https://news.ycombinator.com/item?id=32745467

As with everything it touches, it's the intrinsic failure of capitalism (ofc success for the capitalists / bourgeoisie). It's the amount of capitalism that defines prices. In every other country the more healthcare is a public matter, the cheaper it is for the people.

Healthcare in the US is definitely not driven by the free market. It is probably one of the most regulated industries. Whatever disfunction you want to call out in US healthcare it is going to be difficult to pin that on the free market.

Free market? Capitalism. I know we're on HN but, say the word? Capitalists take a cut. Shareholders of big pharma, insurance companies and hospitals are why healthcare in the US is expensive. Public sector not being monopolistic is why healthcare in the US is expensive. In France, social security reimburses about 70% of most costs. Cheap private insurance reimburses the rest. About 75% of public hospitals and not for profit. Generic medicine being prescribed is the norm. The state naturally fixes healthcare prices because it's monopolistic on healthcare. Same as all public services.

Non free market? Communism. I know we’re on HN but, say the word?

Of course the US market is highly regulated and so the market is not free to lower prices. Of course the AMA is a racket. Of course needs of certificate are abhorrent.

Given the customer non—coerced access to his preferred provider, and not taking his money and slapping a bunch of regulations on him will of course lower prices and give him better care.

I don’t see why the other side can’t see it.

That's right, communism. Social security in France is literally a communist system, founded by a communist minister. Hence why neoliberals want to destroy it.

Just a nitpick, when there is a single purchaser it's called a monopsony.

> Healthcare in the US is definitely not driven by the free market.

You're conflating 'capitalism' with 'free market'. You can have either without the other and OP was calling out 'capitalism' specifically.

Number one is full price transparency of the whole chain. I work for a medical device company and even the marketing people can't really tell what our stuff costs. There are a ton of middlemen with obscure contracts and very high markups. My ex got one of our devices and I was told by our people that the hospital should have received the device for between 20k-30k (nobody seems to really know) and the hospital charged 80k for the device alone. They also charged another 200k for a one hour surgery with a total hospital stay of six hours.

It's also hard to explain that US patients pay a multiple of the drug price people in other parts of the world pay for the something.

The problem is that if the US wastes 10% of GDP on health care inefficiencies this creates a huge lobby that will fight tooth and mail to keep that money.

The prices as charged in the US regularly make it onto Twitter and Reddit etc where us Europeans wonder how on earth it's possible that something in the US costs $ 800 which is charged at less than $ 100 over here (and then paid by insurance). Same for that $ 30k device being sold for $ 80k.

What we all forget is that nobody is actually paying the US healthcare invoices.

Roughly two options... 1. You have insurance and they negotiated a different (much lower) rate or 2. you don't have insurance and can't pay the amount on the invoice.

In option 2 you either declare bankruptcy and they get nothing or they sell the claim for something like 20% of the invoice to a collections agency.

Not correct. The insurance paid 80k for the device and 300k total for the surgery after one year of fighting almost daily.

Also: if you make a certain amount of money and they hit you with a 100k bill you can't just declare bankruptcy. The court won't allow you to do it because you make too much money.

> you can't just declare bankruptcy. The court won't allow you to do it because you make too much money

Isn't this always the case? My understanding was that bankruptcy is for when you don't have enough income to pay bills, so if you have a bill for any amount but are able to pay it then you wouldn't be allowed to declare bankruptcy

I’ve heard a lot of complaints about Medicare/Medicaid. It does not inspire confidence in single payer.

There's always complaints about healthcare and probably no perfect system, but a bad one where everyone has coverage seems a lot better than a bad one where everyone doesn't

Is it really the same standard of care? I would speculate that the standard of care in the US is at least marginally higher than many other developed countries based on my admittedly anecdotal experience, especially if you plug wait times for providers into the calculation (this seems to be the number one complaint that comes from people I've met that have immigrated to the US).

If your outside experience was in the UK, I would tend to agree. Their healthcare is drastically underfunded.

In comparison to France, Germany, Belgium, the Netherlands, etc I would disagree.

Google search for the McKinsey report on US healthcare spending - I think it was around 2009.

I work in the industry as well and it’s one of the few reports that actually breaks down the spending in a logical way.

They basically adjust US spending by GDP (high GDP countries spend more generally) then compare each category to the OECD average (also adjust by GDP), on a price and volume measure.

The answer is - yes, higher price are a factor, but volume is also a major factor. In hospital spending is actually in line with other countries. Drugs costs more but it doesn’t contribute that much to total spending. In terms of durables (equipment) the US spends less.

The biggest driver? Out patient procedures. Not just price, but Americans get way more out patient procedures done compared to other countries and it accounts for like half of the “excess spend” of the US compared to other countries.

> if we're spending 20% of GDP on something other countries accomplish with 10%, then that's a huge waste

I don't think that money is necessarily a waste if it goes back into the economy one way or another. There are very few things that are actually a waste, one example is probably flying first class or private jet. If you literally burn money then it's clearly a waste. A part of me thinks the huge cost of healthcare is contributing to more R&D by the big pharma and possibly the reason we're seeing RDNA breakthroughs. Yes a lot of that money also ends up in the pocket of people running the show, but they most likely then invest it with a Blackrock which in turn pushes the money back into the economy in form of private equity, VC funds, etc. For the record I don't like the high healthcare prices and wish US was more similar to other countries in this regard.

> Do you consider the amount that the US spends per capita on healthcare relative to other countries for the same standard of care a "failure" of the healthcare industry?

That we spend more per capita for approximately the same level of care as most other first world countries is certainly annoying. But sometimes I think we are too focused on that and not putting enough effort into trying to stop the cost from increasing.

I think increasing costs are a more serious problem because the problem of spending so much more than the others is a US problem. That suggests it is just something we are doing wrong, and by making our system more like some of those others we can fix it.

The problem of rising costs also plagues those other countries, and to about the same extent as it does the US. That suggests it is a much harder problem to solve.

Here are some examples of rising costs per capita.

How much costs per capita went up from 2000 to 2018: US 2.3x, Germany 2.1x, France 1.8x, Canada 2.0x, Italy 1.7x, Japan 2.6x, and UK 2.6x.

Costs per capita in 1980, 1990, 2000, 2010, and 2020 divided by 1970 costs:

     1980 1990 2000 2010 2020
  US  3.2  8.2 13.9 24.1 36.3
  UK  3.1  6.3 15.3 27.8 40.5
  FR  3.4  7.6 14.9 21.1 28.5

Here's the ratio of each given year to the cost 10 years earlier:

     1980 1990 2000 2010 2020
  US  3.2  2.6  1.7  1.7  1.5
  UK  3.1  2.0  2.4  1.8  1.5
  FR  3.4  2.2  2.0  1.4  1.4

Data source: https://data.oecd.org/healthres/health-spending.htm

If "latest data available" is checked, uncheck it to unlock the slider that lets you look at historical data back to 1970.

Data doesn’t make sense. If US costs went up similar to other countries but US is significantly more expensive than other countries today, does it mean costs in US have always been much higher?

Yes (at least as far back as the data at oecd.org goes, which is 1970).

In 1970 US health care spending was $327.0/per capita. France was $192.1, and UK was $124.0. That's 1.7x France and 2.6x UK for the US.

In 2020 it was $11859 for the US, $5468 for France, and $5019 for the UK. That puts 2020 US spending at 2.2x France and 2.4x UK.

From 1970 to 2020 US went up 36x, France 28x, and UK 40x.

It looks like much of the first world has a serious rising health spending problem, with costs rising roughly the same over time everywhere. The US was more expensive long ago, and since the rising costs have been roughly the same the US has stayed more expensive by about the same ratio.

If we could get our spending down to match the rest of the first world, without reducing the level of care, that would be great.

BTW, it is similar if we go by percent of GDP instead of per capita.

US was spending 6.2% of GDP on health in 1970, France 5.2%, and UK 4.0%.

In 2020 that was 18.8% of GDP for the US, 12.2% France, and 12.0% UK.

There's many things wrong with US healthcare. But somehow the USA comes up with the the first vaccines for the coronavirus and if you want any sort of complex procedure you travel to the US to get it.

So maybe thats where the extra cost goes? To drive research, and support the infrastructure that creates good to better health outcomes on average vs the rest of the world.

Saying something is a failure just because it costs so much is only looking at one side of the coin.

On average healthcare outcomes in the US aren’t particularly great compared to other developed countries though (https://www.commonwealthfund.org/publications/issue-briefs/2...).

In particular life expectancy is very low by developed world standards and deaths from preventable causes are very high.

I don’t doubt that the US has world leading hospitals but the population level outcomes delivered are poor by developed world standards.

The US is a net exporter of healthcare services but mostly to developing countries and the numbers involved are tiny (https://www.usitc.gov/publications/332/executive_briefings/c...)

The idea that people who want any sort of complex procedure travel to the US is pure fantasy.

As for the COVID-19 vaccines. The first approved vaccine was the “Pfizer” vaccine developed by BioNTech in Germany (https://en.m.wikipedia.org/wiki/Pfizer–BioNTech_COVID-19_vac...).

Vaccines for the COVID were developed simultaneously in multiple countries.

> But somehow the USA comes up with the the first vaccines for the coronavirus and if you want any sort of complex procedure you travel to the US to get it

This isn't true, the US didn't make the first vaccines, it was created by a German company that partnered with Pfizer for trials/production/distribution[0]. People more often travel outside the US for care, we actually have the second highest amount of people leaving their home country for medical care[1], with the top destinations being in South America [1a].

> creates good to better health outcomes on average vs the rest of the world

This would be nice if true, but we spend more and still have worse outcomes in almost every area[2]. The only things I could actually find that are better here is post-op sepsis and 30-day heart attack survival, but in just about every other area it's more dangerous to get care in the US.

[0]: https://en.wikipedia.org/wiki/History_of_COVID-19_vaccine_de...

[1]: https://www.health-tourism.com/medical-tourism/statistics/

[1a]: https://amjmed.org/medical-tourists-incoming-and-outgoing/

[2]: https://www.healthsystemtracker.org/chart-collection/quality...

I think the preceding comment was operating on the presumption of linear returns from medical research. Since higher medical costs in the US goes directly towards medical companies, and indirectly to medical research after taxes and dividends and stockbuybacks...

Of course the biggest issue of all time is that germs are evolving to survive our antibacterial soap, we may need to develop a large variety of antibiotics.

The US is (exaggerating a bit) a nation of obese, sedentary substance abusers. We are sicker on average than other developed countries and thus have a higher demand for healthcare.

We might be able to eke out some minor improvements by tweaking the payment model and eliminating some waste. Those things are worth doing, but they won't fix the fundamental problem. The US won't get healthcare spending down to Japan's levels until Americans start acting like Japanese.

There are some other key factors as well. A large fraction of healthcare spending goes toward treating elderly patients with serious chronic conditions in their last few years of life. Some countries explicitly deny care to such patients because they don't think it's justified on a QALY basis, but Americans seem uncomfortable with rationing on that basis.

And some aspects of the US healthcare system are top notch. For many types of cancers we have the world's best 5-year survival rates. There is a thriving medical tourism business where patients from countries with socialized medicine such as Canada come here to receive rapid treatment instead of waiting for years for something like a hip replacement.

I’m not the OP and have no deep knowledge, but I’ve often heard cited that the US out-researches other nations, so we incur “R&D” costs for healthcare that other nations use. Eg pharmaceuticals are researched in the US while the patents are used in other nations through a cost structure that doesn’t allow the original researching party to recoup costs.

On-shoring that research also seems to be an advantage -Looking at the astounding amount of research that poured into covid post 2020 would show that we have a huge dormant muscle that can be flexed in unison during an emergency.

I've never seen any convincing evidence for this theory.

Then why do they spend so much more on marketing than R&D?

https://www.ahip.org/news/articles/new-study-in-the-midst-of...

I’m not trying to defend pharma companies… they’re generally pretty scummy. But I’m guessing most companies spend more on marketing than R&D. Beyond that, the theory that they need to recoup costs still holds true with this. In fact, a big marketing budget indicates that they’re aggressively trying to sell the drug (maybe to recoup costs?).

Generally in business marketing budgets should generate more sales than they cost (in ideal case), so big budgets doesn’t mean that they’re “wasting” that money that could go elsewhere. If the sale wouldn’t happen without an ad, then that’s a necessary ad.

> If the sale wouldn’t happen without an ad, then that’s a necessary ad

I think that's the core issue here, healthcare and pharmaceuticals have basically inelastic demand. The US is one of only two countries where it's even legal for pharma companies to advertise directly to consumers.

I know in practice they can create demand for products, but that doesn't necessarily seem like a good thing, so I think you could argue that it's still a waste of money even if it does create profit for the company.

In your opinion, what would be the lowest hanging fruit that could be changed to have the largest positive impact?

People are rarely satisfied with this answer but its demonstrably true and was proven time and time again at the facilities ClearHealth managed.

1) Feverent, almost religious, adherence to hand washing. 2) No neck ties or dangly sleves whatsoever in buildings that house patients. 3) Change from stainless steel hardware for doors and travel touch surfaces back to "brass/copper".

Those are simple, virtually free, things that have a very meaningful impact on outcomes. Some of the most viscous fights I've had with hospital boards were over what amounted to the "uglier look" of copper/brass.

It is an extremely unpopular topic in healthcare but the area that takes a lot of effort to solve but also has a tremendously out-weighted benefit is reducing preventable medical errors. My opinion after being in healthcare ~20 years is that preventable medical error is absolutely in the top 3 causes of death in the US. The easiest subset of it to resolve is prescription related errors, we have all the tools to resolve those but not the will.

Well, I'm satisfied with that answer. But maybe that's because I think brass and copper look better than stainless steel.

>"3) Change from stainless steel hardware for doors and travel touch surfaces back to "brass/copper".

Because of the pandemic I started encountering doors that have a shoe pull, where you can use your foot to open the door instead of having to touch the handle. I really hope these catch on, but they are still quite rare.

Also stop getting rid of paper towels if you still have manual faucets. Nothing grosses me out more than going to a public restroom with only air dryers, but manually operated faucets that now require you use clean hands to turn off after you turned them on with presumably dirty hands.

Just like the door foot things, you’re supposed to Bruce lee the faucet afterwards and turn it off with your foot.

Use your elbow to turn off the faucet(as long as it is lever type, if twist type then good luck).

I want paper towels for the door knobs/pulls and the trash can should be located near the door so I can throw it out after opening the door.

Or make the door push to leave, pull to go in. I don't understand why it's not a thing.

Bathroom doors are usually off a small hallway, sometimes a busy one. By design, they don't have windows.

So you run the risk of hitting people with the door. Also, you will still need to interact with the door to open the lock. Having a door that unlocks if you push on it would be a bad thing for people who use the bathroom with their children.

> Change from stainless steel hardware for doors and travel touch surfaces back to "brass/copper".

I have never heard of this. I had to Google it to even understand your meaning. It's eye-opening to learn that different metal surfaces have an effect on the spread of germs.

Could you post some good links you read/browsed? Google is providing too much junk and difficult to reach any high level conclusion.

https://en.wikipedia.org/wiki/Antimicrobial_properties_of_co...

Copper is a well-known drain additive to kill roots.

What about the incentive for non profit hospitals to grow so that they can better compensate leadership, resulting in capital that must be spent on facilities and equipment to retain non profit status. Leading to a spiral?

It is hard to compare details of the systems and outcomes across countries, but surely we can find where the money apent ends up? Construction firms? Doctors? Equipment manufacturers? Hospital administration?

Is there a rule that says a certain percentage of revenue must be spent on a facility to retain non-profit status? It can be spent on equipment and salaries, both of which would benefit much more than upgrading the building to no patient care benefit.

This is anecdotal but the number one complaint I've heard from physicians about patient care is facilities being run and and managed by non-clinical MPH/MHA "business types" whose primary focus is almost invariably cutting costs, increasing physician workloads, and fighting salary increases tooth and nail.

No, but there is a "rule of thumb" that a hospital will prefer private insurance patients to medicaid patients (due to reimbursement), and private insurance patients will go to hospitals with newer and nicer facilities. If you want the elective hip replacement patient, then having a newly remodeled orthopedic ward / office building is critical. Patients probably can't tell one doctor or nurse from another, and hospitals don't advertise on actual quality measurements like staffing ratios...

> Those are simple, virtually free, things that have a very meaningful impact on outcomes. Some of the most viscous fights I've had with hospital boards were over what amounted to the "uglier look" of copper/brass.

Am I the only one who finds copper/brass much more aesthetically pleasing than plain and boring stainless steel?

It was most likely a retrofitting discussion. Copper doesn't blend with modern designs and color schemes so retrofitting it would be ugly

I've been told credential easing is by far the easiest one to implement. Doctors often do 2-6 years of excess schooling residencies learning areas of medicine that will never be relevant to them. That's 10-20% more time working for existing doctors, and who knows how many more people would enter the profession. Nurses could be empowered to make doctor lite decisions very easily.

> Doctors often do 2-6 years of excess schooling residencies learning areas of medicine that will never be relevant to them.

Where in the world did you hear this? Don't trust anything else that person told you.

Aside from some low-income clinic hours for certain specialties (which is objectively a societal good, not to mention typically specific to a given specialty, e.g. OBs have an OB clinic not primary care) no doctor is spending 6 years of "excess schooling residencies" learning anything.

Med school is 2 years of classes then 2 years of rotations where the students - who aren't yet doctors - do 4-12 weeks of rotations through various core and elective specialties. After they graduate they're now doctors but have 3-6 years of specialty-based residency training where for 80-100 hours a week, 50+ weeks a year, they do nothing but their specialty. ACGME limits weekly hours to 80 (I think over a 2-3 week average), but 90% of the doctors I know said they regularly broke that and just didn't log the extra time.

Especially in surgical residencies, all you're doing is your specialty-specific stuff during that period of those.

> Don't trust anything else that person told you.

You just said what he said, but with emphasis on 100 hour weeks for years on end being good instead of bad. Why did you disagree with me, then go on to list how much doctors work before the get to practice on their own? His point was they get too much training, with much of it being irrelevant (not all). If you're this angry and reactive, you really shouldn't be a doctor.

People here seem to love the NHS. In the UK, doctors are not forced to study something irrelevant for four years in college, then do med school, then do a 4 year residency (i.e. age 30). They are often done by age 24, and ready to help.

One thing that makes conversations with doctors about regulations around board certifications easier to understand is that anybody who is currently a doctor in the US is heavily disincentivized from improving or changing the system in any way. The absurdly onerous restrictions on becoming a doctor work to the benefit of current doctors by artificially restricting supply and thus keeping wages high. Why would doctors want to get rid of those very regulations?

This is correct. And the AMA isn't ignorant of this, either.

I'll be more clear - doctors have almost no extra or unnecessary training during their residencies. It's all very specialty-driven, or at the very least is specialty-specific public service (e.g. low-income clinics). If anything, the doctors I've spoken to said they should all probably be a year or two longer across the board if only to allow for better work-life balance, but none of them would want to have to go through that obviously.

The closest thing to "extra training" they get is fellowship-related rotations, but even this is all things they'll see in practice so they need to know how to handle it initially, if for no other reason than so they know when to offload it to a specialist.

> They are often done by age 24, and ready to help.

I'm sure this is fine for whatever the equivalent is to an urgent care doctor in the UK (bottom of the barrel family med in the US, probably not board certified - e.g. failed the exam or not qualified to take it - or doing transitional residency because they didn't match anywhere), but I'm not really interested in my orthopedic surgeon or neurologist just getting through their training as quickly as possible.

There are lots of ways the US could increase the pool of doctors, and most doctors are probably paid way too much (paradoxically, probably most egregiously at the low end of skill), but "cut out a bunch of training" is a dumb way to do it.

Taking this discussion at face value, it sounds like US physicians go through substantially more training than their UK counterparts. If true, does that manifest itself in substantially better outcomes for their patients?

You realize that 4 years of residency isn't the magical number of the perfect amount? Two could very well be sufficient, and the other two "extra or unnecessary training." Also, you keep ignoring the college requirement, which makes you seem very disingenuous, and if you are a doctor, makes me worry for your patients.

I'm not a doctor, but why would you want a doctor who didn't go to college?

I was pre-med in college and quickly changed after I realized I didn't actually like biochem all that much. Imagine what that would have looked like had I been attending a medical school instead of a "normal" college.

It sounds like what you actually want is an NP or something like that. Which is fine, there are plenty of those around.

What? Why should I care whether or not they went to college? I want them to be able to do their job, and I don't care about prestige whoring over competency.

Maybe if they hadn't required classes that are irrelevant to 95% of doctors (orgo, biochem and pchem), you would have been able to pursue the career you wanted. This is yet more support for the idea my friend who "I should never ever listen to" said about requiring far too much credentialing.

NPs would be fine... if they were allowed to give medical advise. Unfortunately, we still have to pay for someone with 6 years of excess schooling to come in to weigh in officially and to pay a huge premium for it.

I've worked in the medical device industry for 20 years and have a similar takeaway. I often describe it as the "hospital insurance company industrial complex".

I might be joining a large EHR company in the near future as a VP and am wondering if I can send you a question from time to time as they come up via email? Would love to connect but don't see anything on your profile here.

I'm akemendo at the google mail service

> Accidents of history and the massive federal beauracracy created the crazy monster of ICD/CPT codes

Erm this is incorrect given that ICD are international it's actually the WHO that creates them source:

https://en.wikipedia.org/wiki/International_Classification_o...

It's more it's like 38%. Hollywood accounting all the way. In particular the deadweight cost of the the AMA monopoly on licensing is like 50% of GDP, which doesn't sound possible but if you know what a deadweight cost is it's a part of the nation's income that can't exist because it isn't there. It's how much better life would be if a doctor were as cheap as an uber driver, or if people healing others didn't get medium security prison as a result. It's the greatest threat to National Security, more than Russia China and the Middle East combined. And it's a military problem, wounded soldiers yeah get help from the Veteran's Association but they have to compete for those doctors and it ends up...out of pocket if they really want good care. Military gets fucked paying for doctors. America spends more money on obesity, than it does on defense. AMA is treason.

Standard Oil had a lot of different shareholders, John D. Rockefeller was never majority owner, that was an organization AMA is an organization there's now medical families. Common heirs. Medical students from a medical family get little hazing compared to the rest. All the maneuvers they make to avoid the words "monopoly" and "cornered market" are of no help and mitigate nothing. So they know people get fucked off with those words, like bad, they're afraid of those words.

In a vacuum ...

It does not seem reasonable that 20% of a countries economy is spent on health care.

Just as it doesn't seem reasonable for the cost of healthcare to be ~12% of the household income for a family (third highest living expense).

I work in data at https://www.carrumhealth.com/, and I've been parsing this data for weeks. The transparency prices allow us to meaningfully negotiate with providers, and make tangible, incremental progress toward cheaper health care. Providers and existing insurance carriers leverage information asymmetry to control the market otherwise.

For context, we bundle the 100's of itemized costs into a single, static bill per surgery type. In doing so, we've built a custom virtual-network with the most efficient surgeons. These surgeons are able to meet the volume and quality requirements to allow for lower margins. We're able to get negotiated rates that are 10-40% cheaper than traditional insurance contracts when we have data that we trust.

Unfortunately, this data alone isn't enough to properly determine prices because organizations will spread costs across procedure and billing codes that often occur in aggregate groups. For example, in a joint replacement surgery, some organizations may dump the cost into the billing for the implant itself, while others may put it under the procedure code. You have to gather billing data en masse to see which charges occur together, then combine this pricing data to determine what costs will actually look like for someone experiencing a procedure.

It's a nightmare!

How much do you think it costs to maintain all these negotiated contracts VS just having a single payer system with the same price for all procedures?

It's very expensive, carriers have an economic incentive to simplify it and this is still where they end up. There are a long tail of provider circumstances that the single-payer model will need to figure out. Some examples:

* Small hospitals in low-density, underserved areas have to make up for underutilized equipment and personnel costs. They raise prices on unrelated, common procedures to break even (This is very common)

* CMS (medicare/medicaid) sets a low price for a procedure that's overly common in a particular facility, now that facility loses money for each occurrence. They choose other procedures to raise the price to try to break even.

* Larger hospitals have higher administrative and operations costs (for things like training and research) that benefit society, but need to be averaged out across all procedure costs. This differs from hospital to hospital.

* Smaller professional facilities or physicians groups (like Ambulatory Surgery Centers) have much lower administrative costs and a smaller staff, so they have lower overhead per procedure. They are designed to be efficient, and can handle lower prices. However if there are any major complications, they won't be able to service the patient, and have to send to a hospital. This then pushes all the highest-cost, ICU-type procedures into hospitals, where there is already a higher overhead, causing hospitals to need separate pricing to cover more complex patients.

A large single payer price set will probably force efficiencies into the healthcare system. It'll be great for folk's costs, but we may see many facilities close, and lines of care will be consolidated into specialty centers. (more travel to get imaging, procedures, or to see a specialist)

What do you think about how Kaiser has handled the whole thing? The insurance company employing the doctors and just paying them a standard salary seems to create all the right incentives.

My experience in talking to people with chronic conditions that aren’t easily treatable is that Kaiser’s model works great until anything that’s slightly out of the ordinary happens, and then it falls apart. If you’re a zebra (as in “when you hear hooves, think horses, not zebras”), their model is pretty horrible.

Isn't it pretty bad to be a zebra in general though? Certainly there isn't any place where zebras have it better than horses.

Yes but if you're at Kaiser in San Francisco and have a zebra there may only be one doc (or a small group) at UCSF that can treat your zebra, and they are not in the Kaiser network, so you go to Los Angles where Kaiser's specialist is, get treated by a lesser doc with a virtual visit assist from LA, or pay cash out of network.

I think their point is that it's relatively better under another system, not that it's amazing there.

Sounds like they have intelligently optimized for the common case.

The best thing about Kaiser, IMHO, is there is never a surprise out-of-network astronomical charge on the bill as I've seen with regular insurance.

Have insurance split into two parts, the 95% cases and the rare and expensive?

>>* CMS (medicare/medicaid) sets a low price for a procedure that's overly common in a particular facility, now that facility loses money for each occurrence. They choose other procedures to raise the price to try to break even.

This is precisely why most Doctors I speak with are abhorrently against a single payer system.

Most doctors I talk to vaguely run around the answer before mumbling that a huge way to cut costs (which will surely happen) is to cut doctors salaries.

Source: once engaged to a doctor who had doctor friends and doctor parents/family.

And there is a reason why we shouldn't go off of anecdotal evidence. It's blatantly false.

Doctors’ salaries account for only about 8% of U.S. healthcare costs. A 40% cut in these salaries would reduce healthcare spending by only about 3% [1][2].

Doctor salaries are not a huge way to cut costs. If anything this would make the problem worse.

[1] https://www.latimes.com/opinion/story/2021-09-14/dont-blame-...

[2] https://pnhp.org/news/doctors-salaries-are-not-the-big-cost/

It’s not false that doctors worry that. Doctors worry that single payer system will reduce their salaries. They’re an easy political target. They’re rich and (in this hypothetical case) their salary would come from the taxpayers. Taxpayers don’t like expensive salaries.

It’s irrelevant how much of the budget it is. It’s about perception and power. If you try to cut soap in the operating room or other supplies, you’ll look bad for endangering the patient. If you try to cut procedures you’ll look bad. If you try to cut doctor salaries, those “overpaid” doctors look bad for complaining.

Doctors have a reputation in america for being extremely well paid. If you tel people making $60k a year that their tax bill for medical costs could be lower if you reduce it by taking $50k from a doctor making $500k (taxpayer dollars!) they’ll support that. Even if it’s not a big amount.

Reducing healthcare spending 3% without any systemic change in medical treatments or equipment or negotiation with pharmaceutical companies is a huge and easy win.

PBS put out a documentary ages ago comparing America to other countries. At the time our administrative overhead was 25% while Taiwan's overhead was 2%.

Not much.

The net cost of insurance represents 6.4% of all healthcare spending.

https://www.ama-assn.org/delivering-care/patient-support-adv...

Sounds like an application for ML, to determine which codes frequently coincide per-patient at each provider and then assign those groupings to cross-provider "Treatment XYZ" buckets to enable apples-to-apples comparisons.

Great call, many orgs in health tech use billing/procedure code embeddings to group, just like you're suggesting.

I would think a basic statistical analysis should suffice.

most software billed as having 'ML' capabilities is just basic statistical analysis anyway - but that doesn't make for good marketing-speak.

Applying ML to health care is a guaranteed path to wealth, and later, insanity.

Calculating a basic median for those groups would be a non-trivial (indeed, probably quite difficult) exercise at this scale.

Is the data unique or has it been duplicated for multiple formats? In other words is there a CSV file right alongside a Json file and an XML file that contains the exact same data, just in different formats?

Is the data partitioned at all (e.g. by state) so that you can just download the data for California without downloading all the data; loading it into a huge database table; and then querying it (e.g. SELECT * from <table> WHERE state = 'California')?

There is some duplication, where different networks under the same carrier could benefit from normalization, but in-general duplication isn't the primary issue.

The data is partitioned for some carriers at the network level, but unless that carrier has networks that are unique to a given state it's difficult to partition by location.

The majority of the data is lumped into very large, single JSON (not newline delimited), so an initial parsing step is required to break out substructures for parallel processing via warehousing technologies. I think Aetna has a 300Gb compressed (single) json file.

After breaking the json to a single array entry per provider/network, parsing is still a bit tricky because there are some very "hot" keys. Some provider array entries may only have 1000 code and cost entries, others may have 100k. We've seen array entries >50Mb for a single provider/network/carrier.

How do you get info on bills for historic procedures? Do patients opt in, or will the hospitals provide that information as part of their cooperation with insurers?

Someone with the right connections should call up Google Cloud and ask them to ingest the data into BigQuery as an example dataset like the NY taxi trips. It would be a great way for them to show off the capabilities of the engine and helpful for everyone wanting to do analysis on it.

https://cloud.google.com/bigquery/public-data

ProviDRs Care network is hosted in Google Drive. All 200gb compressed. The article writer has probably never heard of this network.

https://drive.google.com/drive/folders/1zmNEPoVCa0kIVBIu2hu7...

I don’t think you can run BigQuery over a Google drive document.

Least you could do is search for something so simple before asserting it on HN https://cloud.google.com/bigquery/docs/external-data-drive

Nah this was a 300IQ pro gamer move. Cunningham's Law.

Hahahaha. That genuinely made me chuckle :)

saying you think something and asserting that it is true are not the same thing

This is exactly what I was thinking. This is perfect for BQ. Google might do this internally anyways for their healthcare efforts.

To save anyone else similarly curious the trouble, here's a sample record from the Humana data set:

  {'REPORTING_ENTITY_NAME': 'Humana Inc',
   'REPORTING_ENTITY_TYPE': 'Health Insurance Issuer',
   'LAST_UPDATED_ON': '2022-08-24',
   'VERSION': '1.0.0',
   'NPI': '1629053517,1659354272',
   'TIN': '593279318',
   'TYPE': 'ein',
   'NEGOTIATION_ARRANGEMENT': 'ffs',
   'NAME': 'Nasal Prosthesis Replacement See Also Code 21087',
   'BILLING_CODE_TYPE': 'CDT',
   'BILLING_CODE_TYPE_VERSION': '2022',
   'BILLING_CODE': 'D5926',
   'DESCRIPTION': 'Nasal Prosthesis Replacement See Also Code 21087',
   'NEGOTIATED_TYPE': 'negotiated',
   'NEGOTIATED_RATE': '906.98',
   'EXPIRATION_DATE': '9999-12-31',
   'SERVICE_CODE': '',
   'BILLING_CLASS': 'professional',
   'BILLING_CODE_MODIFIER': '',
   'ADDITIONAL_INFO': '',
   'BUNDLED_BILLING_CODE_TYPE': '',
   'BUNDLED_BILLING_CODE_VERSION': '',
   'BUNDLED_BILLING_CODE': '',
   'BUNDLED_DESCRIPTION': ''}

I think I agree about the negotiation arrangement

For comparison, here's the first bit of an Anthem file (which contains some of the data that's just another row in the Humana record), along with the first record

  "reporting_entity_name": "Excellus BlueCross BlueShield",
  "reporting_entity_type": "Health Insurance Issuer",
  "last_updated_on": "2022-06-14",
  "version": "1.0.0",
  "provider_references": [
    {
      "provider_group_id": 302.1518360704,
      "location": "https://mrf.healthsparq.com/exc-egress.nophi.kyruushsq.com/prd/mrf/EXC_I/EXC/providerReference/Providers/S-000000001063.json"
    }
  ],
  "in_network": [
    {
      "negotiation_arrangement": "ffs",
      "name": "Brief (20 minutes) care management home visit for an existing patient. for use only in a medicare-approved cmmi model. (services must be furnished within a benefi",
      "billing_code_type": "HCPCS",
      "billing_code_type_version": "2022",
      "billing_code": "G0081",
      "description": "Brief (20 minutes) care management home visit for an existing patient. for use only in a medicare-approved cmmi model. (services must be furnished within a benefi",
      "negotiated_rates": [
        {
          "negotiated_prices": [
            {
              "negotiated_type": "fee schedule",
              "negotiated_rate": 51.1,
              "expiration_date": "9999-12-31",
              "service_code": [
                "11"
              ],
              "billing_class": "professional"
            }
          ],
          "provider_references": [
            302.1518360704
          ]
        }
      ]
    },

> "negotiation_arrangement": "ffs"

Negotiation arrangement: for fuck’s sake

:) I couldn’t help but read it that way as well, even though I know it’s most likely “fee for service.”

Anyone else get the feeling this is malicious compliance on behalf of the insurance companies?

"Oh, they're going to force us to publish our prices are they? Well we'll publish so much data it'll take a herculean effort to make it readable to anyone that doesn't work in data engineering"

The article mentioned CSV files, it seems more like a reflection of what a huge bureaucracy the US healthcare system is. I liked their suggestion that the government should have created the database as part of the law, done the processing on the raw data, and made it more accessible.

meh, I'd prefer the raw data. We can always create DBs out of the raw data, we can always link data. Handling this after the fact would be impossible.

Linking a few trillion records doesn't seem that difficult. It should be doable with a good data warehouse and a reasonable entity linking model. I suspect that we'll find more than a few instances of fraudulent behavior once the data is linked.

My father was nearly pushed into ~2 Million dollars worth of brain surgery that was unnecessary. Not only was the procedure unnecessary, the price for it was >5X what a top-3 hospital would have charged. I only became privy to this once I pushed him to come to Mass General Hospital (MGH) for a second opinion. The surgeon we saw at MGH also believed the suggested procedure to be dangerous.

I wonder if it's possible to cross-reference mortality/complication rates with prices...

In their defense, if it was anything but CSV files, they would be accused of making it too complicated/locking into proprietary formats and so on. I can't say CSV would be my first choice, but I don't really want to think what the alternative would be.

Millions of .xlsx files

NDJSON? Sqlite?

csv is many times over again a simpler format than sqlite and easier to understand by anyone across the world.

Never heard of ndjson, can’t see one publishing this data in a format that isn’t nearly as common as something like csv (or regular json which some of the data is published in).

CSV only seems simple. Lots of parsing edge cases. Sqlite isn't readable by hand but it's basically bulletproof. NDJSON is literally just newline seperated JSON, it's just easier to process as a stream without a special parser.

Sure, could be simpler, but there's a spec and multiple implementations: https://www.rfc-editor.org/rfc/rfc4180.html And the spec is ~5 pages.

Not sure why NDJSON is considered simpler, as json objects can be arbitrarily nested. Breaking into records is easier, but parsing is harder.

(ND)JSON is simpler because people actually follow the spec, unlike with CSV.

People violate the JSON spec all the time.

And following the CSV spec is much easier than following the JSON spec. And there's only like three edge cases.

> And there's only like three edge cases.

Unless you involve MS Excel or, worse, MS Excel on macOS. OTOH, pitfalls are: UTF-8 BOM, comma vs semicolon, single vs double quote, multiline cell content and escaping, escaping in general...

Then you’d have to get your hands on a parser. Who wants to write up the business case and spend months going through change control (they’d probably just say no).

JSON and NDJSON can also be much larger than CSV files if the wrong structure is used.

All this banter arguing over CSV, JSON, sqlite seems unnecessary when you can just push format X through a pipe and get whichever format Y you want back out: https://github.com/liquidaty/zsv/blob/main/docs/csv_json_sql...

(disclaimer: I'm one of the zsv authors)

import a CSV into Postgres

    with open(filepath) as fd:
        first_line = fd.readline()
        cols = []
        for col in first_line.strip().split(','):
            col2 = f'''"{col.strip('"')}" text'''
            cols.append(col2)
        cols2 = ','.join(cols)
        print(f"create table {table_name} ({cols2});")
    print(f"\copy {table_name} from '{filepath}' csv header;")

this variant will ingest whatever trash is in your CSV fields as-is (cast & cleanup later)

run the output in a psql instance connected to your db

(important note: \copy is a psql client command and it is critical to use \copy instead of COPY in many cases where the server process may not have the permission to read your CSV file. with \copy you can read any file the user that launched psql client has permission to read. to make things more confusing it is indeed possible to stream stdin through psql but you use the regular COPY for that instead of \copy)

Loading up 100TB of csv data into a Postgres db is not a realistic proposition.

Do NOT read a CSV file by splitting on commas. Python has a perfect CSV library built right in: https://docs.python.org/3/library/csv.html.

If you split on commas, your code will fail for quoted fields with commas in them.

This is obviously a quick and dirty hack. It only splits the header by commas. Postgres has its own read in logic you can adjust by passing arguments to \copy or copy. If you have anything more complex you need to handle it by parsing the header more intelligently than splitting on commas and adding appropriate arguments to copy or \copy

Oh totally. It also probably is the formats they already had -- so they just dumped them into a file -- versus making something more orthogonal and ergonomic.

I'm not sure what format they store their records in, but I have a hunch it's a lot more structured than what we see in the CSV files. The data dumps have to comply with some CMS guidelines set out here: https://github.com/CMSgov/price-transparency-guide

They use relational databases. Then a zillion ETLs to massage that data into every format they need it in, of which this is one of them.

lol, have you ever worked with data from a non-tech company? This is probably the best they have, even inside the company.

Can confirm. Also, it is not better in tech companies, they just have the same data in higher variety of formats and storage systems.

Not only was this probably a best effort, but I would bet that at least a few people were busting their asses trying to pull this data together and clean it up.

Just be glad the lawyers didn’t make the prices exclusively available via the traditional UHaul full of Banker’s Boxes.

There are a lot of billing codes. It’s not as simple as you hope. A giant csv export is easy enough to process and synthesize for normies.

They may have that thought but crunching large amounts of data is not exactly hard these days. Better too much than too little data.

Keep in mind these files are called "Machine Readable" for a reason. Yes, they dumped everything. Machines and 3rd parties are supposed to sort it out. Best be assured each carrier now has full visibility of each other leading to "transparency".

It might be a little exciting to be an underwriter right now :D

Of course it is.

The problem is that the health care costs situation results in many deaths and very severe economic consequences for much of the country.

Until lying, cheating, and scheming, and screwing over the public have consequences like prison time, you can expect executives to do everything possible to avoid complying with the spirit of laws like this.

There probably was an effort to create a more useful and sanely worded law that would provide a uniform format for rules that could reduce dataset sizes by a factor of 100, but was killed by the healthcare industry because it would require some implementation costs on their end and make the data files actually useful.

More like "how we do it in the cheapest way with minimum possible effort". It doesn't earn them any money, so they don't want to spend money on it.

They should be forced to provide the costs of procedures up front. As in the whole procedures not just provide prices for a million sub-procedures that the _might_ bill you for. This is how it works in basically every industry. Healthcare tries to argue that it's impossible for them to do this, but is just a load of bullshit.

Came here to say the same thing. I would expect their internal systems to calculate certain pricing components on the fly so it feels like they’ve deliberately built all possible permutations and data dumped that.

Basically a document dump - https://en.m.wikipedia.org/wiki/Document_dump

I wonder what percentage of work in the US healthcare system is completely unnecessary from a general perspective but made necessary deliberately to justify the unethical system that allows millions to die unnecessarily.

Judging by the US's price/outcome ratio compared to other developed nations, a little over half[1].

[1]https://www.pgpf.org/blog/2022/07/how-does-the-us-healthcare...

Why that article points out the US spends $12k/capita on healthcare the singles out administrative costs at $1k/capita while ignoring all the other relevant factors is beyond me. They then use the misleading infant mortality stat, ignoring that the US considers vastly more babies viable than any other country, meaning we try to save infants that other countries write off, thus they count against the US when it fails, but not against the other countries that don't count them as viable. It's a really poor article ignoring important nuance in what it presents.

The US pays about twice per nurse or doctor in the system, and part of that is because the US pays nearly twice for most skilled work. So, to get prices like most other developed nations, we would be forced to cut nurse and doctor salaries, which would likely lower quality of workers as future workers went to more lucrative fields, which would likely lower outcomes.

The US can have higher cost or lower quality. How would you make this tradeoff?

> So, to get prices like most other developed nations, we would be forced to cut nurse and doctor salaries, which would likely lower quality of workers as future workers went to more lucrative fields, which would likely lower outcomes.

Why are you ignoring all of the costs that go to people besides nurses and doctors? I know very rich people whose entire careers are built around selling overpriced products to hospitals. These people are leeches that provide no value other than profiting off of dumb compliance laws. If you can buy the same product at any store for 1/10 the price, there is no benefit to requiring it be gatekept by people whose sole incentive is squeezing blood from a stone.

Get rid of graft. The problem is the system and the incentives it creates. US healthcare is dictated primarily by insurance companies who care more about maximizing profit than providing healthcare.

To fix the system you start with increased transparency, then you focus on accountability. Why do we allow such blatant corruption? Let's get rid of all the leeches first, since they provide no actual value while jacking up prices. There are so many areas we can improve results and cut costs before we address the salaries of doctors and nurses.

Which part of this equation is contributing to hospitals charging 50 dollars for a bag of IV fluid? I'd cut that part out. Whatever it is.

That price pays for the parking deck, security, janitors, nurses to administer the bag, needle disposal, IT, admin salaries, the hospital building itself, etc etc.

An urgent care can probably administer an IV. If that’s all you need, go there. They are far cheaper and not as lavish (or equipped) as hospitals.

It’s crazy how every other western country also has those things and yet… no 50 dollar saline bags. Keep defending graft though

> The US pays about twice per nurse or doctor in the system, and part of that is because the US pays nearly twice for most skilled work.

which is in turn because in the US an average GP comes out of medical school with $200k-300k of student debt that has to have interest serviced and paid off within some 10-20 year timespan. That cost ultimately ends up being borne by the patient and their insurance.

unfortunately the US is very resistant to the idea of education reform in general, very very resistant to student debt relief, and very very very resistant to student debt relief for "high earners" like doctors and lawyers, even when a huge chunk of that earn is going to debt service. But there is a shortage of doctors and we're doing everything in our power to make the path unattractive for new students. And this time the problem isn't even the AMA - the AMA agrees there is a problem and is onboard with expanding the pipeline... it's just not all that attractive a profession anymore when you can make equal/higher compensation (after considering the debt) in software or other fields.

doctors are still extremely well-paid professionals in other countries, but if we tackle the cost of education we can get our numbers down much closer to theirs. conversely if you push salaries too low then servicing $200-300k of student debt won't be realistic and the path becomes even less attractive.

medical care is probably the single most complex political problem in the US because it's basically at the nexus of every single social and political problem we have. doctors are too expensive... because they're trucking around a quarter million of student loan debt from our shitty education system. we spend way too much on end-of-life care and not enough on earlier care... because seniors vote. we have way too much overhead due to the multi-payer insurance system and the market-driven pricing system's overheads... and all those insurance companies are huge lobbyists too. Drug and device costs are out of control... because the US doesn't allow conditioning of regulatory approval on price negotiations, or reimportation from other countries, etc. It's just every single political problem in the US in a single field all at once and every hand is dipping into the till as much as they can get away with, and it's politically infeasible to slap the hands that are necessary to slap to actually get costs reduced.

A debt of 1 to 1.5 years salary does not go very far to explain why US doctors are paid double what they would be in other countries.

The US brought this problem upon itself by cutting medical school funding in the 1980s to reduce the number of doctors and keep salaries high. That situation remained until 2005. Now we have too few doctors, too few schools, and a generation that grabbed all the money for themselves and is now retiring.

My understanding is that the largest portion of the discrepancy with other nations is the price of facilities. And that those facilities cost much more at non-profit hospitals (which is most of them). The hypothesis is that administration compensation is proportional to procedures performed, but money taken in can't be kept, so it is pumped back into facilities perpetuating the cycle.

>the US is very resistant to the idea of education reform in general,

I suspect almost all Americans are interested in education reform, but are split between two opposing directions: getting rid of nondischargeable, subsidized federal loans; or making the whole thing run on federal money.

Probably because the people pushing for free college etc tend to be ones studying the humanities, which gives people a bad impression of the whole thing. People make fun of Fox News touting lesbian dance studies majors, but the reality is most people don't support funding your bullshit gender studies degree with their tax dollars.

> the AMA agrees there is a problem and is onboard with expanding the pipeline

Oh come on, they could start by accepting everyone with a 3.5+ and decent MCAT instead of requiring that you have a 3.95, volunteering experience, clinical experience, and near perfect MCATs. The path is unattractive because it's filled with bullshit requirements that don't matter.

On top of this most med schools discriminate against their largest pool of potential top students: Asians. It's well known if you're Asian you need much higher MCATs and GPA to get into med school. How many people have been pushed out of considering medicine because of this?

>>Oh come on, they could start by accepting everyone with a 3.5+ and decent MCAT instead of requiring that you have a 3.95, volunteering experience, clinical experience, and near perfect MCATs. The path is unattractive because it's filled with bullshit requirements that don't matter.

I for one am glad that it s hard for doctors to get into med school - allowing less qualified people to practice medicine sure doesn't sound like a recipe for good outcomes.

As far as the non-academic 'bullshit requirements' as you put it, they matter - last thing you want is someone going to med school because they were above average smart, and there parents told them to goto med school (it happens) - much better to have people that have been in the trenches dealing with medical issues at some level who know what they are getting into - i.e. people who perhaps were a nurse first, or EMT or paramedic, or even a non-skilled person who provided personal care to dementia patients in nursing home - just being smart isn't enough to be a good doctor - doctors deal with a lot of things that most of society would find distasteful - better to weed out those folks before they ever set foot on campus taking up the slot of someone else that is more well rounded and proven they are not choosing medicine just because it pays well and their parents pushed them to it.

I would take a smart doctor motivated by money over a dumber one motivated by caring for people.

The reality is all of the top surgeons, cardiologists, etc. didn't become those professions just because they were "well rounded", they were smart and they wanted prestige/money. It would be good for medicine to have more smart and ambitious people.

Well rounded is just a euphemism to discriminate against Asians through affirmative action.

>>I would take a smart doctor motivated by money over a dumber one motivated by caring for people.

Luckily we don't have to make that choice, we can have the best of the best - the smartest people who want to go into medicine for the right reason - thats why its hard to get into medical school, as it should be.

>>"The reality is all of the top surgeons, cardiologists, etc...."

I assume since you are making such a sweeping statement that presume to know what motivates 100% of MD's, that you have a link or reference to back up that unequivocal statement? I thought so.

>>Well rounded is just a euphemism to discriminate against Asians through affirmative action.

Are you one of those people that assumes if you simply mentioned race in your argument, you win by default? Pathetic.

> thats why its hard to get into medical school, as it should be

We literally have a shortage of doctors and this is your attitude? Someone who wants to make money is an equally good or better doctor than the person who wants to help people. Medicine is scientific: you either do the operation successfully or you don't. You diagnose the patient successfully or you don't. A person's motivations for becoming a doctor doesn't play a factor in their skill.

We don't ask McDonald's workers why they want to work at McDonald's, why do we need to do it for doctors?

> Are you one of those people that assumes if you simply mentioned race in your argument, you win by default? Pathetic.

Do you deny that terms like "well rounded" and "holistic" are used to discriminate against Asians? Or should I point you to SFFA vs. Harvard, which showed that your coveted "well-rounded" personality traits can be and are used as tools of discrimination? I'll remind you that Harvard intentionally reduced the personality scores of Asians to make them seem less "well-rounded".

Med school admissions would be fairer without requiring such things as "well rounded" candidates. Personality scores are subjective and subject to bias and foul play, MCAT scores are not.

> to justify the unethical system that allows millions to die unnecessarily

Which people are those millions?

The system saves millions of lives that would have died in generations past. How do you factor that into your claim?

There are lot of people who don't go to a doctor when they should. Even taking an ambulance after an accident is a gamble a lot of people can't afford.

>>There are lot of people who don't go to a doctor when they should.

and there are an awful lot of people, even if it is free or paid for by a great health insurance plan that ALSO don't go to the doctor when they should - thats just human nature

and on the other hand, lots of people running up ten's of thousands of dollars in unnecessary tests because they are hypochondriacs and run to the doctor every time they have a sniffle and demand every treatment and test under the sun.

I'm comparing the number of preventable deaths in the US vs countries with similar GDP/capita

https://www.oecd-ilibrary.org/sites/3b4fdbf2-en/index.html?i...

The US has a mortality rate due to preventable causes comparable to Poland/Slovakia despite having nearly a 4x higher GDP per capita. Even poorer countries with better systems do far better w.r.t preventable mortality. This amounts to an extra 100,000 deaths per year approx vs countries like Italy, Germany, Switzerland, Sweden, etc.

Those countries have lower obesity rates.

It's pretty bad probably. It's basically a system that is incentivizing companies to make lots of money where a lot of the checks and balances are misaligned (in some cases intentionally so) which further enables this. So, you have pharmaceutical companies charging extortion rates for products that they sell for next to nothing elsewhere. Insurers that squeeze their patients hard. And hospitals that blindly prescribe medication because the patient demands it because they pay so much money for their insurance. Hospitals don't care because it's not their money and they get to bill the insurer for all sorts of bullshit. Insurers simply raise the prices for their customers. And they can actually cut loose patients over all sorts of technicalities so patients don't complain about this.

Aligning the incentives is pretty hard but not impossible. The Dutch system was facing rising cost a few decades ago. It was split in a private insurance and public insurance system. Privately insured people enjoyed all sorts of perks (like private hospital rooms, less waiting time, etc.). The same system still exists in Germany (I live there currently).

To improve financial efficiency the Dutch government decided to get rid of public insurance and empower people to switch insurance. Everybody has to have insurance, all the insurers are private, and they have to compete to keep people as they can choose to jump to another insurer and they don't get to reject people. They all have to offer the same base package of care to everyone but can choose to diversify on top of that. This results in people shopping around and being treated like customers by insurers.

The second thing they then did was empower insurance companies to make deals with care providers. After all, they are paying the bills and if some hospital is being inefficient, they have to pay for it. They can't reject patients. But they can make deals with certain care providers or refuse to do business with others. This incentives care providers to align with insurers.

Likewise, pharmacies that supply medication are incentivized to look for cheaper alternatives. So, pharmaceuticals end up competing with each other for some things and pharmacies will pick what's cost effective rather than what doctors prescribe (in case of compatible alternatives).

It's not a perfect system but it has resulted in hospitals and insurers improving their game and getting rid of inefficiencies or bad service. Bad insurers lose their customers, inefficient hospitals result in insurers taking their business elsewhere and they suffer financially. Smart hospitals and insurers align what they are doing and avoid needless treatment. Patients and employers shop around for the best insurers based on the needs and means and to get the best rate and care or access to their preferred care providers.

I actually live in Germany which has a system that resembles what things used to look like in the Netherlands. It's a bloated, inefficient system. There's stupid bureaucracy left right and center, endless referrals and waiting lists, and you are treated like cattle. I have private insurance so I get to jump the queue but I also get to deal with doctors that are a bit too trigger happy with treatments and needless appointments that they can squeeze the insurer for. The insurance is super expensive for me. And I can't easily switch insurer so they can squeeze me hard and up their rates. The hospitals are pretty bad and miserable compared to Dutch hospitals.

Here is a golden opportunity for the info/data visualization community to show how their tools can handle big datasets to make them comprehensible to the public.

Seems like every week there's a new massive scale DB project or company getting announced on HN.

If they're looking for projects that create public value and demonstrate the power of their products at scale, digitizing this and making it searchable may be a good marketing project that's appealing to certain kinds of customers.

Figuring out the size of this data was part of the research phase for doing just that: building out that database. I'm curious to know if other people are already working on it (maybe Turquoise Health?)

Yep, we have built this database at Turquoise Health. I agree, the data is massive - and don't forget that it is all refreshed monthly!

Is that from the hospital side or the insurer side?

It’s my understanding these prices are negotiated to some degree, so it’s probably both sides at various times.

We have built databases for both and can compare between them.

It's cool seeing that Turqoise Health exists. One of my first programming projects back in the day (when I was trying to get a jr role in 2014) involved building a simple version based on data.gov medicare data. The inputs were terrible and tiny (e.g. chest pain at hospital X costs ~$60k on average across 5 patients), so I was always curious what a real world version might look like.

edit: As I reflect, I'm amused to recall that this was early enough in my path that I didn't know about DB indexes, so I was very proud that I figured out how to basically roll my own indexes by pre-sorting the columns by lat and lon. I don't remember whether my solution actually prevented a full-table scan, but it felt like a major breakthrough at the time.

Very cool. Who do you see as the likely users of that database? Is it primarily for researchers/data journalists, or is there a commercial value to it?

I'd be very curious to read more about the data cleaning phase when you get there. Specifically, how hard it is to combine this data and construct good schemas.

As someone who's worked on the provider side in different capacities, I can tell you that there could be tremendous value on the provider side.

It's entirely possible that two surgeons with offices next to each other could be getting reimbursed at wildly different rates for their most common procedures for their most common procedures by the same provider.

If you're that provider, you ABSOLUTELY want to know what the surgeon next door is getting paid the next time your group is negotiating with the insurance provider.

Interesting. I'm kinda surprised this is handled by the doctors themselves. I'd expect there to be professional negotiators who parse this data themselves and then use it to negotiate on their behalf.

It would appear us SQLite zealots have encountered the final boss.

Petabytes uncompressed would be tricky if you need to slice those columns. SQLite caps out at ~281 terabytes of storage before it can't track any additional pages.

None of this is to say you couldn't partition the data across a lot of SQLite instances in varying ways. I will probably take a shot at it this weekend. Looking to see just how unlimited my AT&T fiber connection is anyways.

> It would appear us SQLite zealots have encountered the final boss.

That's cute. :)

There isn't much value in feeding it all into a conventional RDBMS. OLAPs and columnar stores are what is needed here. But first it will need a great deal of grooming and ETL work.

Yeah.. It would be much easier to copy the data to S3/any object storage (better to convert it into a columnar format like parquet) and query it directly using a SQL on lake engine like Dremio or Athena or S3Select would work too.

>It would appear us SQLite zealots have encountered the final boss.

Just wait. It's actually a multi-boss fight, since you have to wrangle the Pharmacy Benefits Management datasets, plus Medispan, plus Medicare, plus all the MedicAid datasets, plus VA.

Are you and all your mightiest boxen bad enough dudes to make sense of the entire U.S. Healthcare industry?

You are not prepared!

I'm the CEO and cofounder of a health insurer that published its pricing data. See it on GitHub at https://github.com/evryhealth/price-transparency To add some fuel to this discussion, US healthcare has grown 3x as a percentage of GDP in 60 years from approx. 5% to more than 15% [1]. It has done so at the expense of the rest of the economy and communities.

Pricing transparency is only one piece of the puzzle. It is a tremendously antiquated industry. Fax is still state of the art -- welcome to the 1980s!

[1] CMS. https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

India is considered a "cheap and poor" country in many ways. It's GDP is 1/10th that of United States. Even then, India has free health care, and in many states (out of the 30+ states), Govt run healthcare is the best. Woman give birth to babies and walk out paying almost nothing, men break their bones and walk out paying nothing after a month of staying in hospitals and such. Insurance is never heard of or forced to, unless you own a automobile and pays insurance to drive it on roads. No monopoly of any kind.

And there are arguments against all these points, I concur. I just said it for the American folks to know.

Even private providers are affordable.

Must be fairly recent then...cause 10 years ago it was poor quality care by untrained staff.

https://www.mhtf.org/2017/06/23/quality-of-routine-labor-and...

Huh. 8 or 9 years ago I visited somebody in a hospital in rural India (maybe 100km from Hubli), and this was definitely not the case. A man was being ejected (after intake!) from the hospital with acute appendicitis because he and his family was unable to pay. There were probably 3 nurses in the hospital and 40 patients over several floors. The degraded ductwork and disgusting window mount aircon looked like legionnaires disease would kill anybody who could afford to stay.

Has a lot changed in the last decade? Is the “good” healthcare just in wealthier areas? Was this just an extreme outlier?

Obviously, this is just one (anec)datapoint.

Nominal GDP is not the best way to compare countries in these matters. Purchasing power parity might be a better metric as we are talking about service Indians can get in their own country.

This "data dump" is step 2 of 4 to deliver "on President Trump’s executive order on Improving Price and Quality Transparency in American Healthcare to Put Patients First."(1)

By January 1, 2023, plans and issuers must make price comparison information available with respect to an initial list of 500 identified items and services. By January 1, 2024, plans and issuers must make price comparison information available with respect to all covered items and services. This information must be made available through an internet-based self-service tool and in paper form, upon request. Typically, consumers receive an Explanation of Benefits after receiving care, which details the prices charged by the provider, the plan’s contracted or negotiated rates, consumer cost-sharing obligations, and other information. Consumers will have access to this type of information before receiving care and can use it to compare prices and better estimate potential out-of-pocket costs.(2)

(1)https://www.cms.gov/newsroom/fact-sheets/transparency-covera... (2)https://www.cms.gov/healthplan-price-transparency/consumers

I don't understand why this took so long when it was part of the ACA in 2014 [1].

How did it take another administration, an executive order, and 8 more years?!

Hell, even the Clinton plan was calling for it in 1993 [2] but that never went anywhere.

[1] https://www.healthleadersmedia.com/finance/new-price-transpa...

[2] https://www.heritage.org/health-care-reform/report/guide-the...

I think the reasons are just that: an administration change, fumbling about, lawsuits (if any) among other things. One specific reason appears to be that some hospitals were able to file waivers apply for exceptions. [1]. Not that I agree with any of these reason.

[1]https://www.cms.gov/files/document/hospital-price-transparen...

6000 hospitals x say around 10000 priced items, on average, per hospital x 100 different negotiated pricing formulas = 6 trillion unique prices.

Of course many hospitals negotiate en bloc as part of a healthcare network, and there probably are more than 100 different organizations that negotiated unique healthcare pricing but the ballpark number seems to make sense.

Seems crazy that SEC rules require structured data but these health accounting rules did not. I guess health care has better lobbyists.

This data is already available cleaned here.

https://turquoise.health/

I think that's hospitals not insurers.

I know it's not in the business interest of Turquoise Health, but I'd like to see that data be downloadable. There's a lot of insight sitting in the data.

This blog was a feasibility analysis to see what kind of work it would take to get that data. If we do get it, we plan on making it free to download.

Those are hospitals' cash prices, not the negotiated rates with insurance companies.

No they have everything.

https://turquoise.health/researchers

Unrelated: “dolt” vs “doIt” is one of my standard font competence tests

dolt vs do<capital>I<\capital>t you mean?

No, do<lowercase>l</lowercase>t vs doIt.

I would love to hear from an insider on what the difference is between these published files and the internal databases - I'm sure the difference between the two is striking. Malicious compliance, indeed.

It's really not malicious.

What you are seeing here is essentially part of the claims adjudication process output.

This takes as input the procedure (ie the ICD/CPT code) and the provider, and runs it against the 'plan design' (which essentially is what includes the provider networks and the associated negotiated rates per procedure) and outputs the resultant cost.

Same can be done on the PBM side, just substitute drug for procedure, and 'formulary' for 'plan design'.

The interesting question when you look at cross plan, cross provider, and cross carrier variances, is why :)

Many companies, careers, and lawsuits, are being born from this data drop. Will be fun times the next decade or so to see how this plays out.

Internal systems are rules engines with hundreds of branches for the most seemingly simple claims. If every payer tried to encode the rules instead of the outcomes of those rules, it would also be entirely unusable, but for a different reason. There is no standard way to encode these contract rules. There aren't any constraints on the legal language that can exist within a contract. When CMS passed this regulation, lots of insurance companies were stuck with systems that flat out could not generate this output. They then had to pay millions to consultants to crunch historical data in order to create these files (which, by the way, is technically not in line with the regulation -- historical data should NOT be used to generate these files). CMS defined in painstaking detail the format and content of these files. Health insurance companies flagged to CMS early on that this would result in a huge amount of data, but at least at the end of it all you get a bunch of dollar amounts, instead of legalese.

Where is the raw 50-100TB of compressed data available for download?

Is it fully public or does it require registration to access?

It's all fully public. Here are some tools that will get you the negotiated rates links along with the sizes of all the files: https://github.com/alecstein/transparency-in-coverage-filesi...

This won't get you all of the insurers, but it'll get you a a few of the major ones.

If you want links to the files of more insurers, here's a project from one of my friends at Postman: https://github.com/postman-open-technologies/us-cms-price-tr...

So - veteran data wrangler here. I skimmed some of Humana's files. There's lots of repetition that can easily be removed when converting from a raw input to an analytical dataset - basically the huge blocks of text in "BILL_TYPE_CODE: 130,139,..." in the ADDITIONAL_INFO field can be normalized away by building a quasi-Huffman-encoded lookup table.

Noteworthy(?): there seems to be a limit of ~100~ 140 sets of prices, as seen in the filenames:

2022-08-25_NNN_in-network-rates_0000000XXXXX.csv.gz

~Did I miss something? ... or is this some kind of technical limitation for Humana?~ Edit: I missed the alphabetical ordering. Still, only about 140 price sets.

Also, each plan member's JSON file has a small chunk of useful information, then a useless list of all 15k gz parts of a relevant NN_in-network-rates file (you only need the first filename to figure out which NN to reference).

For these files, you can use Range requests to download only the first, say, 50KB, and pipe it to gunzip and jq. (https://github.com/stedolan/jq/issues/31#issuecomment-900184...)

I would also be interested in helping throw such an analytical dataset into BigQuery. It'll be great for sharing an open dataset. No doubt this will still be a gigantic headache, but it is tractable.

Love the insights! Making a note to dig deeper into this. Feel free to reach out to me via email as well if you want to discuss more: alec@dolthub.com

This is the real solution to healthcare costs and quality. Instead of the government handing hospitals a blank check for low quality services in a single payer scenario, we allow price transparency, competition and the free market to drive down costs and increase quality. Hate him if you want, but this was a huge accomplishment by Trump that has just started to take effect.

If you think the government can bring down the cost of anything please see education and NASA for great examples.

You had to know you'd be downvoted mercilessly for that, comrade.

I'm hovering at zero lol, a lot of my comments are a war between up and down voters. I wish I could see total votes.

NASA?

NASA’s budget for 2022 is about $24 billion or roughly $145-$150 per working person.

Perhaps a lot of money depending on what you think should be prioritized. personally I think it’s hard to argue that they aren’t delivering something of high value to humanity, especially recently with the success of the JWST. And maybe very especially compared to other agencies.

NASA is wasting the bulk of their funding in an obsolete launch system. Over the he past 50 years they have held back any economical progress in access to space.

https://www.washingtonpost.com/business/nasas-artemis-rocket...

> NASA is wasting the bulk of their funding

SLS is expensive, but it's nowhere close to the bulk of NASA's funding. It's about 10%.

???? NASA brought us SpaceX and other competitive private space companies... can't blame them when Obama got rid of the budget for these wasteful things then they had to back peddle because of politics ... "jobs" lost in all those states... basically a socialist program for those workers to have a job.

"Over the he past 50 years they have held back any economical progress in access to space."

without NASA there wouldn't be any SpaceX's and others doing space projects ....

You don't know that.

?? umm SpaceX was going bankrupt ... this is a fact... without the contract that NASA gave them there would be no SpaceX, are you a Musk fanboy i am not sure why your saying.

Price transparency is an essential part of a healthy market. Or so says the theory. I hope they release it. I wonder what I can do to help? I’m capable in db design, sql, etc being a data engineer by day perhaps I can help this effort.

I started a healthcare cost transparency platform in 2014 [1] and struggled to find costs by CPT code. The best we had was medicare reimbursement rates, which were hardly a good litmus for out of pocket costs. It's nice that after 8 years, things are finally shifting. Just shows how important timing is in entrepreneurship.

[1] https://ethansteininger.com/portfolio/comparedcare

Say someone ingests this data and clean it up make it usable, who's the customer for that service? What would they want to know from it?

I want to be able to visit a website, select my hospital, the procedure, and my insurance, and see what it will cost. Next to the result, please show me how much the same procedure would cost with the same insurance at other hospitals near my location.

You will literally save American lives.

Turqoise health kinda does this now, not as robust yet but I have been using it to check out prices. Hopefully, your use case becomes a reality soon.

Restoring sanity and making it like any other product or service.

I think that there is opportunity for some neat visualizations with map overlays, average costs of various categories of procedures, etc. As for the customer, I wouldn't know.

A patient wants to know how much a procedure will cost. Now the hospital can look up that data, since apparently (from experience, not hyperbole) no one who works there actually knows.

I work for a company (https://careviso.com) that is in this space.

We will sell our benefits investigation services to providers (hospitals, clinics) so that they can give better information to their patients. However our main customers right now are labs that do diagnostic testing.

What we've been able to do is build data-backed algorithms to determine whether a given patient's health insurance will cover a given test. Since patients are (obviously) more willing to get tested if they know that their insurance covers it, labs that work with us can increase their volume. Labs' sticker price for tests can be thousands of dollars, and they don't want to advertise that. They need information about what insurance the patient has and whether that insurance will cover a given test.

I think most of our data is internal data we've collected, but the Price Transparency Act is definitely useful to us in delivering accurate estimates.

(This is an oversimplification of our system. If you work in the space and want details, I'm sure our team would be happy to talk with you.)

Maybe good, maybe bad. I suspect the good will be lower prices as we resolve major conflicting prices for the same service. Maybe bad as we find that nurse Jackie is spending too much time taking care of your sick husband and that needs to cut back as the prices the hospital is negotiating drops. The service will become more standardized and robotic.

FYI, if you want to view the data in a reasonable format replace ~ with comma, but first make sure to replace any commas with something like a semicolon. I guess csv delimiters can be anything and they chose ~! Good thing there are no insurance company names with a ~ in it.

From my understanding though, these 'prices' are outdated nearly as quickly as they are published. I.e. sure you have a set, but everything is dynamic and changing. Seems like it would require a ML approach to 'understand' such a dataset going forward.

What happens if we mandate that hospitals cannot charge patients more than the lowest negotiated price they have for any procedure? That is to say, if you have offered to perform a procedure for $X, you can not charge anyone more than $X for the same procedure.

A common complaint here is that the single payer systems / public run systems have very long wait times compared to private US systems (this is true where I live as well. A simple MRI is a five month wait and that requires traveling to a different city).

Is it possible that they intentionally bloated the data to make it difficult to use effectively?

This seems very much like the episode of Veep'Boxes of lies' where they try to hide their nefarious deeds alongside the real day to day inter-workings of the vice presidents office but inundating the public with data.

This is a common strategy in litigation as well - if someone complains that you have pricked them with a needle, dump haystacks on your opponent's doorstep while also insisting on your right to a speedy trial.

A bit off tangent, is there something that can ingest unstructured data and output something meaningful? Something like GPT-3 but huge amount of data.

Aren't the costs of the US healthcare system largely driven by the cost of the healthcare workforce - basically, not enough trained personnel leading to the absence of competition, leading to doctors getting paid much more than they should? Of course it's going to be more complicated, with doctors' insurance issues and the price of meds into the mix, but still, how far does this factor goes into explaining the extraordinary cost of getting a basic treatment (let alone surgery) in the US?

this disclosure was spurned by recent federal legislation that required it. Im a full cynic on the disclosure, so be warned.

- these prices, as negotiated between insurers and providers, were already well known inside the industry. so much so that many procedures could be declined coverage well in advance of a customer ever needing one. this insider knowledge formed the core of many earnings reports for insurers and hospitals alike,

- Disclosure is meaningless if the customer has no alternative. most health services that bankrupt are emergency medicine, and as such youll pay anything to save your own life. thrusting a stack of price sheets at a faceless national healthcare monopoly and demanding a fair price is a laughable if not sad idea. Healthcare is not something capitalism is equipped to competently support.

- hospitals have zero incentive to work with you on any price for any service, and no federal state or local law will compel them to do so by virtue of a combination of bureaucratic deadlock and regulatory capture. is it, for them, more profitable to sell your arbitrary debt to a credit collection agency? shove you into a debt counseling service they get kickbacks from? work a long and grueling payment plan through their own financial services division to bolster quarterly profit long-term in a recession? or just ignore your pleas entirely? what they charge is not up for debate by you.

For profit Health insurance is a scam.

It´s like if you signed a contract to pay Netflix a monthly fee to eventually watch a movie, and for some reason Netflix profit would be based on you watching as little as possible. They would do all in their power to minimize the amount of content you could really watch. Unaligned objectives. And the problem is that unlike Netflix, Health Insurance (at least in the USA) is inelastic: You MUST pay for it.

I wonder what their egress bill will be if a large number of people are interesting in parsing this data.

Yeah the whole SaaS breaks expectations as far as using a server.

This is unacceptable. Perhaps it meets the letter of the law, but certainly not the spirit. This doesn't begin to make healthcare anything like a "free market". It's dishonest in the same way a restaurant might be forced to release a nutritional analysis of their food, and so they release a molecule-by-molecule description. Despicable.

You assume that they’re being intentionally nebulous but in actuality it really is that complicated.

I said precisely what I meant: they've failed to meet the spirit, if not the letter, of the law. Whether or not it's intentional is beside the point.

I wonder if our entire health care problems in the US stem from the medical cartel itself. You have medical schools limiting seats, you have physicians and head physicians and medical groups lobbying for changes, and you have inflated doctor salaries…

A sane approach might be to let more people graduate medical school and increase the number of applicants…

I don't think he meant largesse did he? He seems to mean "large size."

A worthy cause. Thank you so much for your work. Please keep it up.

Anyone knows if this dump contains drug insurance coverage?

I believe this was a Trump policy

This is clearly obfuscation. There is no way they have "negotiated" half a trillion of anything.

De-reg. De-reg. De-reg.

Could we rename the title to: "Health insurers just published close to a trillion hospital prices"

This post is lot more interesting and important than the current short title would suggest.

Seconded

Sure.

USA Healthcare is 19.5% of GDP. Canada + Australia + UK + (a few similar countries) average 10.5% of GDP.

The USA healthcare price gouges via run away prices. Healthcare corporations corrupting congress is the fuel that forces this on people (and breaks a free market).

But looking from another perspective - if healthcare is 20% of GDP, an awful amount of people are therefore paid directly due to this "waste".

Any improvement in efficiency would mean those people lose out on jobs. A new use for them must be found, or there will be massive unemployment (at least, short-medium term).

Yes, and we should also think of the blacksmiths and the elevator operators, milkmen and horse carriage drivers, who will unfortunately be out of a job if we make our society more efficient.

Why not go further still. Smash a window so that window makers can make a living, slash someone's tires so that tire companies can employ more people.

I heard some people in all seriousness explain, that they throw their garbage just on the way and not in a bin, to create cleaning jobs.

I’ll go one better - pay they rat catchers per rat so they start breeding them.

aka https://en.wikipedia.org/wiki/Great_Hanoi_Rat_Massacre

My current job depends on the current system being wasteful (healthcare insurance administration). But I'd much rather have to find a new job in a new industry than have the current healthcare system of the United States.

Not sure why you're getting down voted so bad. It's a valid point. I recognize that there is waste and inefficiency in the system, but I can guarantee that any effort to "streamline" or cut "waste" will inevitably hurt everyday people... Even outside of job cuts.

If keeping existing inefficiency protects jobs, perhaps introducing new inefficiency creates jobs? But that would mean that we should force people to do wasteful things in order to stimulate the economy!

Thankfully the economist bastiat solved this absurdity in 1850.

https://en.m.wikipedia.org/wiki/Parable_of_the_broken_window

> we should force people to do wasteful things in order to stimulate the economy!

you laugh, but this is exactly what the US gov't does, esp. with military budget allocation. Why do you think all sorts of military products are split into different pieces for manufacturing, separated into different states? It certainly doesn't help efficiency.

I'm not saying that healthcare shouldn't be improved via efficiency increases - it needs improving! But let's not kumbaya and ignore the plight of those whose livelihood would be disrupted (and not of their own fault).

Most want be unemployed they will just make a lot less. Doctors, Surgeons and administrators are barely breaking 6 figures in many socialized systems, and those come with far higher tax burdens typically.

Yup. For the (downvoting) peanut gallery: aka "political economy". Obama Admin's compromises wrt ACA reform vs jobs has been written about.

Another example of political economy is two different efforts to address climate crisis, with very different outcomes.

During the Obama Admin, the push was for carbon taxes. Wonks loved it. Logical, concise, moral. Complete nonstarter. Because carbon taxes has no built-in constituency that's willing to advocate and defend it.

Whereas in 2020, progressives pushed "green new deal" themed industrial policy and investment strategy. Made most everyone a benefactor. Millions of jobs. 100s of billions of dollars. Much better political economy.

This is a peculiar perspective to see on HN. Isn't the entire business model of startups and YC based on ruthlessly "disrupting" industries using efficiency gains achieved through technology, causing the same sort of unemployment? Why should healthcare billing and administration be any different?

Actual founders are maybe 0.1% of the HN reader base. Most everyone else are tech workers not looking to disrupt anything.

I'm mostly interested why the USA suddenly becomes pro-worker when it comes to this expensive and inefficient healthcare system they have. I swear you could be talking to the most hardline GOP guy who wouldn't spit on a trade unionist if they were on fire ... but if you mention, say, single-payer healthcare they'll start weeping for the all the workers in hospitals' billing departments and in health insurance companies who will lose their jobs.

I mean I don't want anyone suffering either (one would hope you'd have adequate social safety net to take care of these people until they find another job) but it's such a bizarre exemption to carve out

No, they're worried that single-payer would increase healthcare costs and/or decrease quality. They might be wrong, but that's not why they'd be worried.

I've heard that too, but I have heard on multiple occasions that this will cause a lot of people employed in the field to lose their (sometimes quite well paying) jobs working in billing.

And for some reason it seems like a lot of those jobs are staffed by right leaning people, even if left leaning areas…

What do you mean by left leaning areas?

Probably they mean most cities, look at the voting statistics in various somewhat recent elections. If you don't buy the left/right dem/repub mapping, you can look at the various stances of the actual local officials elected.

There's a large web of insurance companies, hardware and chemical companies, provider networks, and universities that benefit too greatly from the current inefficiencies to ever move away from private insurance. Hardware and chemical companies like LifeSys have contracts with insurance companies and provider networks that state the insurance will only pay for things if the tests or treatment are done with that supplier's tools and that the work will only be done if it's within the network.

For a theoretical based on what actually happened where I live, Hospital X is contractually obligated to use a specific kind of infusion pump from supplier Y and order blood tests from specific supplier Z in order to get Blue Cross Blue Shield coverage. Meanwhile the state university pushed out the other hospital in the city and heavily expanded the surviving hospital campus they sponsored to take on the increased capacity and introduce the services they were previously lacking compared to their now dead competitor. So Hospital X is just following the policy of University Network A. All of which is a common practice.

In many states the state university sponsored medical care networks are the or are close to being the biggest employers. The University Of Iowa medical network, the West Virginia University network, and University Of Pittsburgh Medical Center network all have taken over a majority of medical care functions in their states, leaving mostly specialists and those in mental health to independent practices. That exacerbates the issue of insurance and supplier contracts, because these small places that are competing with the university networks often don't bother with insurance unless it's government provided and just prefer patients pay up front instead. They lose too much time and money sorting through the myriad private insurance providers, plans, and coverage obligations without full time staff to handle that for them. Medical billing is a massive industry for a reason.

Now, if everyone wasn't chained to private insurance and juggling all of these providers, coverage limits, and contractual obligations the number of inefficiencies and thus the overall cost would decrease. We have historical examples of this even in the U.S., by comparing what happened between 1960 to 1975 and it's modern equivalent of 2005 to 2020. Healthcare costs were increasing rapidly, doctors were dwindling in number, and there weren't enough medical students for generalist fields in the 1960s just like the 2010s. The major difference is that while quality of care continued to increase through the 1960s and early 1970s, both the efficacy and quality of care has gone down since the 2000s. The several minor differences were that nationwide coverage was rarely available in the 1960s compared to the 2010s, that Medicare was spending more than it was receiving in the early 1970s thanks to how Medicare was funded in the 1960s, and that privatization of entire hospitals was uncommon and frowned upon in the 1960s because of the income impact it had on the doctors. The U.S. barely survived the 1960s medical crunch with enough government intervention, but it is dying under the weight of the 2010s medical crunch because the government can't easily intervene and is lobbied to maintain distance.

So the reason the lead figures in the American right are worried about single payer is because they won't make as much money. And they're very good at convincing people to vote against their own interests because they know those people don't care to look into complex systems too deeply. As a result many of the regular voters and workers are worried because someone told them a lie about where the money is actually being wasted and what the actual history is.

> the government can't easily intervene and is lobbied to maintain distance.

Just picking this point out - how can lobbying stop something? As in it's worth too much lobby money to politicians to change it?

There was a quote by an opposition politician in Germany to the argument that Germany should buy the Eurofighter (which had huge cost overruns etc.) because it creates jobs. Loosely translated: "We can also build a pyramid for Helmut Kohl [chancellor at the time] if the goal is to create jobs".

The defence industry is treated like that in every country. Part of the reason why a country wants to retain some military industry domestically, is to ensure production capacity during a security crisis (kind of like for agriculture). It's not just "jobs", but "jobs" with that particular skillset.

For instance, Germany is producing the Leopard 2. They may export most of them during peacetime, but should they need to, they could start pumping out those tanks for the Bundeswehr instead. Furthermore, with the skills available domestically, it would take much less time to repurpose VW/BMW/Audi factories to also produce weapons.

Or maybe it would mean that more people actually receive quality care? In AU, at least, our waiting periods for pretty much everything are ridiculous.

Two economists are walking in a forest when they come across a pile of shit.

The first economist says to the other “I’ll pay you $100 to eat that pile of shit.” The second economist takes the $100 and eats the pile of shit.

They continue walking until they come across a second pile of shit. The second economist turns to the first and says “I’ll pay you $100 to eat that pile of shit.” The first economist takes the $100 and eats a pile of shit.

Walking a little more, the first economist looks at the second and says, "You know, I gave you $100 to eat shit, then you gave me back the same $100 to eat shit. I can't help but feel like we both just ate shit for nothing."

"That's not true," responded the second economist. "We increased the GDP by $200!"

They did produce $200 worth of value - i'm sure if the first economist didn't enjoy watching the 2nd eat some shit, he wouldn't have paid.

You used a wrong allegory to try to demonstrate a point that noone was making.

I’m a Canadian, and I would never want to give up our single payer system.

That being said, Canada has a huge health care problem right now. Frequently they need to close emergency services in major (& minor) cities at night due to staff shortages. The wait times for basic diagnostics is on the order of months (not days or weeks). For example, a relative of mine has lost 90 pounds since the start of the year, complained of chest pains and couldn’t (still can’t) swallow. They just got a basic scan after 6 months of waiting to confirm a baseball sized tumour in their lungs.

For many years we ran with just the bare minimum of staffing and equipment to keep costs low, and now, due to a number of factors our system can’t keep up.

Waste is not good, but a little bit of extra capacity (and cost) isn’t a bad thing when it comes to emergency services.

To be fair, I think at least some of that is burned out healthcare professionals quitting after two+ of pandemic ridiculousness.

(Ridiculousness not being the pandemic itself, but inadequate resources, planning, and political cover from all levels of government.)

Much of the current failures are due to conservative provincial governments (looking at you, Ontario...) purposely underfunding before and into the pandemic.

We are now reaping what they have sown.

This is a classic "underfund to prove the system doesn't work thus we must privatize it!" move.

How much do you estimate this is being underfunded, and do you believe proper funding for healthcare would push the percentage of GDP closer to the US number?

You're assuming the US healthcare system isn't equally underfunded. The US has massive doctors shortages (especially in rural areas), and that's not counting all the care the US just doesn't do because people instead just die since they can't afford to go to the hospital.

> You're assuming the US healthcare system isn't equally underfunded.

You don't have to assume. It costs twice as much as the most expensive health systems on earth, but delivers Afghanistan-level life expectancies. The problem isn't that we're spending too little.

And yet people skip tons of routine checks because they cost too much.

I have really no opinion on any of this, but please realize there are more factors than health care on life expectancy.

What is a better metric and how does the US do on it?

Infant mortality (but that's also tricky because of differences in reporting between countries), cancer survival rates.

Life expectancy is a particularly bad metric to use to compare health care systems, because it's heavily influenced by (1) how much people drive, (2) how much violent crime there is, and (3) how much drug addiction the country has. None of those are health care metrics.

I don't believe there's any credible critic of American health care that premises their complaint on America delivering bad health care. We deliver pretty excellent health care, and we deliver it faster than a lot of countries with better health care outcomes. We are in many places in the US overprovisioned for care (by measurements like empty hospital beds, or overprescription of elective procedures). The chief complaint about American health care is how expensive it is, not how good it is.

That distinction is especially important because getting costs down may involve confronting the ways American care is better than it needs to be or should be. For instance: we do a lot more elective surgeries than countries with better outcomes, in part because we do them outpatient here, and they're inpatient (a much bigger deal) elsewhere. For example, my understanding is you're much more likely to get a hernia repaired (probably needlessly) here than in the UK.

I don't know, but almost everything is more complicated than people often make it out to be. Unless you'd like to spend 40+ hours/days/years researching it, you're probably better off trying to be more laid back.

If you are going to use life expectancy you should at least not use hyperbole to compare. It would be fair to claim the US spends the most on earth but only gets Polish levels of life expectancy.

Afghanistan is a whole decade off that cohort.

Ontario is consistently the lowest spender per capita on health in the country.

Ref: https://www.fao-on.org/en/Blog/Publications/interprovincial-...

It's being underfunded by at least 10-15%, which is a lot for a system expected to run as cost effectively as possible. I'm getting that number from the average of $5336 vs ON at $4800. 4800/5336 = ~89%

I don't think we should aspire to US levels of GDP share. That seems quite excessive.

I think the solutions to our issues are structural changes and adequate funding.

It seems a bit strange to call out the Conservatives specifically. Ontario has been purposefully underfunding healthcare for decades upon decades, with most of the damage done decades ago. Peterson (Liberal) forced practitioners to operate under fixed rates defined by the province, which even lead to a doctors strike. Rae (NDP) eliminated 8,000 acute care beds. Harris (PC) eliminated another 6,000 beds.

Governments of the last 20 years have held the status quo, which leaves them equally culpable.

Conservatives hate that their money is taken away to fund poor people and take money away from their rich friends, and it brings them to defund healthcare, liberals hate that it creates a natural monopoly and their inability to see a functioning society work without private hospitals brings them to defund healthcare

There's no point pretending you know what people's motivations are. Conservatives I've read/heard seem to generally want similar outcomes, but disagree drastically on the methods.

First sentence: don’t guess people’s motivations

Second sentence: explain people’s motivations

No, that's a category error. I'm not talking about every conservative. Just the ones I've listened to explain themselves.

I believe that guess and explain are two different verbs

This is happening in the UK too.

The NHS is still wildly popular so it's politically impossible to privatize from the outside in but it's becoming less popular as its effectiveness declines due to expanding mismanagement, underfunding and corruption when awarding contracts.

The frog has to be boiled slowly though.

>Frequently they need to close emergency services in major (& minor) cities at night due to staff shortages. The wait times for basic diagnostics is on the order of months (not days or weeks).

Part of this is COVID burnout. It wasn't this bad in 2019. Wife works in healthcare and sees the difference every day. Nurses crying etc.

Well, I'm here in a major metro area of the US and it's 6 months or more for every doctor I try to see. Very difficult to get in to see anyone for anything.

What's that major metro area? I'm in San Francisco and I have family in Boulder and in both primary care is like one or two weeks. Dermatology was a week and a half for me. A few months ago I needed imagining for a foot thing and it took three days for ultrasound and one week for an MRI. I thought this was the norm on big urban centers.

I live in a suburban area and I go to the doctor for completely random things for my kids because it’s so easy. I can get appointments to be seen within hours.

Midwest, large city; pediatrician is same day, Allergist same week, Developmental Pediatrics was 4 months, Pediatric Ophthalmology was a year, it really varies. I'm lucky to have all these specialities available, people drive 2 or 3 hours to use the Midwest Eye Institute.

Every "Family" doctor has stopped practicing or gone to a no insurance model that caters to wealthy people. You can only get "internal medicine" doctors for primary care. I've seen waits ranging from 4 months to a year, depending on what your dealing with.

It's also impossible to get a 2nd opinion. The specialists all tend to belong to the same groups so you'll call a different doctor and eventually get shunted back to the exact same doctor you started out with. Where the the competition?

Chicago. My actual GP schedules months out. An appointment with "any doctor in their practice" is within a week. An appointment at their affiliated urgent-care takes hours, usually less. The correct strategy is to get a GP affiliated with an urgent-care, schedule a checkup with the GP, and, meanwhile, just go to the urgent-care for everything; they'll send records over to your doctor if there's anything complicated.

Chicago, I can make a televisit appointment to my primary care doctor typically with 1 day lead times. In person is typically 2 so he can schlep down to his office. He is a single practitioner with part time office and IT help. He recommends going to the minute clinic a block away from my house for most things that I can recognize and only calling him for a yearly consult which is a review of blood tests and a discussion about my health or for something the clinic didn’t figure out.

This seems like a completely reasonable approach and I’m always surprised that it’s not the default.

> The wait times for basic diagnostics is on the order of months (not days or weeks).

The crazy thing to me about this is, most Americans simply skip medical procedures, or tests due to cost.

So American wait times aren't lower because their hospitals are better, they just server a much smaller pool of people due to so many being priced out of being healthy.

And honestly, the longer you go without doctor visits, more expensive, complicated and involved the process is.

This is a gray area too as unnecessary testing can be costly and lead to worse care: https://www.npr.org/sections/health-shots/2022/06/13/1104141...

“Most” Americans do not skip procedures due to cost. About 1/3 have (https://www.kff.org/health-costs/issue-brief/americans-chall...) and that is mostly dental procedures.

That is an atrocious number and something that needs fixing but we don’t need to exaggerate it to make that true.

Good link there, but assuming I’m looking at the same section as you, it seems like the 1/3 figure is for skipping or delaying tests and treatments recommended by their doctors, which doesn’t really tell us how many people forego seeing a doctor altogether due to cost concerns.

Technically it was 1/3 had or had family members, which means the number is actually much better than 1/3 but I was being generous.

We don’t know how many people skip healthcare because a doctor is inconvenient (in the states or in other regimes) either. So it seemed the most appropriate comparison to make.

That's the lowest percentage out of all the sentences from that paragraph.

The 1/3rd is people avoiding treatment recommended by a doctor. 43% of people reported to have avoided healthcare due to costs.

To me "Not most people, only 43%" isn't what I would consider too much of an exaggeration.

And also...

For many years Canada (and similar countries) have relied on cutting costs by importing health care professionals from other countries. That pipeline has now shrunk considerably, resulting in the exposure of the underlying problem.

For what it’s worth, this experience isn’t entirely uncommon in the US either. I live in a rural area that has a trauma center and a hospital because it is X distance from the next closest hospital and gets money from the state/county to exist. But that is all they are. Outside of diagnostic imaging and very basic healthcare, you are shipped off to either Portland, Seattle, or in some cases Idaho. Everything is backed up and it is largely due to a lack of personnel because people are just not joining the field. It is basically the inversion of your problem. We burn out everyone who works in a hospital specifically because of the pursuit of profit. They’re all understaffed and everyone works shifts that are unsafe due to their length to compensate. Hospitals are an incredibly stressful place to work and doctors and nurses have inherently difficult jobs. Yet they’re treated largely like disposable assets to be burned through. It is bad for patients and it is bad for the staff. But it is apparently good for business.

AU is closer to double that

Reference please.

This says 10.2% as of 2020 : https://www.aihw.gov.au/reports/health-welfare-expenditure/h...

We detached this (mostly off-topic) subthread from https://news.ycombinator.com/item?id=32744719.

My current assumption is that private healthcare/insurance is to blame, because countries without that or with less generally have better outcomes at less cost. Looking for evidence to the contrary

As two quick examples, both Switzerland and France have private healthcare providers and insurers. I think that’s enough to falsify your assumption :)

Those countries both have "less generally" than the USA.

I don't think that disproves a general trend that increased socialization in healthcare costs leads to better outcomes and less per-capita spending.

Also FWIW France and Switzerland both have universal healthcare, under different systems where France splits payments 3 ways and covers more with the govt[1], and Switzerland seems to have a system like the ACA in the US where it's compulsory, but they also set caps on the deductibles and maximum price.

[1]: https://en.wikipedia.org/wiki/Health_care_in_France

[2]: https://en.wikipedia.org/wiki/Healthcare_in_Switzerland

> France and Switzerland both have universal healthcare

You said private healthcare/insurance were to blame. Switzerland has private health insurance.

Universal healthcare is a separate goal post. For what it’s worth, I’m unclear its comprehensive iteration is compatible with America’s immigration model. (It absolutely is for life-saving measures.)

What aspect of America's immigration model do you think intersects with this?

> You said private healthcare/insurance were to blame. Switzerland has private health insurance.

Private business in all western countries operates within the regulations and laws that cover them. The health insurance industry in Switzerland operates under a very different set of regulations and laws than the same industry in the USA. If you want to blame the OP for not being more explicit - "private healthcare/insurance and the regulatory framework are to blame" - then fine, but ... this is actually the crux of the issue.

> but ... this is actually the crux of the issue

I'm not sure it is. Universal healthcare is orthogonal to private health insurance. That's the lesson of Switzerland's example. I don't believe this is commonly known or accepted in American politics. Instead, any attempt at reform is pitched and vilified as an attempt to end private health insurance and healthcare.

Not sure why you're getting downvoted, but this is exactly correct. Universal healthcare != public healthcare.

It may not be commonly known in the USA. However, I'm a european immigrant of 33 years, and it's well known to me.

However, "private health insurance" is not, in and of itself, really "a thing". Only "private health insurance plus a regulatory structure for it". It is in this department that the US falls over so badly, while, for example, Switzerland gets it (mostly) right.

Switzerland has very strictly and non-deniable obligatory minimum (very broad in coverage) insurance, with regulated yearly price adjustments and on top of that, publicly funded hospitals and clinics (mostly unprofitable but of high quality and offering treatments that would not be profitable for private hospitals) that issue their bills to the health insurances. And, to put the icing on the cake, there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.

Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.

> Switzerland has very strictly and non-deniable obligatory minimum (very broad in coverage) insurance

So does the US: https://www.healthcare.gov/glossary/minimum-essential-covera...

> there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.

> Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.

You're mistaken, Switzerland has no centralized social insurance — it is fully privatized (for real medicine as well as alternative medicine), and is decentralized among its Cantons. It's just that the private Swiss insurers tend to be non-profits (same holds true for the US, e.g. Blue Cross, Kaiser, etc) and the for-profit insurers' profits are heavily capped/regulated (same holds true for the US).

TIL Blue Cross is a "non-profit"

Blue Cross is sort of a franchise system with different regional/state franchises. All of them were originally nonprofit but many have changed over the years to be for-profit (notably BCBS of California, for example). My local franchise, BCBS of North Carolina is still not for profit: Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham, Fayetteville and Winston-Salem. https://www.bluecrossnc.com/about-us

Social insurance is covered by AHV/SVA/IV (funded by salary deductions and cover congenital defects, invalidity, some rehabilitation therapies and other non profitable coverage) and of course healthcare is not fully privatized as you say: private insurances are private, offering highly regulated compulsory insurance and can offer less regulated additional insurance. Some hospitals/clinics/health and elderly centers (cantonal) are kept with public debt & public donations even if deficitary because private clinics would be unprofitable otherwise.

I don't know if you legitimately do not know that.

I did not talk about federal/cantonal to avoid writing a thesis in a comment. I never said it was centralized.

You're conflating Switzerland's social pension with the Swiss health insurance system. Swiss pensions do not subsidize the cost of healthcare delivery, and are not used to cover health costs at the point of service (for real or alternative medicine). The payment of healthcare at the point of service is facilitated by a fully privatized industry of insurers.

Salary deductions pay for subsidies to lower income beneficiaries to purchase the same private health insurance (KV) as everyone else. This is more or less identical to the US's ACA, and in fact the ACA was modeled after the Swiss healthcare system.

The one big difference between the US's ACA and the Swiss healthcare system is that the ACA also included an employer mandate and stimulated a regime in which the majority of working-age adults receive their private health insurance from their employers as opposed to the individual market, which is not how the Swiss KV works.

I guess that you don't know that, for example, if you get operated of a congenital defect in Switzerland, the bill goes to the SVA instead of to your private insurance (and so on for specific cases)

I am not conflating anything, you have a superficial understanding that makes you think it is privatized. If you dig into the spending public & private and the actual details you would see that Switzerland is not privatized as people generally think.

I'm referring to the majority of working age adults.

Even the US uses Medicare for certain congenital diseases as well (as well as end-stage renal disease).

The Swiss private KV system accounts for the vast majority of health expenditure, even more so than the US where half of health expenditure is nationalized in Medicare and Medicaid.

But another way in which Switzerland maintains its healthcare system with public money is through the -often deficitary- cantonal hospitals/clinics/health care centers (also helped at the municipal level)

As a heads up, ‘deficitary’ doesn’t mean ‘deficit running’ in English. It is closer to the word ‘deficient’ which I don’t think is your intended meaning. Thanks for the insightful comments.

Thanks for the comment! I was meaning the former (under debt).

The intention of my comments was to make clear that in that regard, Switzerland is not an efficient free market private insurance paradise. There are lots of nuances to it, and the private insurance system in fact brings in inefficiencies, namely, a very complex and costly cost itemization and enormous amounts of paperwork and stress for doctors, customers, employers, and the insurances (for example, if there is an accident in a public place involving a car, there are at least one or two days worth of people's times just filling in forms)

OK - sorry then! That makes total sense too; I was simply reading too much into the payments discussion happening. Thanks for being polite and for your contributions.

I'm not sure that your argument makes the case you think it does. The majority of Swiss health expenditure is in the private sector (which differentiates it from many other healthcare systems). Subsidies and municipal market participants do not change that fact. In every industry in the world, the government may play a participatory role within a greater market. We see this in the US in the food industry as well (food stamps, food banks, etc) — but that still doesn't change that it is essentially privatized. If the US adopted, like-for-like, Switzerland's healthcare system, the US's public spending towards healthcare would decrease, not increase.

Fortunately, life-threatening, chronic, bankruptcy-inducing, rare-and-disabling conditions represent a relatively small portion of the total healthcare spending (removing the most widespread chronic conditions). Those are also the least profitable things to insure (require a constant and sustained spending to maintain the knowledge/capability and fund research even if underutilized) if we want to ensure that any human can get reasonable access to those treatments regardless of their wealth. For this reason, countries like Switzerland or Germany maintain a "healthy" public (with lots of adjectives) healthcare system alongside.

This is where you might be out of your element, it seems. Life-threatening / chronic / bankruptcy-inducing conditions do not represent a "relatively small" — at least in the US, 90% of health expenditure is on chronic health conditions (https://www.cdc.gov/chronicdisease/about/costs/index.htm) — this includes heart disease, stroke, cancer, and diabetes. I work in the industry and this comports with what I see on the ground as well.

In Switzerland (and also the Netherlands), the vast majority of this is covered by private health insurance, not via any sort of public health insurance. That's what sets Switzerland and the Netherlands apart from other peer developed countries, and they have results to show for it.

Regarding rare conditions, we agree — even the US has a public healthcare system alongside which covers rare conditions (e.g. end stage renal disease). US's Medicare Advantage system of private individual health insurance for senior citizens (with Original Medicare as a public option) is also a proven model with results to show for it. The CBO expects that by 2032, 61% of health insurance expenditure for senior citizens will be by the private sector (https://www.kff.org/medicare/issue-brief/medicare-advantage-...).

But that’s the same as the US. If you are born with a disability you can get social security insurance (SSI) payments that can also qualify for public (Medicaid) insurance.

https://www.cbpp.org/research/social-security/ssi-a-lifeline...

Ah good catch I was moving the goalposts there - I think in my head public and universal and basically interchangeable - if everyone has it is it a public good regardless of if it's provided by a collection of "private" companies

It's not just Switzerland and France; the Netherlands also has a private-only health insurance system. It's also very difficult to draw decisive conclusions since, across countries, there are hundreds of confounding variables — it's not just public vs private, but it's also which regulations exist in each country, whether it's employer-sponsored vs individual, general willingness to pay, etc. You're correct that Switzerland has a system like the ACA in the US, but the biggest difference is that it's not common for the Swiss to get their private insurance from their employers; it's all on the individual market. The US is actually unique in that regard, and is probably the most significant difference — the vast majority of working age adults in the US get their insurance from their employers, and as a result the ACA's individual market has been in a dire state since the program's inception.

Also "socialization" is very different from "nationalization". The general trend you're talking about is more to do with the fact that having society subsidize healthcare for the poor can lead to better outcomes. As it relates to who actually does the insuring, underwriting, and payment (public vs private), one isn't necessarily better than the other; each has its trade-offs. It's just that the US (in particular) has chosen the worst of both worlds.

I work in this industry, and from where I sit, the closest thing we have to a clean A/B test that controls for all of those confounding variables is actually being run in the US right now, with Medicare. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.

- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)

- For most beneficiaries, Medicare Advantage costs about 40% less than Original Medicare and are, on average, of higher quality than Original Medicare (https://healthpayerintelligence.com/news/medicare-advantage-...)

- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)

So no, you cannot look the cost difference between the US and other countries and simply conclude that it's because of private insurance, because the actual data tells a different story. And "universal healthcare" is not the same as "public" healthcare. It might help to think about it this way: universal access to food can be achieved without nationalizing the food industry, or the food payment industry.

From medicare.gov:

> Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. (emphasis added)

Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.

Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.

I actually work in this industry and adjust claims myself from time to time, so I love talking about this stuff!

> that must follow rules set by Medicare. (emphasis added)

Yeah, I'm not sure that anyone seriously believes that insurance companies should operate in a 100% unregulated fashion. Even the US's food industry (which is predominately privatized) is regulated in some capacity. The argument is whether regulated private insurance can deliver good outcomes. That is very much the case, as evidenced by Switzerland, the Netherlands, and Medicare Advantage.

> Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.

First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.

To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices.

This cocktail of regulations does not exist for Medicare Advantage insurers — even though they are still regulated in different ways. That's a very important distinction. Currently, Medicare Advantage insurers are allowed to return 50 percent to 70 percent of any cost savings to beneficiaries in the form of reduced premiums or expanded benefits — whereas with employer-sponsored insurance, even if such cost savings existed, they would accrue to employers (unbeknownst to worker beneficiaries) — and that's assuming there are cost savings for employers; there aren't, due to the aforementioned regulatory concoction. A big part of why Medicare Advantage actually works really well is because it's effectively a basic income for health insurance, it's just that individuals are empowered to use those dollars to buy whichever healthcare plan meets their needs (including a public option), as opposed to being forced to choose among a small selection of plans curated by an employer.

> Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.

Medicare Advantage plans can both be HMOs as well as PPOs (https://www.medicare.gov/types-of-medicare-health-plans/pref...), it's just that there happen to be many MA plans that are HMOs. HMOs can have very good outcomes with significant cost savings (think of the pre-2010 UK NHS as a public HMO), but can also have bad outcomes if managed poorly (think of the 2022 NHS or US's VA as poorly managed public HMOs). With Medicare Advantage, seniors have the option to choose.

The obvious regulation which almost every other country has is direct price controls on medicines, treatments etc. Not profit percentage controls. A dead simple “this is how much you’re allowed to charge”.

I don’t really understand why anybody would be against introducing this in the US.

It is not so obvious at all. Medicare Advantage does not have price controls, and it still costs less per capita than Original Medicare.

> A dead simple “this is how much you’re allowed to charge”.

This has its own set of unintended consequences, including physician rationing (it's a huge crisis of the NHS right now), and a reduction of investment in new medical research. There are many good reasons to be against introducing this in the US.

Switzerland does not have price controls on medicines, treatments, etc. and the reason why it is so often cited is because it enjoys a comparable level of healthcare innovation to the US while still ensuring universal access (through its ACA-like subsidies). It also costs a lot per capita (among the highest in the OECD), but it actually gets what it pays for (https://pubmed.ncbi.nlm.nih.gov/26766626/) (https://www.theweek.in/news/world/2022/05/07/7-reasons-why-s...)

In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.

> In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.

The UK's difficulty lie in their leadership and political issues and in the economic consequences of Brexit. I'm not sure it's the best example for your argument.

The NHS's difficulty lies in the simple fact that it is understaffed (https://www.express.co.uk/life-style/health/1633058/general-...) and the staff are underpaid (https://www.bbc.com/news/newsbeat-62290577) — leading to unprecedented wait times. This is because the "list prices" that the NHS pays for GP, nurses, and services are not subject to market forces, they are set by the government. The government is currently failing to address the supply loss with little political will to increase list prices (which propagate to the consumer through increased taxes). Brexit's influence is tenuous at best. Switzerland is also not part of the EU and doesn't face this problem. At best, Brexit exacerbated an already existing pricing problem.

Where you're correct is that the difficulty lies in leadership's inability to actually change the prices to attract the supply necessary to reflect the increase in demand — and that's because the Single Provider system is tied to politics rather than market forces. The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary. In contrast, the private sector can (and will) increase prices to overcome demand — we see this happening in Switzerland (https://pubmed.ncbi.nlm.nih.gov/26766626/).

> The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times

So where we may agree to disagree is that the NHS's woes are in fact a very strong example of the greater argument, on net.

>Brexit's influence is tenuous at best.

Indeed. It's basically the convenient bogeyman for opponents of the current government.

>The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary.

Private Eye on "24 Hours to Save the NHS <https://twitter.com/KulganofCrydee/status/833654730849136641>

> The NHS's difficulty lies in the simple fact that it is understaffed and underpaid — leading to unprecedented wait times. This is because the "list prices" that the NHS pays for GP, nurses, and services are not subject to market forces, they are set by the government. The government is currently failing to address the supply loss with little political will to increase list prices.

And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).

It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.

> And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).

Yeah that's completely untrue; the list prices that insurers pay for GPs are heavily inflated by the market distortions introduced by the Federal government. I don't know if you read any of what I've written up-thread, but I'll paste the relevant parts here for your benefit:

"First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.

Put simply, the US healthcare industry is not subject to traditional market forces.

> The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).

It's quite clear that the reason the government is not doing this is because it would further exacerbate the staffing shortage and lead to even higher wait times. That's not a political problem, that's a hard economics problem.

> It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.

There is a key governance difference between making the decision to lift distortionary regulations once & up-front so as to unblock efficient resources allocation vs actively having to continuously adjust resource allocation. With the former, you just have to trust that the "good governance" happens once, whereas with the latter, you have to trust that "good governance" happens forever (politics notwithstanding). The Swiss chose the former, whereas the UK struggles with the latter. Domestically in the US, Medicare Advantage is a proven model — and the governance prescription here is to have the entire private insurance industry look more like Medicare Advantage.

> big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.

I'm going to call you on this point, because what you're hinting at, whether you realize it or not, is that employers need to step up their medical care spend management game, which if implemented, looks damn near dystopian. As someone that works in insuretech, the number of times I've raised concerns about revealing too much about the shape of medical spend to employers is scary to quantify, because once you start going down that road, it isn't that far to "huh, 20% of our workforce is 80% of spend" hrrrm...

We do not want to be going down the road where employers are singled out as the appropriate optimizers there.

That's not what I'm suggesting at all. The point I'm making is that employers are not capable of being optimizers because they will generally be willing to spend more on medical care than individuals, and it's because they think about money very differently from individuals. Employers are generally able to swallow a premium increase of $15,000 -> $20,000 per employee per year (it just gets rolled up into total compensation). It's usually a drop in the bucket for employers, but to an individual that's actually a lot of money. It's the same reason why corporations typically cover business class (or economy plus) air travel without blinking an eye, whereas many individuals spring for basic economy depending on their willingness to pay. Showing employers the shape of their medical care spend doesn't change that equation all that much for the same reason that enterprises today are willing to spend more on SaaS licenses than individuals (or even small businesses) regardless of how precisely their QuickBooks or NetSuite instance shows them the shape of their SaaS spend. I work in insuretech too, sometimes even work directly with employer HR teams, and see this behavior all the time. We agree that employers should not be the optimizers here. It's not that they need to step up their spend management game, it's that the way they play that game will always be different from the way individuals play that game, and that's a big part of why per capita $'s spent are even able to be so inflated in the first place.

What I'm suggesting is that the proven private sector model is one where employers are simply not involved, not a part of the equation. Private insurance purchased on the individual market. That's exactly how it works in Switzerland, the Netherlands, and also how it works in Medicare Advantage (seniors directly buy their insurance plans using dollars they theoretically set aside over the course of their lifetime through Medicare FICA taxes).

The most practical way to get there, in America, would be to either enact Medicare Advantage For All, or to tweak the employer mandate to only include ICHRAs rather than group health insurance. ICHRAs are employer-sponsored funds (in lieu of employer sponsored insurance) that the employee-beneficiary uses to buy health insurance on the individual market.

Most countries don't have price controls, they have purchasing controls for their Healthcare systems. There is a huge difference.

For example, if someone makes a pill that cost $1 million to live one more day, they can sell it, but most national health services won't buy it.

In the US, the national health services and insurance companies are mandated to buy it, and a byzantine system of price controls ensure we only pay 900k.

A big problem with this approach is that if the price limit makes certain medicines unprofitable to invent and produce, they will not be invented and/or produced.

This is of course already happening since, most of the world has price controls. The US market is probably financing most of the world's medical research, and if we stop paying so much, it may shrink a lot.

When I worked in France, I had health insurance through my employer. I never really understood what it was, and fortunately never needed to use it.

That's a mandatory complementary insurance, the base costs are covered by the national insurance. It's a confusing situation that's somewhat similar to the US in that it's wasteful, pointless and mostly serves some private interests, but on a much smaller scale.

It's the mutuelle. The way healthcare works here, the essential medical stuff is reimbursed by the universal healthcare system (sécurité sociale), and the rest is out of pocket. The mutuelle covers the part that's normally for you to pay, which can be quite significant for dentistry and glasses. My employer currently gives me a mutuelle that's decent to start with, and I chose to pay a 15€/month premium for increased coverage.

For example I just got a 900€ dentist bill recently. By default the sécurité sociale would just reimburse 300€ of it, for the essential care as well as a standard deductible on dental crowns. With my current mutuelle there's only 3€ left for me to pay.

As a Canadian I have only know completely socialized healthcare.

One of our largest problems right now is that our system is failing and can’t keep up.

The solutions being rolled out by the provinces to fix the huge backlog of people waiting for care is to privatize more of the service delivery (while keeping single payer).

> I don't think that disproves a general trend that increased socialization in healthcare costs leads to better outcomes and less per-capita spending.

You also haven't given even a hint of proof for this alleged trend.

Maybe there is a trend, but let's look at some serious data before we just assume it's an obvious fact.

Google healthcare cost per capita vs life expectancy.

Last time I checked, Canada, for example, spent 1/3rd less than the USA and Canadians lived a few years longer.

IIRC, of the "universal coverage" systems, Switzerland's ACA-like system had the highest per capita, but still less than USA's system.

Much has changed these last few years. eg Our life expectancy in the USA has fallen.

I know this is really counterintuitive, but last I heard, health care isn't a major contributor to average life span.

A much bigger factor is GDP per person.

I think of it as: The more material wealth you have, the better your life is, and you get less risk of bad health.

Life expectancy is a terrible measure for quality of healthcare. It ignore so many other factors. The only way it could be a suitable measure if you assumed every human in every country was the same except for the healthcare they receive. It's pretty clear they aren't - lifestyle, smoking rates, alcohol and drug abuse, accidents, suicides, genetics.

You’re far better to look at things like “survival after cancer diagnosis” where the US has some of the world’s best outcomes.

https://www.healio.com/news/hematology-oncology/20180131/us-...

> Life expectancy is a terrible measure for quality of healthcare. ...lifestyle, smoking rates, alcohol and drug abuse, accidents, suicides, genetics.

Only if we assume public health is unrelated to individual health.

OK, so if we assume that, then is public health worse in Europe because smoking rates are higher than the US? How about higher alcohol consumption?

Using life expectancy to judge the quality of a healthcare system or quality of public health efforts is like judging car quality by how nice the body work is. It's a component, but a relatively minor one in overall quality.

Why are you asking me when you could just google?

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

Western Europe does better, Eastern Europe does worse. Pretty much as one would expect.

Your prior "5 year cancer survival rate" was pretty random. The cherry picking of one favorable stat while ignoring the mountain of counterfactuals.

I was confused.

Then I spotted this.

https://www.aei.org/carpe-diem/us-vs-europe-life-expectancy-...

Aha. Just another "libertarian" talking point. Good grief.

You're arguing in circles and not making a lot of sense.

First I argued that life expectancy isn't a good measure because of lifestyle, then you say "public health should address those", then I argued Europe does worse than the US on several public health metrics like smoking rates and alcohol consumption, then you go back to life expectancy.

I have no idea the point your making because you're failing to actually provide counterfactuals.

Good article on the topic of assigning a cause-and-effect relationship between life expectancy and health care systems: https://www.bloomberg.com/opinion/articles/2017-03-21/does-t...

I prefer the non-snark, non-partisan version of that narrative.

https://ourworldindata.org/us-life-expectancy-low

Here is your evidence:

In an analysis we published in 2011, the ratio of social service spending to medical care spending was significantly associated with better health outcomes across 34 OECD (Organization for Economic Cooperation and Development) countries between 2000 and 2005.

and

When comparing state-to-state spending between 2000 and 2009, those states with higher ratios of social service spending to health care spending had better outcomes on average.

[1] https://qualitysafety.bmj.com/content/20/10/826.abstract

[2] https://www.rwjf.org/en/blog/2016/08/how_social_spending.htm...

[3] http://content.healthaffairs.org/content/35/5/760.abstract

Private healthcare in France is supplementary to public healthcare and mostly abides by regulations dictating what can be reimbursed by the social security system, there's quite a bit of price control. It only gets wild in niche products (say very fancy dental implants).

Across the board price controls seem to be a common to the various European health care systems. It is my understanding that upper limits are set for the cost of medicine.

There is quite a bit of variety across Europe - U.K. is 100% government run, France is a public/private mix, Germany is similar to Obamacare in some ways, others are single payer, apparently some are private, also. But I've read that they all have cost controls.

beyond Europe as well. Singapore which has exceptionally low healthcare spending (5.9% of GDP) heavily controls prices and purchases down to individual equipment in hospitals.

> Singapore which has exceptionally low healthcare spending

yea because they have healthy population, its not because of some smart govt policy( if only it was that easy).

singapore obesity rate = 10%

usa obesity rate = 42 %

usa obesity healthcare spend = 90%

That 90% number is plain not true. Please cite any source for that.

The costs for obese folk are on average 90%-100% higher than for non-obese folk, but that's not 90% of total spending. (See e.g. https://pubmed.ncbi.nlm.nih.gov/33470881/)

Total cost approaches 20% of spending: https://www.hsph.harvard.edu/obesity-prevention-source/obesi...

Don’t get so hung up on precise numbers. We all know Americans are obese and that greatly adds to healthcare costs.

I can’t imagine any downside of trying to prioritize lowering obesity.

Thank god we aren't discussing your imagination, then.

"Don't get so hung up on precise numbers", uh, 90% isn't just imprecise, it's so catastrophically wrong that it undermines your entire argument

This is a topic that’s always going to have wildly different numbers. Who cares? It doesn’t change what we all know to be true. Nothing has been undermined whatsoever

What we all know to be true is your troll status.

Do you know the right number by any chance?

I was using obesity as a standin for metabolic syndrome to compare populations. Not sure if measure how many ppl have 'metabolic syndrome.

https://www.nhlbi.nih.gov/health/metabolic-syndrome

metabolic disease = all things that can be fixed by lifestyle modifications ( unless you are too far gone, ie).

see my reply here: https://news.ycombinator.com/item?id=32744868

Metabolic syndrome is often a side effect of medication or symptom of other diseases that can't be fixed with lifestyle modifications alone.

For example, there are a lot of people on psychiatric medications that can cause metabolic syndrome as a primary side effect.

> is often

Would be interesting to know how often.

Tens of millions of people in the US take atypical antipsychotics and antidepressants that cause metabolic syndrome as a very common side effect.

I wonder though how much this drives up the cost.

Because obesity also drives down lifespan, and age has a huge impact on healthcare expenditures.

Obesity, like smoking, is one of those morbidities that lower lifetime healthcare costs significantly, as most costs are incurred in old age, as you saisd. Obesity, smoking, etc can kill before reaching an age where people start incurring high costs.

There is a lovely tale from Czech Republic in 2001 where Philip Morris was distributing analysis showing the economic benefits of smoking to their shared healthcare pool.

https://www.wsj.com/articles/SB995230746855683470

My state has a "stupid motorist" law that requires people who negligently put their vehicles in danger and then use state resources to get bailed out, to pay for the rescue themselves. Perhaps we could create a "stupid eater law" for medicare/medicaid, forcing obese people etc to pay for their own private health insurance or healthcare which would free up money for others to buy more healthcare privately (via lower tax burden). My families healthcare would definitely be more affordable if I weren't burdened paying for the negligent actions of others.

Should we apply the same sort of "stupid X law" to people who drink alcohol or drive motorcycles or play rugby? This is one of the moral hazards of a socialized medical system. When the rest of society is paying for your medical care it becomes tempting to save money be dictating exactly how you're allowed to live your life.

Obesity is a serious public health problem but we won't fix it by calling people stupid or charging them extra.

>Should we apply the same sort of "stupid X law" to people who drink alcohol or drive motorcycles or play rugby?

Yes, precisely. Keep chopping down at these factors until all that's practically left is private healthcare -- that's a feature not a bug. It's enough that I have to pay the bill to scrape the blood off the street when a motorcycle is crashed, not interested in paying someone elses motorcycle related health premiums on top of that (I've gotten enough motorcycle injuries while carrying my own private healthcare :) )

>This is one of the moral hazards of a socialized medical system.

As you say with public healthcare the effect (you say temptation) is to socialize your health related losses while privatizing the gains you reap.

Yes, I'm getting sick of paying for people who drive cars, go to restaurants and concerts, and have children.

> socialize your health related losses while privatizing the gains you reap.

Those famous health care gains.

I'm not sure how the heck you jumped from "drive motorcycles" to "drive cars".

Driving cars would be minor and apply to almost everyone, so it would mostly cancel out and be negligible. Really it would be a slight discount for taking transit, and that seems... fine to me.

And those other ones aren't even notable risk factors.

Not people who live in dense cities with good subway systems and a walkable infrastructure. Driving is one of the most dangerous things humans do. The argument that all health care should be private– the perspective this comment addressed– would not make such a consolation simply because it's common.

> Not people who live in dense cities with good subway systems and a walkable infrastructure.

Yeah, so almost everyone.

> Driving is one of the most dangerous things humans do. The argument that all health care should be private– the perspective this comment addressed– would not make such a consolation simply because it's common.

Car deaths are about 1% of deaths. Heart disease and cancer are each around 15x as likely.

Even if it's high on the danger scale, I don't think it would be a very big factor in health care costs.

The US is a big place but most people live in cities. Few car accidents are fatal.

CDC: Motor vehicle crashes are a leading cause of death in the U.S.1, with over 100 people dying every day. 2 More than 2.5 million drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle traffic crashes in 2015.1 The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion."

American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.

> Motor vehicle crashes are a leading cause of death in the U.S.1, with over 100 people dying every day.

Motor vehicle crashes are slightly outside the top ten causes of death. Those 100+ deaths are coming out of about 9300 total deaths.

> The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion.

Productivity losses are outside the scope of medical costs, but even if we include those dollars that's $75B out of $4100B in health care spending.

So I stand by my statement that it's a pretty small impact.

> American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.

And most of the other 55% still need cars.

You said "good subway systems and a walkable infrastructure" and that's what I responded to. We can go ahead and remove the word "subway", but the fraction of people with access to good public transit systems is pretty small.

Sure. As long as we tighten up on other externalities.

You use a lot of energy? You pay for the damage to the world.

Yes I think that makes sense, to an extent. Maybe not specifically those because they are too hard to measure. But it would be a great way to have people put skin in the game. As a taxpayer paying for others’ healthcare I’d love if they were incentivized to live healthier lives to reduce costs

There are people genetically predisposed to gain weight or have heart disease. Cancer can be Russian roulette, as is your immune system picking up random autoimmune disorders. Accidents happen.

There are too many stakeholders with too many backgrounds and conditions for anything like your proposed system to work. Everyone would be angry.

> There are people genetically predisposed to gain weight

And this genetic mutation somehow happened in the last 50-100 years or so? Obese people have always existed. Obese poor people are fairly new. The root cause is diet, not genetics.

Human HLA / MHC have a significant role in gut microbiota composition.

Gut flora, in turn, play a significant role in hormone and appetite.

The interactions are complex, but genetics contributes to obesity.

It's "common knowledge!"

Read "a contamination theory of the obesity epidemic" to see how incorrect your assumptions are.

> Perhaps we could create a "stupid eater law" for medicare/medicaid, forcing obese people etc to pay for their own private health insurance

That might be a good idea after we make sure that every single person has equal access to healthy foods and equal ability to afford healthier options. Maybe we could also ban companies from adding HFCS to everything, ban advertising of any unhealthy foods, fine people for not wearing masks or vaccinating their babies, and police what people are allowed to have in their refrigerators so we can punish anyone who has too many unhealthy foods in their home!

Or... maybe we can let doctors and scientists figure out what the best ways to combat the obesity problem are and try to find ways to help people instead of punishing them while in the meantime making sure everyone has access to the care that they need. If we had universal healthcare the costs for your family would the same as everyone else no matter if you or the next person drinks, or smokes, or likes rock climbing, or plays sports, or drives more than x number of miles in a year, or has more than x number of sexual partners, or doesn't exercise at least x number of hours a day and nobody would have to go around spying on everybody to make sure they aren't doing anything that might raise someone else's costs "or else".

>yea because they have healthy population, its not because of some smart govt policy

yes it is, because the health population itself is supported by strong intervention. Singapore banned the advertisements of sugary drinks years ago, Singapore strictly regulates the number of vehicle licenses in the country encouraging public transport and walking, it forces citizens to allocate money for healthcare to private savings funds which incentives reducing your own healthcare costs, and so on.

The reason American's are obese isn't a miracle or because Americans are stupider, it's because Americans refuse to take collective action when it comes to the health of the nation.

Singapore has a population of 5.6 million. USA has a population of 330 million. How would you control prices and purchases at that level?

Perhaps on a state level?

What difference does the population make other than that at 330 million economies of scale might appear that aren't significant at 5.6 million?

According to this website [0] there are 30 states with a population of less than 6 millions. Why can't they each operate like Singapore?

[0] https://worldpopulationreview.com/states

The problem is that states are like accidents of history and are fairly arbitrary.

You need this with lots of stuff. “Vice” states are adjacent to more prudish states. Think New Hampshire, Delaware, Pennsylvania, South Carolina.

In the case of healthcare, states tend to push costs to somewhere else. As in send the sick person to NYC.

Singapore's area is 283 square miles. Rhode Island is the smallest state, and it has an area of 1214 square miles. Four times larger, with people throughout needing care. That alone will add a fair amount of cost.

Granted, not the total amount spent, but city states do have some advantages on things like this.

Singapore does not control prices (though it’s moving in that direction), it’s public hospitals are privately run, and it has a system of “forced savings” to make sure patients have enough money to cover out of pocket costs and buy health insurance. It’s ethos is “the patient has to pay something out of pocket, even if it’s just $2”. It’s also more than happy to tell poor patients “if you don’t have enough money, there is nothing we can do”.

It is more similar to the US system than a system like the UK or Canada.

>Singapore does not control prices (though it’s moving in that direction), it’s public hospitals are privately run,

Singapore controls prices through collective bargaining at the national level and unlike the US practically every purchase in its hospitals has to go through registration with the HSA (the country's relevant regulatory agency). You essentially cannot purchase any major equipment without running it by the national government. That's one of the reasons why the country has a very transparent pricing system.

It's not only savings accounts but also a very tight control over costs and acquisitions that keeps the price low, that's completely missing in the American system which just keeps growing.

Singapore doesn’t control all prices - drugs can be freely priced, but as I stated it’s changing right now.

And getting HSA approval doesn’t have anything to do with price - that regulatory. Even the FDA has to approve anything used in the US.

It is true you can’t purchase at the hospital level without some agreement on price, but the hospitals often do their own tenders, which are confidential prices. It’s not done at the national level for everything.

And yes, prices are tightening but companies are already deciding to just not market in Singapore if prices get too low.

Check out Germany, I think it was AZ that decided to just not launch a drug there at all because the price was too low.

Aren’t all 3 major hospital groups government owned? These are not private hospitals, they may charge you fees, but ultimately they’re government owned.

Actually are correct, they are government owned corporations. There is SingHealth and the NUHS system. But they are corporations, with boards of directors, which is entirely intentional since the government wants "private" competition between providers to drive efficiency.

> U.K. is 100% government run

This is not true.

Private healthcare is alive and well in the UK in the supply of both privately and publicly-commissioned healthcare.

You're right, thanks for the correction on that.

Wikipedia said 8% of health care in England is private, mostly specialist, often through employer provided plans meant to augment NHS. The other 92% of health care is directly supplied by NHS [0]. So they appear to be a mix of public and private, like many other systems.

[0] https://en.wikipedia.org/wiki/Healthcare_in_England

> U.K. is 100% government run

I know I'm a broken record on this but people who say this are simply wrong.

1) There is not one NHS for the UK. Health is devolved and there are totally separate systems for NI, Scotland, Wales, and England.

2) Speaking only for England, it's not "run by the government". The NHS in England is run by NHS England and Improvement. The people who work for NHSE/I are not civil servants, they do not work for the government.

> countries without that or with less generally have better outcomes at less cost.

This isn't necessarily a great metric, because almost all countries have better outcomes and all countries have lower per capita cost, whether their systems are public, private, or mixed. The US spends more public funds on healthcare than countries with universal socialized health care systems. The fact that we're also personally bankrupted after spending the same tax proportion on healthcare is just a bonus.

It's not specifically private healthcare or insurance that's the problem, it's the specific corruption of the people who own the healthcare industry and their legislators.

Wow, I had to check your facts here, and I can’t believe it. The US federal healthcare spending is very close to the UK healthcare spending, but we cover WAY less for individuals.

The US federal govt spends >8% of GDP on healthcare, with the current system of all of our insurance and payments and everything that we have to pay in addition, totaling nearly 20% of GDP: https://www.crfb.org/papers/american-health-care-health-spen...

The UK spent 9.6% of GDP on healthcare in that same year (2017) for their publicly-funded full healthcare system: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...

>but we cover WAY less for individuals.

That has to be related to the fact that American drugs are sold to a lesser price abroad than at home, right?

In Quebec, cancer treatment is free. Given that even late-stage cancer patients live much longer nowadays, and those treatments are probably expensive as heck, I wonder how we can afford it.

Most countries have private healthcare (meaning private providers). Many others have a mix of for profit and non profit insurance companies. There’s not a whole lot of difference between Obamacare and say the system in say the Netherlands, Switzerland, or Japan. Those are also “individual mandate” systems.

Argentina has public free healthcare and it still has growing expenditures in the private health sector.

Here in Argentina you only use the public free healthcare if you aren't insured or can't afford private healthcare.

Also anybody legally employed must have insurance (of varying quality).

> countries without that or with less generally have better outcomes at less cost.

> Looking for evidence to the contrary

There was no evidence behind your claim either. 90% of US healthcare costs go to managing ( not treating ) obesity/metabolic disease . Yes 90% [1].

Which country with similar metabolic disease rate has better outcomes with less costs?

1. https://www.cdc.gov/chronicdisease/about/costs/index.htm

That is not at all what your link says.

"90% of the nation's $4.1 trillion in annual health care expenditures go to people with chronic and mental health conditions"

Obesity is $173 billion, diabetes $327 billion.

We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous. Diabetes cost is roughly the same percentage of total expenditure as it is in other industrialized nations. (I didn't check obesity)

It stands to reason that really, the problem is the size of the pie, not the size of the slice.

see: page 20 https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221...

> We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous.

How so? Only recommendation for all these chronic conditions is 'diet and exercise' is it not ?

Obesity isn't the only one. I am not obese , not even close, but I have hyperlipidemia. I am managing it with 'diet and exercise' after initially being put on statins. Same with hypertension, heart disease ect. All of these are metabolic diseases. Sure, I'll give you 'mental health conditions' may not be a lifestyle disease ( Even those are being now linked to diet ) .

No, "diet and exercise" is not the only recommendation. I don't even know what point you're trying to make there - if that were the only recommendation, health care costs would be fairly low.

And it's not just mental health issues (~25% of all chronic health issues), it's also respiratory issues (~10%).

Then add to that the fact that many metabolic diseases have long lists of causes that amount to "not really sure". Atherosclerosis? Can be caused by physical activity. Hypertension? Being older than 65 is a cause.

What the Rand paper does say is "90% of all health care cost is incurred by people with at least one chronic condition". Not metabolic diseases. What it also doesn't say is that the entire 90% are attributable to chronic diseases. (It's sort of akin to claiming that 10% of all healthcare costs are incurred by people named John, Robert, or James. True, but certainly not causal)

Again, I'm not saying that chronic diseases aren't contributing a huge cost burden. I am saying that they're far from the only cause of the cost burden, and that blaming it on metabolic diseases is highly misleading even if you just focus on chronic diseases.

> No, "diet and exercise" is not the only recommendation.

What else is there though? I consulted many physicians for my hyperlipidemia and all of them suggested 'diet and exercise' as the only solution. It is the only thing that worked for me.

yes 'not all' high cholesterol can be managed by lifestyle modifications( eg: your genetics might predispose you to high cholesterol. Do you know how much of healthcare spend goes to to the exceptions you are talking about. I certainly couldn't find any data about this, not sure why.

> Hypertension? Being older than 65 is a cause.

Yes we don't know the cause but we do know the fix even if you are over 65.

AHA recommendation

https://www.heart.org/en/health-topics/high-blood-pressure/c...

Dude.

If "diet and exercise" were the only thing physicians did to treat these diseases, have you tried to think about the internal consistency of your "and at the same time, this is 90% of healthcare costs" argument?

Have you, even for a moment, considered your own statement that your doctor prescribed you statins? Did this not lead you, for a brief nanosecond, to ponder that "maybe other people get treatment beyond diet and exercise too"?

Also, did it occur to you your nows on argument 3? "It's obesity". "It's metabolic diseases". "Actually, I'd like to argue there's no treatment outside of diet and exercise".

Imagine thinking statins are used to 'treat' hyperlipidemia. Statins block the production of cholestrol, they don't treat the disease which is causing your body to produce high cholesterol.

Maybe you need to ponder about the difference between treatment and management, or ask your doctor about it next time. All this was clearly explained to me by doctor when I was started on statins and that only way to treat the disease itself is through lifestyle modifications. Unfortunately, There is a whole swath of idiots on internet who think they know better than doctors and experts.

https://www.aafp.org/pubs/afp/issues/2020/0915/p347.html

Thank you for bringing this up. The medical community's intense obsession with people's size and shape over their health causes a lot of misleading conclusions and misguided efforts.

If you walk into the doctor's office underweight and concerned about an issue you're having, the doctor doesn't put you on a strict fettuccine Alfredo and hamburger diet before treating you.

If you're overweight and concerned about an issue, you're far more likely to be told to lose weight and ignored.

Whether or not you're overweight, when you come in they'll take your vitals and run some standard tests until they find something they can treat and medicate for the rest of your life.

You'll be tested for thyroid dysfunction, for diabetes, for hypertension, for all sorts of stuff that won't be on your radar until a blood test turns up "abnormal" results once. Then you'll get pills, all the pills you care to eat and remember, there is no road map for getting off those pills, you'll just get larger doses and more frequent as your problems worsen (because you're not addressing root causes, just being medicated for "treatable" issues which correspond to existing pharmaceuticals.)

The link you posted says that the 90% is to treat all "chronic and mental health conditions," which is a much larger grouping than just obesity/metabolic disease.

> just obesity/metabolic disease.

yes we don't measure this and is impossible to measure.

Last I checked some >30% of the population were already on Medicare/Medicaid. You already have the "socialism" healthcare.

(This subthread was originally a reply to https://news.ycombinator.com/item?id=32743267.)

Nothing enrages me like US healthcare.

Physicians have a monopoly on treatment and restrict supply through the ACGME.

Hospitals and physicians have spent 1Billion on lobbying.

I could go on, I want a science based healthcare as an alternative to our authority based system.

It would be one thing if our system healed everyone, but the number of mistakes is enough to make me lose faith completely.

I know that most people don't like to think twice when it's about their own health but as a society we have to ask if it's ethical to heavily indebt or tax the young working age population to extend the lives of a few old peoples who often never regain their full health.

In the actual system good lifetime is traded for bad one.

The issue is that states are largely arbitrary historical accidents. You'll need this for a variety of things. "Vice" states are located next to more conservative states. Consider the states of New Hampshire, Delaware, Pennsylvania, and South Carolina.

In the case of healthcare, states have a tendency to shift costs elsewhere. As in, send the sick person to New York City.

Reply on news.ycombinator.com