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Comment by anamax | Hacker News Reader

Please don't confuse healthcare with insurance.

I went for over a decade without insurance yet I was never without healthcare. That used to be quite common, especially among folks in their 20s. Is that unthinkable for the current generation? Why?

Plus, if you're talking about the US, free basic healthcare is almost universally available. It isn't pretty or convenient, but US govt services rarely are.

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If you're uninsured you get price gouged. A simple trip to the doctor with some basic tests can be a months rent. I have catastrophic health insurance; $5k deductible 20% copay to $50k. It won't pay for anything, but it will give me insurance group rates. Where is this magical free basic healthcare? Does not exist. Medicaid is only free if you've already become bankrupt.

You only get price gouged if you don't negotiate or shop around.

My mom is uninsured. She negotiates everything and often pays less than I do (I once compared her bill to mine). If you pay cash up front, the doctor's office will be very nice to you. Additionally, they give you stuff for free that an insurance company might pay for. An actual exchange:

Mom: "$300 for a splint? No thanks, I'll just have my son tape my finger to a piece of wood."

Doctor's office lady: "Oops, my mistake, I thought you had insurance. We only charge people for stuff like that when they have insurance."

$300 for a splint is one thing. Try negotiating an MRI when you've just been in a car accident.

Its a real problem. Insurance companies have a ton of weight by virtue of representing many patients, which they effectively leverage for lower prices. Those paying out of pocket have no such leverage, and pay much more.

She has negotiated for post-hoc price reductions on emergency care.

Hospitals have leeway in what they charge. If you make it clear that you will be a pain in the ass unless they give you a good deal, they will do so. This is where you drop words like bankruptcy, $25/month for 30 years payment plans, and threaten to contest every single item (out of 47) on the bill. They will take all sorts of nickel&dime charges off your bill, lower prices here and there, etc, giving you a reasonable deal.

All this aggressive price negotiation is fine if that is your choice. But keep in mind your company will have to employ other people and if the company does not provide health insurance you will be expecting your employees to also perform these same kinds of price negotiations for their medical services.

I negotiated a $40k hospital bill down to approximately $15k.

That was still a lot more money than I had at the time. If I wasn't lucky with good credit, I would still be in debt.

Much like vaccination, this only works because many other people are covered by insurance. What the hospital doesn't charge you (and thousands of other people without insurance), they make up for by raising rates across the board. Just because you negotiated the rate downward doesn't mean the procedure's cost went down for the hospital.

Your Mom obviously gave birth to you. Out of curiosity, how did she pay for it? Did she negotiate the price?

I've been doing this for years.

Need medicine for high cholesterol? Doc prescribes $100-a-month latest whiz-bang pill. Say to doc, "Dude, can't you do better than that?"

Get a $10-a-month pill from Wal-Mart that works just as well.

It's a real eye-opener. Businesses will charge anything as long as the customer doesn't actually have to write a check for it.

EDIT: Since many of you haven't experienced this, I'll share another story.

I tell the doc I have sleep apnea and would like to try a CPAP machine. He says first I need sleep study, which is around $2K. Why? Well because the new insurance guidelines say you should have one. So we talk a bit, and it becomes clear that it's not needed. Cross out $2K.

So he writes a prescription and sends me to a place in town that sells the machines. Cost? $1600. Price for same machine on the net? $350.00

I call the doc back and he faxes the prescription to the internet vendor and Bob's your uncle.

This is about $3500.00 that 99% of everybody else would have had their insurance pay that wasn't strictly necessary.

Negotiating your own healthcare prices is a terrific eye-opener.

I would like to have a proactive patient such as your self. As a student, I am always put off when a physician prescribes an on-patent medication when there is an equivalent that is off-patent (assuming that the research supporting both is equivalent).

Hope I didn't give the wrong impression -- my doc rocks. He's just a busy guy, and the drug companies are making pitches all day long about how the new and patent-protected stuff is so much better than the other stuff. He's just playing it safe. He's always open to a conversation, however, and most times once we talk we arrive at a better place than the one he first recommends.

And I'm not being a "proactive patient" out of any kind of charity on my part. My money rides on all of this stuff, and every little bit is very important. I'm just trying to make very certain that each little thing we do is priced at exactly the least amount is has to be.

[There might be a lesson here, but I refuse to spell it out.]

Except under very strict circumstances, not charging everyone (including insurance companies) exactly the same amount for everything according to a practice fee schedule is illegal under the US healthcare system. Just because the insurance company doesn't actually pay the full amount (contract law gets mixed in here), it doesn't mean that a self pay patient gets to have free services. One reason medical costs are so high is because doctors are generally paid the lesser of the service charge amount on their fee schedule or the insurance company contractually allowed amount. Simple game theory dictates their prices be as high as possible.

Self pay patients can be charged less if a standard sliding fee schedule is created by the practice. This is to make sure that discounts are applied uniformly across all self pay patients against some criteria (e.g. 10% discount for families at 400% of the federal poverty level). I'm sure there are other ways too, but they must be applied consistently.

In the highly unlikely event the doctor's office is prosecuted for failing to charge her for a splint, I'm sure they could plausibly call it a billing error. Note that they didn't charge her less for the splint (which only cost them a few dollars), they simply took it off the bill.

I'd love to see the DA actually try to prosecute the doctor for this. It would make a great reelection platform: "I prosecuted doctors for failing to charge uninsured patients $300 for a $6 splint."

Tell me the story about how she negotiated minor surgery that one time. "$20,000 for a C-section? No thanks, I'll just have my son sterilize the dremel and the staple gun." That story is awesome.

When my wife was pregnant, and on health insurance that didn't cover pregnancy she told her doctor she didn't have insurance. End result flat fee, under 2K to have the baby and about double if a C section was necessary.

I can only tell you what the average of the two C sections we were billed for cost. Uninsured cost of a C section without a prolonged stay in the hospital appears to be under $10k, anecdotally from G searches on "uninsured C sectio cost". Our son stayed in the NICU ($$$$$$$) for a week; your wife can also wind up in the hospital for an extra day or two.

Yeah I am glad we dodged that bullet. The insurance was odd they wouldn't cover the pregnancy but they would cover the kid after birth so any NICU costs would have been covered.

This isn't odd; it's standard. Covering normal pregnancy and birth is a pricey add-on if it's available at all, but by law the new child must be covered.

> You only get price gouged if you don't negotiate or shop around.

Nonsense. Health care isn't something you price-compare on Amazon and Best Buy before making a purchase. It's something you need right now when an unexpected medical emergency happens. That's why an insurance market exists in the first place.

His story works because he's framing it as getting a broken finger set or getting meds for an ear infection, and ignoring the fact that what we need insured is prolonged illness and hospitalization. What his mom really is is "very lucky"; also, not afraid to throw "bankruptcy" onto the negotiating table.

But catastrophic insurance will cover prolonged illness and hospitalization, and quite cheaply if you're able to shoulder $5-15,000 of the risk yourself. We're talking about how to get around the price-gouging that accompanies everyday lab work and routine care.

The problem isn't cost. Of course you only want to get catastrophic coverage. But you're as likely to be declined for high-deductable coverage as for low-deductable coverage; at least, we were.

Yes, being declined is the problem. I suspect it's more or less of a problem depending on what state you're in, though.

A quick google search suggests that emergency care makes up less than 3% of medical spending in the US. So negotiation and price comparison is possible for about 97% of medical spending.

http://www3.acep.org/patients.aspx?id=25902

You're excluding the cost of inpatient care, which is not the same as Daniel Markham's anti-apnea sleep mask.

That might work for small things, but wait until you get really hurt or sick.

Eg, the HIV positive friend? His meds w/o insurance are $1700/month. The price with insurance is $60. The manufacturer doesn't negotiate on price.

> Where is this magical free basic healthcare? Does not exist.

It's called the county hospital plus medicaid.

> Medicaid is only free if you've already become bankrupt.

Medicaid is extremely cheap to free if you don't have an income, which is the premise of the question.

I agree with this point, except even basic health care (in the US) is expensive especially for someone on a ramen diet.

If you plan correctly financially this doesn't have to be a problem.

edit: My biggest issue would be hiring my first full time employee.

The big trick about uninsured healthcare in the US now is that you will pay 2-3 times market rate for everything. My local hospitals wins with a 9 times multiplier on some emergency care.

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