people often remember things when asked latter. this gives more opportunity to ask about everything you care about even if you forget the first time.

people sonetimes grab the wrong chart. This helps ensure that they check for things that matter to you and not someone else - your history is on the chart if they are watching you for something weird in you history this is important.

Of course, another key problem is trying to divide distinct parts of health care into distinct costs. Everyone benefits from having a good quality hospital in their area and so assigning a health care provider's cost to just a given patient and then trying to reduce the patient's cost is quite irrational.

Essentially, you have a public good that the state and private interests are trying to make into a public good. A lot of profit comes from this but little good for the patients.

Sticker price on my partner's medication is $10k/mo. Insurance alone refused to pay anything. This third party negotiator managed to get insurance to pay some, the manufacturer to discount it, and a "copay card" with several thousand dollars preloaded appeared to pay the rest.

We ended up paying zero out of pocket for the medication but it took two weeks of thrice-daily phone calls with various entities.

The very notion that an entire company can exist and sustain itself solely on negotiating with your insurance provider on your behalf is utter insanity. I've heard horror stories about communist bureaucracy from Soviet-occupied European countries, but I don't think even the USSR can compete with the modern American healthcare bureaucracy. It's outrageous and unconscionable.

You can eliminate most of the problem by mandating true cost billing by hospitals (get rid of their insurance mandated 500%+ markups to make it look like your insurance does anything at all besides make your care as costly as possible).

As you said, it's oftentimes cheaper to buy drugs without insurance.

The average person would quickly find out that insurance doesn't pay for anything at the hospital (most of the time).

~80% of healthcare spending is already at the tail end, and the state already covers most of that through Medicare and Medicaid.

The bottom ~50% of spenders (healthy people) only spend ~3% in total of healthcare (~$900 per year per person, about 1 month's PREMIUM).

Health insurance is a MASSIVE tax on the bottom ~3% of spenders (~50% of the population), when the state ALREADY covers the vast majority of people that need covered for tail end expenses.

Think about this: the MEDIAN adult in the US pays <$1k in personal income tax! Yearly health care premiums (that do nothing) are 3x that! 75%+ of the median person's true tax is going to health insurance that does NOTHING for them.

We already have the European model. Health insurance as it is is a tax. It just could not be designed to function more poorly than it does for the average healthy worker.

It benefits literally no one besides the health insurance industry which does not employ that many people, and is not strategically important for national security.

If the state completely covered the tail, and we had true billing at hospitals, almost no one would need or want insurance besides people that already have it through Medicare and Medicaid.

Insurance is (should be) addressing the risk of unexpected expenses that you cannot afford. Not predictable, small expenses that everyone has.

There’s so much rampant profiteering in the US healthcare system it’s unbelievable. Other countries look at it from afar in utter disbelief. I’m glad I had no serious health problems when I lived there 25 years ago (and I had health insurance via my employer).

In the UK prescriptions are effectively capped at about USD125 per year:

https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-pr...

I recently collected 4 prescriptions from my local pharmacy (3 for temporary conditions, the other one was ADHD meds which I’ll be on for the foreseeable future) and the pharmacy didn’t even want to see proof of my prepayment certificate, I just said I had one and they ticked the relevant box and handed me the prescriptions.

(The implication is that the NHS will check this and come after me if I was lying.)

Don’t get me wrong, there’s lots wrong with the UK healthcare system but the access to regular medication has very few barriers.

The #1 thing we need to do is make it illegal for your healthcare to be tied to your employment. We can still have your employer provide a X% or $Y to an HSA account that the employee can buy health coverage wherever they like. (I'm not optimistic that this will ever happen politically)

The issue today is that NOT healing you makes everyone more money, like a LOT more. There is no incentive for anyone to help people get healthy just to have a different insurance company benefit from the decreased claims.

This is also the only way forward to value based care (for primary) where doctors (providers et al) can take on the risk/reward. They get some amount (say $1K ??) per year and they keep it and submit no claims. However, if there costs go above, they eat it loss. Now the doctor and the insurance company (payer) are all incentivized to get and keep people healthy.

> And I think part of the answer is that in most cases, individuals and families themselves must allocate resources they control to make this happen.

Assuming uniquely American selfishness got us in this mess, I don't buy that rugged individualism is the route out. You'll just get that classic pattern of those with enough resources to manage criticizing the resource management of those with too few resources to learn to manage. That just further corrodes solidarity.

This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.

Or so people keep telling themselves to not feel completely fucked?

Yes. Or at the very least, stop making it mandatory. Health insurance should work like literally everything else: your employer pays you money, and you use that money to buy it.

I learned a while back that there are two industries you should never ever touch as a startup:

- Healthcare

- Education

Both systems are so broken (for different reasons) that it's a fool's errand.

spend more money. you DO live in the greatest country on the planet, surely if an american citizen cannot raise the funds for healthcare, in what country can you expect to?

Having had my share in the administrative part of the medical field, that figure is most probably somewhat misleading. Every time you deal with billing you are bound to deal with granularity. On one extreme you could bill per case, on the other extreme you can count the paperclips used. It could seem at the first glance that the more you move towards the latter, the more time has to be spent by someone to somehow eventually form the invoice.

However, this surface-level conclusion misses the fact that patient care does not start and stop at the the operating room door. Some processes mandate transparency/traceability and thus documenting what's being done and used is part of the process anyway. [edit: the final deliverables are not a treated patient, but rather a treated patient and documentation complete with medicine authorizations / prescriptions (including for drugs used internally), sick-leave certificates, etc.]. That data is then effectively reused for billing, with minimal overhead hopefully. Yes, there's a lot of room for improvement and automatization, but activities not directly related to active care make up a sizable portion of the time.

The Woolhandler/Himmelstein 2020 figure ($812B) updates to $1.13-1.66T in 2023 dollars when adjusted for healthcare inflation. The CMS narrow admin estimate ($410B) plus CAP's billing complexity analysis ($496B) gives a $906B floor. Those three methodologies agree on the floor, disagree on the ceiling. Issue #5 covers all three and explains why the range is so wide. Coming soon.

Healthcare is nearly 20% of GDP (and growing), so administration is 3%-6% of the US economy!

Yes, this is an important piece of the puzzle. The "medical loss ratio" for large insurers (the kind we all know and love) is set to 85%. So they can keep up to 15% of their revenue as profit.

As you said, if total spending goes up, they get 15% of a larger number.

"The discovery of Kato's remains sparked a search for other missing centenarians lost due to poor recordkeeping by officials. A study following the discovery of Kato's remains found that police did not know if 234,354 people over the age of 100 were still alive".

Less than 5% of Japanese are obese (BMI >30) compared with 36% of Americans, additionally 1 in 10 Americans are severely obese (BMI>35) whereas the number in Japan is negligible.

https://theworlddata.com/us-obesity-rate-compared-to-other-c...

I think a gradual move to single payer is the way, but even if you could get that passed as legislation, which you can’t due to a rigged senate balance, and not struck down by SCOTUS, you’d need 10 years to begin the changeover. It’s really that massive of a project.

But it won’t happen with the current solidifying conservative governmental systems. Say hello to your future, it’s now.

Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible

How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.

In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own

Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off.

Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers

If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health insurance.

Insurance is the natural solution to this, but to be effective it requires most people to not need it while still paying into it. This is what Obamacare tried to fix by mandating insurance, but healthy/young people got sticker shock and bailed.

Doesn't this already partly exist? My (US) employer offers an HDHP (high-deductible health plan) that comes with an HSA.

(It's not quite what you described, because you have to use the insurer that the company picked. I think you're describing something more like the Singaporean system with Medisave.)

Yet we're ok with spending trillions on AI to eliminate jobs everywhere, including healthcare.

I don't think that's the reason.

Personally I'm of the opinion the reason it isn't being solved, is because the people whose job it would be to solve it get to keep their jobs due to donations from pharma and insurance companies.

Why not simply hire them to do something that isn't pointless - like dig ditches or clean garbage

One thing which is not terribly popular to point out is that at least on procedure pricing - wages are way way higher here. Some of that is that education is far more expensive so then we need to pay very well to pay that down. Also we have a cartel that limits the number of medical graduates.

NYC have been striking and to quote the union-friendly NYT "The three hospital systems affected by the strike said their nurses on average make about $160,000 a year and are seeking raises that could propel nurses’ salaries on average past $200,000, according to the hospitals."

By comparison UK pays nurses like US blue state fast food workers. Per google - "Average nurse salaries in London are the highest in the UK, generally ranging from £37,000 to £55,000 per year." Note NYC minimum wage is at $17/hr though many hospitality workers in the $20s, with a renewed Mamdani push to $30/hr minimum.

And US tax rates at these 3-4x higher compensation levels are same/lower than the UK..

Then add Americans having generally unhealthier lifestyles, being more litigious requiring higher malpractice insurance, etc..

https://apps.schools.nyc/dsbpo/sbag/default.aspx?DDBSSS_INPU...

That's the reason why a lot of inefficiencies are kept in countries around the world: it keeps people employed and moves money through the economy. If broken things were suddenly to be made efficient overnight, the government wouldn't be able deal with masses of angry people/voters suddenly out of a job.

The nightmare isn't just for her; it's also for her patients. She now spends almost as much time walking her patients through the insurance bureaucracy than she spends on actual treatment. And it's so sad because her patients are so desperate (parents of extremely sick children), but often get nothing but bureaucratic run-around from their private insurers.

So yeah, it's been a lose-lose situation since private insurance took over.

No comment on drug pricing and its incentives, the existence of America's prescription drug markets drives the new innovative drugs that the rest of the world picks up for cheap.

But anyway we really do need to go after providers and end the racket that is employer provided health insurance.

Put another way, in both countries a hip replacement surgery is almost exactly 1/8 of someone's per capita GDP.

[1] https://puc.overheid.nl/nza/doc/PUC_789284_22/1/

Yeah no thanks, let’s do the tried and true universal healthcare that literally every else does. They get better results AND it’s cheaper. We’re literally paying more for something worse.

For-profit health insurance. Which imho should be illegal.

A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by:

1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too)

2. Tying financial incentives and disincentives to outcome-based KPIs

By the way, as much as people complain about the profit seeking motives of insurers, many of them have been performing abmysally in the last six months. As it turns out, our current system is bad for just about everyone.

The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum

Yes, and you can fix it by the state covering ONLY tails - which it ALREADY essentially does, just as expensively as humanly possible.

Democrats and Republicans spend all their time arguing about whether to have sweeping changes that won't drive down costs or do nothing (which obviously won't bring down costs).

You could spend less money and get better outcomes by officially covering the tails instead of un-officially.

Instead of ~50% of young, healthy people paying a MASSIVE tax for "insurance for all" which doesn't really do what it says - you could just officially cover the tails, use the existing tax dollars, and accept that instead of ~30% of people "not having coverage" everyone would have tail coverage and ~50% of people wouldn't have "coverage".

You get a better, fairer system - that costs less overall, and that I think the American people could actually vote for.

Republicans would like it because it costs less and doesn't cover abortions or whatever they bitch about.

Democrats would like it because it officially covers everyone and prevents medically bankruptcies, and it doesn't FORCE anyone off insurance, and it would bring down private insurance costs significantly. They'd bitch that we should just do Universal Healthcare instead, but it's hard to argue it's a step in the wrong direction.

Pipe dreams don't pass. Reality does. You're never getting anything passed that massively fucks over a huge relatively popular special interest (like doctors).

You might be able to pass things that piss off unpopular powerful special interest like Health Insurance (or, previously, Fossil Fuel companies).

Everyone pays a little bit towards it all via general taxation but if you prefer a system where individuals have to front the vast majority of their own costs, much of which is just being extracted as profit, then you are welcome to that. I prefer the option that leans a lot more towards socialism than rapacious capitalism.

Removing that layer of indirection would make it your own choice to pick a provider, and the provider is then incentivized, at least a little bit, to provide you with a good outcome or else you may freely switch to another provider.

There's also the component that, right now, you lose the discounted group rate insurance premium as soon as you lose or leave a particular job. Putting the purchasing power with the end consumer means that you can keep your provider at the same premiums even if you switch jobs. All that might change is your employer contribution.

I'd offer a slight tweak. None makes sense in a vacuum or solely considering efficiency. It all makes sense seeing the evolution over time and the misaligned incentives.

What's wild, is that at least in the slice of healthcare I'm in, Medicare is one of our best most reliable payors. In fact, in some cases, our contracts with private insurers have them promise to pay at least 80-85% of what Medicare would reimburse us.

The other benefit with Medicare is that they just give us a lump sum of money and let us do what we want with it as long as we get good outcomes. Which means we don't have to fight for every visit we make to the patient. And they base it off of a public formula that we have access to (unlike with the private insurers).

If this were true then private insurers would have paid comparable rates to Medicare prior to the ACA passing, and that's just not the case. This fact has been a fixture of the US healthcare system since the creation of Medicare.

More here:

https://healthcareuncovered.substack.com/p/self-dealing-ille...

https://www.cms.gov/priorities/key-initiatives/hospital-pric...

But at a consumer level it's still quite difficult to predict what your total out-of-pocket expense will be for the same course of treatment at two different facilities.

It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment.

I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years.

But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!"

After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need.

(I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)

Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault.

The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.

I strongly think that covering everyone in the existing system is not the best way to go.

The existing system is designed to cost as much as possible, and we have way too much demand for treatment (as is) and not enough supply. ER wait-times aren't 2-4 hours just because.

First, that needs to break.

Then, you can cover everyone.

We simply do not have enough doctors for how many old and unhealthy people we have. We should be thinking about how to keep people from going to the hospital that don't really need to be there. Do you really need to go to the ER because you stubbed your toe? If you didn't have insurance, you'd go to a low-cost clinic and get the same treatment for 1/10th the price.

We are slowly getting there already. Low cost clinics weren't widely available, but they are becoming more and more available as the cost of health care even WITH insurance is too high for most people.

The infrastructure for the bottom ~50% of people needs to exist to break free from a system that is not designed for them BEFORE they can move off it.

It's almost there.

Since One Medical became widely available, I basically have not gone to the hospital in 5+ years. Before, you kind of needed to go even for routine things (or at least I didn't know of a viable alternative). More and more places like this are springing up all over the US.

Most Medicare recipients do get supplementary private insurance though? It's called "Medigap."

Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people get Medigap coverage.

See, for example, “Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland” by Jonathan Metzl

The regional differences are quite odd.

I got my ADHD diagnosis via Right-To-Choose, so it is considered an NHS diagnosis and I get my medication via the NHS (and therefore cheap). But the RTC pathway isn't available in Wales/Scotland/NI. I'd either have to wait years for an NHS diagnosis or go private and then have to pay £££ for my prescriptions privately.

The UK system has many problems but at least the general population are shielded from the exorbitant individual costs. We pay for it through general taxation but that, at least, spreads the load a bit.

But Medi care was right with the commercial insurers on reimbursement.

The unit costs of doing business with the US government are higher than with private companies even after accounting for economies of scale. The US government also requires that they pay the lowest price. Consequently, unit economics are usually worse when dealing with the government than when dealing with private companies.

The maths often don't math but the law doesn't care. Most inexplicable and bizarre pricing you see related to government procurement are structural tricks vendors use to indirectly fix the unit economics across their customers while technically staying compliant with bad regulations. Everyone else who is not the government is collateral damage of that byzantine theater.

Ideally, we would all drop the pretense that the US government deserves the lowest price just because they are very large, instead letting it reflect the true overhead cost.

That said I don't think there's evidence that lack of doctors is what is driving up cost in the US. Just an example, growth in hospital administrators has significantly outpaced medical staff over the last decades, which will directly increase cost.

Are you arguing that since we think we're all special that we should be accepting that other people think they're special?

Meanwhile, people getting laid off (just so the jobs could be exported to countries with more poverty and lower pollution, worker's rights, and standards for working conditions) were getting berated that they should "learn to code" for decades, while we laughed and discussed our stock options.

I think if we dig into the numbers we're likely to find those effects, even if we maximize them, are marginal, unless we do other structural things to untangle the provider pricing system and do price transparency. Like: you could posit a material impact on CVD costs by making statins more widespread, and that should make a dent somewhere, but I don't know that CVD costs in non-Medicare-insured patients are really that big a line item, and non-Medicare is important here because people already Medicare-qualified generally have all the statins they want already. Meanwhile, providers are still ripping patients (and insurers) faces off for shoulder impingements, stents, and spinal fusions.

It's a super interesting comment. Thanks!

https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locat...

So the USA is still significantly more expensive as a portion of actual income. “GDP per capita” is a relatively useless figure

Someday I should go buy some produce from each store at peak season and try them side by side.

One note: the doctors won’t agree or want to hear this, as they too are human, but listen to how they talk about nurses. Hit me once I had both a CRNA (advanced nursing degree in anesthesiology) and an anesthesiologist friend

Edit: glad I did add an empty cosign, right after replying, the parent is now downvoted to gray. And gets it much, much, better info than any other comment, and I read all of them. Last thing I’ll throw out to back it up is, check into who decides how many seats there are at med schools. Can’t remember the exact name but it’s basically the doctors union / professional organization. AMA?

There is no imposed limit on the number of residency slots.

There is a limit to the amount of money the US government is willing to spend on slots.

Keeping people employed through inefficient bullshit jobs is better for the government than paying them to sit at home, since this way you have control over their livelihoods and their votes.

That's the ludicrous propaganda that you've been fed but you really should be intelligent enough to dismiss it.

The world would get along just fine without you overpaying for your drugs. You pay for marketing costs.

To some extent it's circular: the US has a higher number of GDP because it spends more on healthcare. The broken leg version of the broken window fallacy.

The median equivalised household disposable income of a US household is over twice that of a household in Japan.

This is one of many reasons why it’s so misleading to compare prices across countries in a vacuum. All of the people doing the work for those education, transportation, and other services and all of their inputs aren’t going to work for Japan-equivalent pay when they’re living in the United States.

So that's about 6% of the difference? I'm not immediately saying no, but it sounds like that's not the real problem.

The only reason you would pay that much is if you're visiting a private no-insurance clinic and not using insurance. And private clinics pretty much only exist to prey on people who identify as expats and make zero attempt at learning non-English languages, aside from a few exceptions (certain speciality dentists, plastic surgery, anonymous STD treatment, some cancers).

Private insurance subsidizes Medicare and Medicaid even after you add in admin overhead.

https://relentlesshealthvalue.com/episode/ep502-how-some-pre...

Why do their stocks underperform so badly?

https://imgur.com/S8bNSM2

No argument from me that insurance is not competitive enough. But they are almost all public corporations that are highly regulated so the numbers on profit and expense ratios are easy to get for yourself to prove the point. No need to take my, or anyone with an agenda word for it. Almost everyone wants a simple answer to a complex interdependent problem that does not have one.

If there was a single solitary answer of “what is the problem with US healthcare” I’d have to go with it being a principle agent problem. If everyone who consumed healthcare had to pay up front very few services would cost what they do. Even changing it so people were billed directly and then had to submit insurance claims later like how pet insurance or car insurance works would go a long ways. But even that doesn’t solve the problem entirely, as it leaves massive gaps. Second answer would be “administrative class bloat” like in all areas of the US today.

Single payer is certainly a major part of the answer, but in isolation it’d solve almost nothing and potentially make things even worse as all the inane cross-subsidy comes crashing down overnight.

Edit: the point is medical loss ratios, admin overhead, etc. is public information not hidden behind some private company firewall. The fact non profits haven’t captured 100% of the market by being crazily cheaper should be telling on its own.

Patient populations are up, nursing FTEs down. Support staff down.

Nursing is one of the most physically and mentally demanding jobs I know of, at least in Germany.

And I bet 80% of the Techbros here wouldn't last a month in it, given how many lost their minds over a simple RTO-Mandate.

Maybe watch the movie "Late Shift" to get an idea of how a Workday is https://m.youtube.com/watch?v=C7o-omvW_DI

I doubt that "directionless" people would put up with those working conditions, and many leave the sector after a few years, simply because they burn out. Nearly no one works 100% long-term, just because it's too much too.

Medicare is as I described. Every specialty and procedure has its quirks though, some even make a killing on Medicare and not commercial but the hospital kind of represents a portfolio and the overarching economics in aggregate favor the commercial insurance. I’m guessing your wife’s specialty had decent Medicare rates but it’s not always true.

There’s even some private insurance which is effectively Medicare that has different reimburse ranges (Medicare advantage plans).

Executives like to lament the lose money on Medicare but I never really saw it that way. If you look at it isolated, sure it’s true. But if you look at it as a portfolio where your fixed costs are covered by another cohort, then it’s a huge volume to add and make money at the contribution profit line. You just have to be careful not to run fixed costs as a percentage of total revenues or something like that. The extra volume Medicare brings to a hospital or network of hospitals also has tremendous negotiating power for pharma, medical supplies and devices, etc.

As I said in another comment, I'm with a provider and Medicare is easily one of our best payors. We actually have contracts with private insurers that say they have to reimburse us at least 80-85% of what Medicare would. They also give us the money up front, with a public formula that we can count on vs. a hidden formula that requires us to go back for more auth (and thus needs more people to manage).

> However, new research by Stanford health economist Maria Polyakova and colleagues — using unique data on physician income — shows that physicians’ personal earnings account for only 8.6 percent of national health-care spending

https://siepr.stanford.edu/news/just-how-much-do-physicians-...

This is why even the meager amount of wealth redistribution we got (which was really young to old and not wealthy to poor) came about due to a fluke 6 months in 2009 that one party had 60 senate votes, and 58 or so votes supported a taxpayer funded option, but 42 did not, so the taxpayer funded option did not make it into the final bill.

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

ER wait times are long because ERs are the only place in the country where we effectively have medicare for all, albeit in a particularly perverse and dysfunctional form. Everyone gets treated at the ER even if they're broke & uninsured as long as they're willing to wait long enough. Now imagine if those folks could go to any primary care doc or even use One Medical, CVS walk-in clinic etc. That would go a long way toward fixing our overloaded ERs. We've legislated quazi-medicare for all but only in the most inappropriate part of the system.

The Medical Loss Ratio (MLR) requirement established by the Affordable Care Act (ACA) is 20%.

Typically it's closer to 15%.

As these are private companies, some percentage of that is obviously profit.

It doesn't cost that much more to run private insurance than Medicare.

The problem is the incentive of insurance to drive up cost to get a larger fixed cut, and the lack of a public option (which would require private insurance to actually be worth it).

This subset does exist, but is smaller than the percentage of people who think the system is broken - and the solution is not to just open up the floodgates and make it even more broken and even more expensive.

You FIRST have to fix the system before you open up the floodgates.

I am on your side that I think it would actually cost LESS to move all high-cost patients off of the ER and onto Medicaid.

But that's not a big enough problem to actually move the needle. In the rosiest scenario, you might save 2% per year. That's still like $20-40B, so nothing to scoff at - but in realistic scenarios, I'm doubtful it would save >$10B.

Even if they had Medicaid, they're so conditioned on going to the ER for everything, a lot of them might still go there instead of somewhere cheaper. For one, they might be convinced they get better care there (and maybe they would).

There's way bigger fish to fry.

The surprise was nonprofit hospitals: median markup of 3.96x actual operating costs, versus 2.39x for for-profit and 1.87x for government hospitals. That's hard to square with the narrative that nonprofits deserve their tax exemptions ($28-37B/year) because they serve charitable purposes.

On the self-funded employer point — you're correct that self-funded plans have more negotiating latitude, and thousands of them already use reference pricing (capping hospital payments at a percentage of Medicare). That's actually the policy fix this analysis proposes. Montana Medicaid implemented it and saved $47.8M. The question is why it isn't the default.

That's assuming price is the only variable.

Suppose one insurance company is accepted by more providers, including ones that might be closer (but pay higher real estate costs) or have nicer rooms etc. Meanwhile employers are looking for cost/benefit rather than just cost. If they give employees a better insurance plan they could pay them less or provide less of some other benefit and still get people to work there.

So before the insurance company didn't really care if you got a $10,000 plan or a $20,000 plan if they both had a $2200 margin, or if anything would prefer the former because they make the same money with lower costs. The employer is likewise fairly ambivalent as long as the more expensive plan seems like it's buying something (even if the something is convenience/luxury). But now the insurance company isn't allowed to have a $2200 margin on the first plan and still is on the second, so that's what they market, and then what more employers choose, resulting in higher average costs.

> Insurance providers also rarely operate at the full freight 20% either way though.

There are only really two options, right? Either the market is actually competitive and then a margin cap has no effect because competition would prevent margins higher than that regardless and the rule should be gotten rid of as totally redundant, or the market is less than perfectly competitive and then it does something but the something is a bad perverse incentive to raise costs to cheat the rule and it should be gotten rid of as actively harmful.

We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required.

I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.

I highly recommend you read the book "We've Got You Covered." It's an economist's view of health systems and how we can rearrange government spending to provide coverage for everybody and prevent medical bankruptcies.

One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized? Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists? Are they servicing only the young and healthy?

Their senior care plans tell an interesting story. They only work with Medicare Advantage plans, specifically those known for up-coding, excessive pre-authorization requirements, and high rates of care denials. Medicare Advantage is an interesting failure in the marketplace in that it costs the government significantly more than classic Medicare and provides worse-quality care.

For the rest of us, we can skip the ER by going to an urgent care. But around here, urgent care offices are owned by private equity, have deceptive billing and are part of the reason why medical care costs so much.

We're going to need to make more doctors. To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

I hate to break it to you but insurance is meant to be a tax on the entire risk pool. What changed after the ACA is we couldn’t kick anyone out of the risk pool for getting sick.

In a Medicare-for-all scenario, the individual price of a given procedure doesn't need to be so high, because the reimbursement is guaranteed. Right now, the "list" price of the procedure has to be high to subsidize the uninsured and Medicaid who lose money.

I'm sure there are single payer health insurance countries in which people still purchase insurance, which should inspire debate about the universal insurance cost-sharing.

Regardless, the only viable solution in the US is a single payer insurance model.

The more critical, and yet smaller, subset is the people making bank from the current system. Get their money out of politics and watch resistance crumble.

Definitely not cheap (I would prefer the £9.90 NHS prescription fee) but I get the feeling that it's cheaper than I would pay elsewhere in the world anyway.

So if United is the insurer they’re owned by an umbrella, that umbrella takes 20% or less. However United makes special deals and steers people to providers owned by the Umbrella. So that the Umbrella makes more money as well. This is true for medicine as well. For example Cigna requires all maintenance medication be purchased through express scripts as a means to retain or increase profit.

United has a history of also squeezing organizations by forcing them into pre-payment review when they’re high volume. This causes the providers to basically not have no revenue for months on end until it gets sorted. Then they might get a chunk or settle out of court. Often they go bankrupt and are purchased by the umbrella.

In terms of Medicare/Medicaid another catch-22 is that insurance handles the claims for providers. The insurance can recode claims and pocket the difference without telling the provider. It’s on the provider to catch it.

There is a tremendous amount of dark money, shadow games, hidden corporate structures, Wyoming and NM LLCs with Anonymous owners, etc.

Insurance as a whole tries to own the entire feedback loop for healthcare. They don’t like you going out of their feedback loop.

It has no military, and is effectively dependent of the US and in best cases neighboring countries. It has excellent weather and soil which account for its fruits exports… and outside of some niche industry, is mostly reliant on tourism which means importing money.

I love that country and have been many times. But if it were god forbid wiped off the face of the earth, it would be sad and annoying at best.

Costa Rica has “free healthcare” / healcare from taxes because it has 5 million people, about 1/2 of New Jersey.

This isn’t some mechanism that the US just refuses to use. It’s a matter of scale. You either don’t know and should remain silent on the topic, or do know it and lack the honor to not state it.

Most of the costs are ultimately salaries to Americans, and money handed to American companies, so most savings would come from someone's livelihood. That's why we cannot reform: The party that actually cuts costs will build resentment for decades, and create a blip of unemployment. Nobody wants to do that, and therefore you aren't going to be a serious, relentless attempt at cutting costs. We've seen how the attempts that the ACA made were counteracted by consolidation at all levels.

Serious cuts have to have no mother. Say, if we ever did have an AI that worked well enough at this, and outcompeted primary care physicians. Foreign pharmacies bypassing all controls and being able to hand you much discounted drugs the day after. Telemedicine and cheap travel put together to make surgery that didn't involve an ER visit just as easy and much cheaper than using the US system. Straight out disruption, because the incentives are such we sure aren't getting improvements in regulation.

There's a common, misleading, claim that Medicare is more efficient because they spend far less than commercial insurance on overhead like claims processing. This claim is true. But the impression that it gives is absolutely the opposite of reality. The reason that Medicare doesn't spend as much on admin is that they offload all of this work onto the providers. Every hospital in America has a "Medicare Reimbursement" team. A moderate-sized hospital is going to have something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid. And that's a lot more work than just filing the right forms for each case. There's a ton of additional work. Each spring they have to file a HUGE "Medicare Cost Report", requiring a couple of months of work to get all the data in place for it. (Source: my wife was "Director of Reimbursement" at various hospitals for quite a few years, before going into consulting.)

That Medicare Cost Report that I mentioned is, beyond a huge effort sink, the source of many other evils. Because of the amount of work that's needed to gather and collate all this data, hospitals naturally structure their Accounting around the way Medicare wants them to report. The thing is, that's largely orthogonal to the way a rational person would do cost accounting. The result is the common criticism about how widely varying the cost of a given specific line-item is between hospitals: they don't really know how much a given procedure costs because that's not how they track their expenses, so they apply some allocation heuristics, and every hospital does that a bit differently.

There are also various perverse incentives in the system. For example, Medicare is smart enough to know that it costs more to deliver care in NYC or SF and so forth. Every locale has a Cost Index that scales how much they expect to need to pay. This leads to hospitals needing to show that their expenses are higher so they should be classified into locale X rather than neighboring locale Y.

Another one my wife told me about her hospital: Medicare realized that a lot of UTIs were hospital-acquired, and they rationally said that they would no longer pay for UTI treatments unless the hospital could prove that they were not hospital acquired. Well, maybe that wasn't rational, because with Medicare/caid being such a huge portion of their business, they changed their policy to test for UTI for everyone at admission, so that they could furnish the proof demanded. Think of all that wasted lab work...

So no, Medicare is NOT more streamlined and efficient. It's absolutely, 180-degrees, the opposite of that.

before the ACA, insurers could deny coverage for pre-existing conditions

people have forgotten how bad things used to be

I love the particular irony of people who advocate for regulations then attempt refutation of free market theory for what is already unquestionably and objectively not a free market.

I'm not sure how the other Nordic countries do it but I think it's probably similar.

We could import them.

We have tons of options. But the medical industry likes a shortage, because they like high wages, so I won't hold my breath.

They pick the rules. The rules favor them.

That's going to remain true for the foreseeable future, and on the list of problems, that's at the absolute bottom of things to fix that would actually move the needle.

The cost you spend on DIRECT HEALTHCARE is only ~20-30% of all spending. The rest is administration, drugs, insurance overhead, profits, ACTUAL insurance costs, cost overruns due to insurance making everything as expensive as possible to scrape 15% off the top, fraud, legal fees, etc.

The biggest benefit to moving to a centralized insurer is that fraud is centralized.

If you're a Republican and skeptical of government, you might assume the government will let massive fraud slip through to insiders, and you don't like that.

If you're a Democrat, and think the government can generally be good, you think the government can catch a lot of the fraud and cut total costs by 10% to get to fraud levels that are similar to other advanced countries (with similar systems).

You didn't read the post.

The sick are mostly the old (if you're looking at total spending), and they are already covered by Medicare.

The sick young are a minority, and are often times covered by Medicaid.

If the state covers the tail end and assuming they aren't covered already by Medicaid, there just isn't that much spending remaining.

They can get private insurance to cover the under $10k per year - but there's not really a product that covers that effectively - so unless a new insurance evolves, it still wouldn't make much sense.

The sick, young, non-medicaid tail is VERY small compared to the rest of the tail the state already covers. Just add it in. A 1% global tariff could easily cover it. You've still got 9-14% left to spend on more bombs, tax breaks for the rich, paying people to get underwater basket weaving degrees, whatever.

I've watched friends go through it here in the US and I have zero interest in working 24 hour shifts and sleeping in break rooms, working 80+ hour weeks for years. There just is no need other than hazing and keeping artificial scarcity of doctors for inflated wages. There are plenty of brilliant, scientifically minded, hard working people that care about others that probably could be great doctors, but the US training system is just hostile towards most people.

"Blood libel" refers to a specifically anti-Jewish trope of alleging that Jews murder Christians, especially children, to use their blood for religious rituals. Grandparent comment is 100% not blood libel.

Meanwhile we’ve spent close to £7k on my kids ADHD/ASD diagnoses privately as it was a 4 year waiting list for a NHS CAHMS referral. Luckily the GP has agreed to take on the private diagnosis and prescribe the meds under a shared care agreement.

I’ve no idea what happens in a few years when my kid hits 18. I’m hoping they don’t have to back out of the SCA leaving them without access to meds. It’s something I need to research although the fallback is paying privately I guess.

Big players like United just shuffle money around because they own the entire vertical market. Their insurance arm is regulated so they just move the money to to their service provider arms like Optum which are unregulated with uncapped profits.

Nothing's perfect, but the plan differences seem stark. For example, my wife had a crappy marketplace plan and I had a plan through my employer. For her, an MRI was denied, denied, then finally approved with many calls. For me, it was approved immediately. For her, pre-auth to a specialist was denied until her doctor went and tried a different referral strategy. For me...well, I haven't been denied yet. It goes on - same city, same hospital, some of the same referrals, etc.

I've come to think the price discrimination really does mean we have class-based care which seems to allow for the sensationalism. Combine a dire scenario with a working or indigent class American, and they don't have to exaggerate much at all.

It does make a big difference exactly where you are in the US, however. Some places have a glut of healthcare providers and other places don't.

You are clearly not in the bottom 50% of health care spenders. You would be in the group that would keep private insurance and be happy.

> One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized?

No.

> Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists?

The vast majority of their "doctors" are Physician's Assistants. You can see whoever you want for whatever you want (that they provide).

> Are they servicing only the young and healthy?

Mainly. It's a clinic. You can't go there for Open Heart Surgery and cancer treatments. They'll just (cheaply) refer you to a specialist (who will be expensive and require insurance).

What you can do is avoid huge wait times and get good enough treatment for ~90% of what the mostly healthy group of ~50% of the population needs for fair up-front prices - which previously did not exist.

Also, I'm not going to trust a podcast owned and operated by Stacey Richter, who also just so happens to be the co-president of Aventria Health Group and QC-Health.

Insurance as standalone entities are not much better or worse for total cost than these giant vertical monopolies. At least yet, thy are only recently becoming large enough to truly put the screws to people. Because insurance was not all that profitable made it prime targets for these sorts of shell game shenanigans.

It’s basically the point I was making. Fixing “insurance” isn’t a fix at all because the problem is far greater than just that layer of the onion. Costs are hidden and embedded and cross-subsidied to the point no one can unwind it without burning the entire thing to the ground. It’s grift from bottom to top. Aside from a few poor souls actually at the ground level who are still true believers trying to provide service to patients. And a lot of those are burning out. I think out of the 5 or 6 medical doctors I met while they were in medical school, only one is still practicing. They would now be late 30s to early 40s and in theory at the prime of their careers. Instead they got out as soon as medical school debt was paid off and moved onto other less stressful things. Another hidden cost in the shit-tier system rarely talked about.

I’m simply pushing back on the idea that the 20% medical loss ratio is the source of all (or even most) issues for the cost of healthcare or why insurance sucks so much to deal with. It’s nearly irrelevant.

Where in the US did you have to wait months? There seems to be an MRI/imaging location in every other shopping center in the US right now. I've never had a problem getting a same day MRI when needed. Perhaps you were waiting for the 'free' one your insurance would accept?

The real players are big corps like United and CVS, who control the whole vertical of provider and payer. They own the doctors, the pharmacies, and the insurance.

[0]File under "damning with faint praise".

https://www.commonwealthfund.org/publications/issue-briefs/2...

>For example Cigna requires all maintenance medication be purchased through express scripts

Important note: Cigna owns Express Scripts. Today the biggest "insurance" companies are actually massive conglomerates that own the clinics, the doctors and the pharmacies. United = Optum. Aetna = CVS + Caremark. Humana = CenterWell. Elevance/Blue Cross/Anthem/Carelon. Centene = Envolve

Once a giant like United gets big enough in a city, say ~40% of the population, they lower the reimbursement rates for independent doctors and if the doctor refuses the contract, they are kicked out of network and lose 40% of their patients. Go bankrupt or sell to Optum.

Digi is also right about Medicare upcoding. It is a well-documented $$billions scam where Medicare Advantage insurers comb through patient records to add diagnostic codes making the patient look sicker on paper than they actually are so the government pays the insurer a higher flat rate for that patient.

Guess which other country has universal healthcare - China. They are just slightly more populous than the US.

> This isn’t some mechanism that the US just refuses to use. It’s a matter of scale. You either don’t know and should remain silent on the topic, or do know it and lack the honor to not state it.

China does have a military…

Maybe you should take your own advice. Every other country in the world seems to have figured this out.

Many of my health needs are not expensive, but my body's reaction to treatments is. Frequently, cheap drugs are all side effects and no benefit. Also, private insurance has bizarre coverage gaps. For example, ambulance costs. When I had a heart attack, I drove myself for 45 minutes to the nearest hospital with a cath lab rather than take an ambulance and end up with God knows how many thousands of dollars in uncovered ambulance fees. Then there are things like cardiac rehab, which go a long way toward restoring cardiac health. 12 weeks, three times a week at $50 copays, was an expense I wasn't counting on. When I qualified for Medicare, the quality of care improved significantly. Usually, wait times for service are much lower than with private insurance.

I also resent private insurance because my premium dollars go toward enriching stockholders rather than providing care for all policyholders.

> something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid

2FTE’s vs what?

The question isn’t is this free, the question is how large is the total staff including price negotiations, doctors, and IT time spent handling billing issues, and is Medicare more or less than 50% of the total.

I am ware of one hospital and 2 medical clinics where the difference is very much in favor of Medicare.

One of many failure modes of the glorious and totally perfect Free Market

Yes most other countries use public money to educate their doctors

This is some idealist fairytale view that people like to believe in but doesn't actually exist.

We're in the totally opposite boat. We actually prefer Medicare patients vs private insurance not only because of the reimbursement, but the way in which they reimburse us (one lump sum vs visit-by-visit auth that requires manpower to manage).

Some of the requirements can be onerous, but on the whole, they're easier to plan for than the private stuff.

It was bad even before COVID, it’s even worse now. There are tons of regulations prohibiting the significant increase in creating new doctors and nurses (and air traffic controllers, but that’s a different but remarkably similar story).

Limits on new providers, and tons of corrupt regulation keeping people from opening new medical schools, clinics, and hospitals.

A ton of it is simple supply and demand - and the supply side is capped. Go to a place with a functioning competitive market and the prices (and wages) are a fraction of what they are in the US.

Not to mention that because of Bush, the government is not allowed to negotiate drug prices.

The ideal long term strategy is to drive everyone’s costs to go up slowly over time slightly faster than inflation. Adding administrative burden to medical institutions is a perfect way to achieve that, but clearly that never happens…

I think you want a third solution - but that seems highly unlikely to be available in the mid term - and it doesn't look like anything is changing in the short term.

Who knows, my crystal ball doesn't work any better than anyone else's.

These are synonyms for having higher overhead, right? If you pay a billion dollars in claims with ten million dollars in administrative costs then your "administrative overhead" is 1%, even if half the claims are fraud. If you increase "administrative costs" to a hundred million to get rid of the fraud, in practice you just saved 410 million dollars but now your "administrative overhead" is up to 20%.

Or doesn’t live.

https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...

All the other managed care organizations have similar 2% profit margins.

It is funny seeing complaints of excess profit margins from businesses earning 2%, that compete against non profits, from people on a forum composed of employees of tech businesses earning 20%+ profit margins. I wonder how much Epics’s profit margin is?

And then there is also pharmaceuticals, also earning double digit profit margins. And then the law firms in medical malpractice suits, who I imagine are not working for 2% profit margins either.

You can find out similar results for longer periods here:

https://dqydj.com/stock-return-calculator/

https://dqydj.com/sp-500-return-calculator/

Not really, because whereas before things were bad for people with pre-existing conditions, now they are really bad for everyone.

People are paying exorbitant prices either for insurance, for routine health care stuff, or for both.

There was no free lunch, so we traded some health care for the chronically ill, for slightly less healthcare for everyone else. The insurance companies make sure it's an extractive zero-sum game in terms of actual healthcare provided.

https://en.wikipedia.org/wiki/Averch%E2%80%93Johnson_effect

If those were malinvestments instead it’s simply throwing money away for not even a theoretical “someday” return. Plenty of ways to look busy while spending massive amounts of capital.

Generally agreed in principle though. Investment in the grid is pathetic almost everywhere in the US and has been for generations.

That’s what I mean when I refer to facile ideological reactions. For many people, “profits” are the problem, and they don’t care that health insurers on average are less profitable than Subway franchises. It’s just the mirror image of people who say the New York MTA is a disaster because the government is running it, and don’t care that governments in other countries manage to run cost-efficient train systems.

In a source posted by another commenter, their wages are accountable for 5% of the difference.

I also don’t think it’s accurate to say regulations are what’s prohibiting an increase in nurses. They don’t have a government imposed mechanism like residency funding that creates a bottleneck like the one in medical training.

We have a nurse shortage because we have an aging population increasing demand, it’s a tough job, and people are leaving the profession.

versus nothing. Hospitals don't have to maintain a whole team for UnitedHealth, or for Anthem, etc.

This is my point. Medicare cooks the books to look more efficient by offloading their administrative costs onto providers. Other payers can't do that because, even if huge, they don't operate at the same scale.

Think about it: we often hear on the news about disputes about contracts when a local hospital's agreement with some insurance company comes up for renewal. They play hardball, getting local news to run stories on how many people will be affected if they can't come to terms. But you'll never hear this in the context of Medicare/caid. Hospitals have leverage to negotiate with commercial payers, but not with the government.

Similarly, insurers would as a matter of course exclude from coverage any woman with one of several extremely common conditions, including endometriosis, PCOS, fibroids, and adenomyosis.

Prior to Obamacare, insurers were free to deny coverage wholesale for these conditions. It would have been fucked up to extend coverage but exclude any neurological conditions from my kid, but the actual outcome was worse: they were under the law entitled to withhold any coverage.

If insurance companies then can wiggle out of covering pre-existing conditions, they're no longer solving the moral problem they were brought into the world to solve, and now we need some other solution to solve the rest of it. Then, whatever that other solution is, it's solving the hard part, so why not extend it to solve the whole thing and cut the insurance middlemen out of the economy entirely? What are they even doing at that point besides extracting a rent?

(This is one answer among many good ones to what is really a bad-faith question—health-insurance is not a lot like fire-insurance at all)

I was also a part time fitness instructor, runner and could past any of the standardized fitness assessment standards for someone who was 5 years younger as far as push ups, sit ups, running etc.

I had a contract so I could have easily paid more based on risk.

Before anyone mentions COBRA, that’s only an option if your former group plan still exists and it didn’t when the company went out of business.

Just looking, even now the ACA Silver for my wife and I would be around $800 a month in my state. Even ignoring medical costs have gone up more than inflation, that would have been $550 a month in 2011 if the ACA had been available.

What if someone gets Type 1 diabetes as a child so they can no longer get insurance because of that "pre-existing" condition: if they get cancer for unrelated reasons they should just be saddled with medical debt? Or because of your Type 1 you can't get coverage, and you get t-boned in your car by a drunk driver.

Certainly it sounds 'unfair' that someone who smokes (a personal choice) gets similar cancer coverage for someone who does not smoke. But it also means that if your ((great-)grand-)mother had cancer, and you get it through no fault/choice of your own (i.e. genetics), you can also get coverage. (This latter effects a cousin of mine: her aunt (mom's sister) died of cancer at 37, her mom at 63; so now she's wonder when here number will come up. We're in Canada, so have universal care, but it's still something in her DNA.)

There are many circumstances in which you suffer through no fault of your own, and universal health coverage is present in many societies because it was decided to protect those people—even if it allows some 'free-riding' by others making poor choices.

People make all sorts of crazy decisions to prevent the "wrong" people from getting what they "don't deserve":

* https://en.wikipedia.org/wiki/Dying_of_Whiteness

The way it was suppose to work with the original mandate is that everyone had to be insured either through their employee or the exchange. So you couldn’t just buy insurance when you were sick. The Supreme Court struck that down.

If you lost your job, before the ACA, you could not get health insurance outside of working for someone and having group insurance at any cost.

But you do realize that the entire idea of not being able to get insurance because of pre-existing conditions is completely unique to the US?

Costa Rica for instance (where I am right now for a month and half) allows anyone to become a resident as long as you have guaranteed income of around $2000 a month or you deposit $60K into a local bank account and they arrange monthly disbursements and you pay 15% of your stated income to CAJA. Healthcare is both better and more affordable here.

The same is true for Panama. Why can’t the US figure this out?

Obama couldn't change that, so the ACA redesigned the system to work with it. Despite being called insurance, health insurance is no longer really viewed or designed to be any kind of insurance. Instead, it's supposed to be Netflix for healthcare. You pay a flat rate, and then get unlimited healthcare. Obviously, the issue with this is that if you don't need healthcare you can just not sign up for the subscription. So the ACA tried to solve this by requiring everyone to sign up. Once everyone is required to sign up, it's not right to discriminate against preexisting conditions. It may not be an especially good system, but it is coherent.

I work in this area and you're right that Medicare can require a huge amount of paperwork from providers. And a hospital will have far more than 2 FTEs for this (it's called Revenue Cycle Management).

Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite:

CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too.

HCPCS codes (equipment and supplies) - defined by CMS.

ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.

While you didn’t ask for a definition, you should try and connect the dots.

You don't need 'insurance' in order to get your vehicle serviced, but that is what the US does with healthcare.

This is a flat out lie. You absolutely could buy health insurance without being at a company.

Maybe a department of Return on Investment. See what those taxes pay for. Contrast to buying private versions of the services at the same SLA or better.

With Canada now ending the life of 100k citizens a year making their MAID program now the leading cause of death in the country out ranking cancer and heart disease? How strange that in Canada you can deduct health expenses on your taxes… what a strange thing for a place with free healthcare?

And in Britain you mean the scandal-free and extremely popular NHS? I guess you have a great point there because it’s not their elite would immediately come to the US for care.

The grass is not greener. This is a bad system made worse and worse by heavy handed government “helping”. Healthcare in the US only got worse after ACA.

The ACA also was written to enforce that through mandates and subsidies - a carrot and stick approach. The moral hazard was caused once there weren’t any mandates because of lawsuits by Republicans and the insurance companies still had to accept everyone.

I can’t say the same about health care

And all of those people with pre existing conditions didn’t have just “delays” getting healthcare they didn’t get it all.

So sure insurance is great in America for you if as your handle suggests you work in tech in SV.

I don’t have a dog in this fight. I’ve got an exit plan if I have to get insurance before I’m 65 amd may just retire here even after 65

Nope. Total MAID deaths (since 2016) is expected to reach about 100k in mid-2026. Most of them elderly people with a terminal cancer diagnosis.

If you were just looking to shout "dems good GOP bad" and find others who agree with you, that's cool too.

(1)https://en.wikipedia.org/wiki/Adverse_selection