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Healthcare is not a free market. People don't comparison shop, and couldn't even if they wanted to. Price lists are secret because providers have two prices, one for cash and one for insurance. People with health problems have stress enough dealing with insurance companies and providers, filling out endless paperwork, to deal with it even if the info was available. People in hospitals and emergency rooms CANNOT shop for alternatives since they are a captive audience.

When the social norm hardens around "don't charge what it's worth, charge what you can get" this is the result. I once asked a hospital billing agent how they could justify a $10k ER bill for 4 hours of waiting and 1 hour treatment, and they responded, "How much is your life worth?"

One place that gets it right is Germany: an inexpensive public option that gets you competent medical care almost anywhere. Bring your card, no deductibles, no paperwork, no complex calculation and a minimum of paperwork (which is a rarity in Germany). This is how it should be here.

They buried the lede:

> "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces"

Blaming insurers and drug companies is fashionable -- and employers is a new twist, I suppose -- but it feels like a desperate search for a facile answer. Nobody wants to hear the hard truth, which is that if you had to pay for it, you'd suddenly become a lot more picky about the health care you purchase.

You don't see the prices, so you don't care, and you can't shop around. I'm not saying there aren't a ton of other negative incentives in the system, but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.

My controversial belief is that the barrier to become a doctor is way too high. I think barriers need to be reduced.. I mean think about it - I learned software pretty much by being put into it and forced to learn.

I understand medicine is slightly different but my hunch is that any sufficiently smart person can do well enough as a doctor after 1-2 years of theory.

This might anger a lot of people because there’s a trend where we elevate medicine and doctors to a godly level.

Thankfully with the internet and AI, knowledge is not gatekept as much now.

I wish we allow more people to become doctors and intelligent people to become doctors. The type of people who choose to become doctors are not problem solvers, at least from my experience.

Of course my argument doesn’t work exactly for surgeons but I think we should not artificially reduce their numbers.

Small(ish) OT, but after years and years of leaning in favor of a private healthcare system I have completely reversed my opinion.

I will spare you the ethical and moral reasons, and give you a practical one.

Private healthcare, being a business, cannot afford the investments of public one. Instead it operates following the Pareto principle where 20% of services and treatments cover 90%+ of patient needs.

Now this works with much joy over most of your life, but there are just too many edge cases over a life time where this will screw you.

E.g. A close friend of mine gave birth in a private clinic. The most luxurious one with almost a dozen people following her.

All of this: pointless. Her child had complications minutes after birth, and no single private hospital in our country has a pediatric intensive care unit, or, to label it more correctly a pediatric _reanimation_ unit.

The only private hospitals that do? University ones, as they operate on slightly different financial basis and incentives.

This goes beyond this example I have. It doesn't matter if you're in a country with good private healthcare (e.g. Switzerland) or a crap one, public healthcare is accepted to be a money loser for the greater good and will cover more services. Always.

Mind you, I'm not saying that a single public hospital will offer everything and private is bad, just stating that there's many situations where it's easier to find the service offered in public rather than private health care.

Zero discussion of the 3:1 premium limit in the ACA. The ACA mandates that you can only charge older people 3x the premium you charge younger people. Older people account for an extremely outsized portion of healthcare services received. This means that no matter how little healthcare you need as a healthy young person, you have to pay 33% of the estimated cost of care for someone who is end-of-life and possibly consuming hundreds of thousands of dollars (or more) worth of medical care.

I had eye surgery three weeks ago. Prior to my eye surgery, I emailed and called my health insurance to get a total out of pocket cost, none could be given. The only thing I heard over and over is your deductible is X.

I spoke to to the eye surgeon's billing department and the same happened. How the F* can it be like this? To top it off, I just got a bill for $300 after paying $1300.

The system is completely broken.

Pretty sure Baumol has like 80% of the blame here.

One major issue with centrally planned healthcare is that the value of health is variable to the individual. Particularly beyond the line between technically dead and technically still alive.

A poor, uninterested, or other valued[1] person would only sacrifice $N to improve their health beyond "still alive". A rich person, or highly interested, or other valued[2] person would sacrifice potentially many multiples of $N.

Take Bryan Johnson[3] for example is willing to spend on many improvements to his life. For example, in Canada he'd be basically unable to do what he wants to do with his own money.

As one such person I am happy to pay more for more. What I really think is needed here is improvements in contracts and transparency. For example, there should be a contractually binding price agreement (of which the prices themselves are publicly available to all including competitors) for any non-emergency non-urgent procedure. (If time is of the essence then we need to prioritize that, naturally)

As an example of being willing to pay more, my insurance isn't willing to pay for the exploratory labs, and software platform, that function health built and provides for $499 a year. I'm willing to pay it, it has benefitted me over the standard annual physical, and to me it was worth $499. It also likely will save my insurance $1000s maybe $10000s over my life time too. (We discovered something concerning...)

[1] - (eg a father who prioritizes spending on their kids) [2] - (eg a father who prioritizes being there for their kids later in their life) [3] - https://youtu.be/pfSFnFWb8X4

I guess it would be a crazy idea to include the people charging for the service as a reason for the rising costs or the fact that they expect high income after paying a $1M to be educated and also have to contend with rising malpractice insurance and fraudulent lawsuits.

> Employers themselves are at the mercy of entities that have even more market power: Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care in the United States.

Yeah, nice headline!

I am really surprised to read that American healthcare costs are not transparent. As I mentioned in another comment I know exactly how much everything costs to me and insurance. My HDHP is serviced by United Healthcare (largest Healthcare company in the US). For every visit to the doctor, I get an explanation of benefits. This tells me what the doctor charged, what insurance actually paid them and what I owe. I'm pretty sure that's pretty standard across the industry. Then comparing costs... It's pointless. I can't afford to go out of network, so I go with who my doctor recommends. They will then get paid the already negotiated rate (which is probably the same rate across the network).

Every area of California is controlled by various healthcare monopolies. In Sacramento, it's Sutter Health. In San Diego, it's Perlman. In Bay Area, you have Kaiser. We have no choice or free market. You either pay them or you don't have access to decent reliable health care. I am honestly starting to think about just not having health care and going to Mexico/Canada when I need something--and we make well into the top 10% for wages. I don't know how others can pay for healthcare and all the premiums. I just paid like $300 for a minor skin care treatment at a dermatologist that I had to wait weeks for an appointment with. It's a clear racket. Oh and despite all this, none of the local speech therapists are in-network so we have to submit individual claims and they don't pay the full amount. It's a scam.

Older male got some Tadalafil from the doctor and not covered by insurance. Cost 530$. Told them i will not be using insurance and did an RX code and the prescription was 11$.

The system is beyond silly in pricing.

Another prescription had a 10$ copay since it was just a generic drug. Again I requested please don’t run through insurance and the rx price was 4$.

I did a deep dive into understanding how prescription pricing works in the US, long story short it is insanely way too complex and for profit private health care insurance is not good for the health of the population.

[dupe]

Multiple discussions this week:

Health Insurance Costs for Businesses to Rise by Most in 15 Years

https://news.ycombinator.com/item?id=45212976

Americans face biggest increase in health insurance costs in 15 years

https://news.ycombinator.com/item?id=45157389

Almost no one gets "health insurance" through their employers. Most employees get health benefits.

In the US, a majority of large employers don't buy insurance in the strict actuarial sense. They self-fund health benefits under ERISA, paying claims directly and hiring insurers only as administrators (ASOs). The plan may contract with an insurer (e.g. UnitedHealthcare, Aetna, Cigna) to process claims and run the network, but for most employees at large firms, the insurer is not actually insuring anything. Self-funded ERISA plans are regulated by the US Department of Labor, not state insurance commissioners.

What about health care providers? They're the ones that are often sending out the bills for service(s) rendered:

* https://archive.is/https://www.noahpinion.blog/p/insurance-c...

Wherever there are high operating margins for an industry, that's a good indication something anticompetitive is happening.

Occasionally, you get situation like Nvidia which has huge margins because their competitors don't know how to make a decent product.

I live in the US. A family member close to me is unable to make appointments any closer than 6 months to receive lifesaving care. This is despite getting the most premium insurance they could find.

They (easily) found someone who will see them out of pocket. It's not a supply issue in this country, it's an incentives issue.

Blame everyone but the government, eh? To be expected considering the source. But we won't solve anything without looking at the root of the problem. Unfortunately, it seems to me like that dooms us to not solve anything.

Really? I thought most of the excess cost of healthcare in the US is due to the artificially restricted supply of doctors, causing them to have extremely high salaries compared to similarly demanding work in the US, or to the same work in other countries (although US salaries are super high in general). But the article kind of handwaves and vaguely blames big business or whatever.

The framing of this article I find quite disappointing from NPR. Sure employers are not about to just hand out free money are going to try to spend as little as possible but to put your employer in the same space as the others or even the government is a... wild interpretation of the problem.

I was half expecting there to be something in here about the average that employers were spending going down to justify the headline but that was nowhere to be found.

> "It's kind of hidden, because [premium deductions are] coming out of your paycheck and if you're not paying close attention, it may not be obvious,

I have to ask, who the hell is not looking at the amount that is coming out of their paycheck when it comes to open enrollment? Sure you may just accept it since what is your choice, but I think the systems I use generally show how much it is going to change.

Am I just becoming more sensitive to clickbait that outright lies or are headlines getting worse? Nothing in this article justifies any blame to your employer.

I buy Gary Stevenson’s diagnosis that the root cause of the rising cost of everything is increasing inequality and industry capture by the wealthy.

There are two sides to this. The first is, hospitals are owned by investors, and have to increase profits. The typical playbook of trying to acquire at least a local monopoly to price-fix is in play everywhere.

The other side is: to achieve high profit margins chase wealthy customers and cater to their preferences. Headhunt star staff with increased salaries. Build shiny new hospitals and prioritize private rooms (HIPAA provided a great excuse here). To woo investors turn administrator into a CEO position with commensurate pay.

None of this incentivizes providing quality health care to non-wealthy people at a fair price. It incentivizes trying to get rid of lower income patients as quickly as possible to make room for high income or well insured patients who can be billed more.

Same as housing, this issue is everywhere in the western world. We can try to tackle it by itself (transparent pricing would probably help a great deal), but the root issue is bigger: the rich are getting what they want on both sides of the equation. They don’t want affordable healthcare.

> Blame insurers, drug companies — and your employer

> That's because employers will be paying a lot more

> Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care

> more people are going to the doctor or other providers. But that surge in demand has also led to a surge in prices.

> Last year, the average U.S. employer spent more than $19,000 per employee to provide family coverage while the employee kicked in $6,000,

Why should health care ever get cheaper? Americans treat our bodies like garbage bins for sugar and fat. Old people spend 100ks just to die in a hospital 3 months later. The narrative is always that some rich dude did it to you though?

You can't be surprised when industries that are shackled to the government through payment and/or regulations end up inefficient.

Saddens me to think about, but imagine if American healthcare and innovation was nearly as "free market" as smart phones, LLMs, etc.