17 ms·

The U.S. could slash health-care costs with two fundamental changes

110 points by Reedx 7y ago

dv_dt 7y ago
The Indiana data point for this was only two years of study, a decade ago 2007-2009, and crossing the very exceptional 2008 recession year. This is a questionable time period to claim proof of savings on health care costs. The Singapore cost savings example is attributed to silver bullets of price tags and deductible scheme while completely ignoring that most care in Singapore are delivered via government owned corporations of hospitals & clinics that service 70-80% of the population. Drug prices for example are controlled essentially by government boards nationally negotiating prices with vendors. This too is ignored in the marketplace article and seems fundamental to making those silver bullets viable. I would submit that the fundamental control of pricing at work here is that the 20-30% private care needs to compete with a basic competent and majority publicly provided care delivered at gov't negotiated prices. The financial structuring of how the care is priced to the user base is a far far lower contributor to Singapore care being 75% less than the US. https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://www.vox.com/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained https://www.vox.com/policy-and-politics/2017/4/25/15356118/s... Edit: I would also say that it's a nice trick to keep some small component of private care boxed into an area where it has to compete on fundamental effectiveness. This allowance I think is a nice way to accommodate some level of private innovation maybe helping to keep a public only system from becoming too stolid.
- lostdog 7y ago
  It also totally ignores that a dollar saved by skipping on short-term care can be a thousand dollars lots five years later. Not sure how it's possible to show much of anything in a 2 year study.
nickgrosvenor 7y ago
This is a critical issue that could throw the whole economy into a recession. Fixing this and the recent prevalence of foreign, disease carrying mosquitos are the two biggest policy issues, that if fixed will cause a world of good.
- borkt 7y ago
  There is already a practical (but unsightly) solution to mosquitos - bug nets. There is nothing stopping people from wearing bug nets covering their entire body if they feel disease carrying mosquitos are a grave danger. It is irresponsible to waste the resources that treating mosquitos as the second biggest policy issue facing the world would require, and it could also cause serious consequences to the ecosystem if we get an eradication solution wrong. https://www.thegreenhead.com/imgs/xl/netsmen-wearable-mosquito-suit-xl.jpg https://www.thegreenhead.com/imgs/xl/netsmen-wearable-mosqui...
- Accujack 7y ago
  >the recent prevalence of foreign, disease carrying mosquitos are the two biggest policy issues This is a weird idea. Are you arguing that native mosquitos carry fewer diseases? Also... I can agree that health care is #1, but mosquitos are not number 2... more like number 900 or so. The amount of disease caused by them is tiny compared to e.g. smoking or obesity.
  - maximente 7y ago
    why weird? some mosquitoes prefer to feed on e.g. birds whereas others do not bite birds at all; that makes them a vector for particular diseases.
  - nickgrosvenor 7y ago
    It's more of a local policy issue for southern California residents. Of course all of this can be debated, and perhaps it's not the 2nd most important, but it's much more important to me and all my friends than most policies. Native mosquitos on the west coast (Culex) do not carry west nile or zika. The new Aedes species does and is extremely hard to control. https://www.latimes.com/science/sciencenow/la-sci-sn-aedes-mosquitoes-california-20180901-story.html https://www.latimes.com/science/sciencenow/la-sci-sn-aedes-m... Further, it caused everyone I know in the Los Angeles area to stay inside during this last summer. My kids and friends kids stayed inside all summer. It was like night and day compared to every other year. Fear of Zika has spread to pregnant mothers around my neighborhood. People are literally choosing not to get pregnant because of the fear of this new mosquito in the area. The amount of fear caused by these new mosquitos has been extreme. They are very hard to control, I think this new invasive species can only be eradicate with government intervention. There are no cost effective trapping solutions. Nets and Deet aren't 100 percent effective and is not something we should settle for being the new normal when government intervention is possible. The sooner it's dealt with the more realistic it can be fixed. I would literally vote for any local politician if this were a primary policy issue for them.
thatfrenchguy 7y ago
> The second policy—deductible security—pairs an insurance policy that has an annual deductible with a health savings account (HSA) that the policy’s sponsor funds each year with an amount equal to the annual deductible. Yeah, people avoid care when they have those plans. Is that a good outcome ?
- deleted 7y ago
  [deleted]
- partiallypro 7y ago
  In many cases, I would say yes. A massive amount of ER visits are not needed for instance, and are more suitable for walk-ins and primary care. And just in my experience my Doctor will often push for various tests, which aren't needed. I've had multiple people tell me the same. Then I've gone to other doctors that wonder why such and such doctor did that other than just to gouge.
  - notadoc 7y ago
    Most ERs would be well served by opening all-hour urgent care clinics directly adjacent, and triaging the roughly 70-80% of people with non-emergent and/or minor issues into that wing rather than to the ER.
    - xyzzyz 7y ago
      How exactly? Since it would do the same thing as ER, it would cost as much to operate as ER. The patients and insurance would win if this made them pay less, but the hospital would be a loser here with reduced revenues.
      - lostapathy 7y ago
        Or it might mean they'd get a lot of business that would go to another nearby ER. Where I live, it's practical for me to go to an ER in at least 3 different hospital systems. If one of them offered 24-hour "urgent care" I would definitely go there vs the one closest to my house.
partiallypro 7y ago
This would definitely help, but the 75% number is just pulled out of the air.
- npongratz 7y ago
  It may have been in reference to Singapore's results, per TFA: > With Singapore’s citizenry empowered by deductible security and price tags, competition has worked its magic, forcing providers to constantly figure out ways to lower costs and improve quality. The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world.
  - ska 7y ago
    It is mostly pulled out of a backside though, because without much evidence it attributes that 77% decrease in spending to a couple of cherry picked difference between the systems. Overall it would plausibly help, but it's a pretty strong claim that these are the only important differences.
    - adventured 7y ago
      It ignores the 30 point gap in obesity - 6% for Singapore, 36% for the US - which is obviously a big contributor to the US healthcare cost problem. 36% obesity is an extreme elephant on the table for costs. I would be surprised if the US couldn't shave 1/5 off its healthcare costs with a 22% obesity rate (comparable to Germany, Brazil, Poland, France, Sweden, Netherlands, Finland, Norway, Austria, Spain, Russia, etc). Singapore vs Japan and South Korea is a more interesting comparison (similarly very low obesity rates) between costs in developed health care systems, if you wanted to see which worked better. Japan for example has a spiraling healthcare cost problem related to its aging population.
      - deleted 7y ago
        [deleted]
rayiner 7y ago
What I’ve always found amazing is how cheap dental and eye care is in comparison to other types of medical care. The fact that you can get laser surgery in your eyes for a couple of thousand dollars is incredible, given that a diagnostic test like an MRI can often cost that much. Clearly there is room for competition to reduce costs. Clearly that doesn’t work for emergency services. But is there room to distinguish emergency from non-emergency services? I had surgery for a deviated septum. I don’t know what it cost, but if I had an incentive I could’ve price shopped for it. There are a lot of non-emergency procedures (colonoscopies, hip replacements, knee surgery, etc.) that could be subject to competition. Also, the comparison to Singapore’s health outcomes is a bit odd: > The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world. Fun fact: Life expectancy for Asians in the US is 86 years (almost 90 in New Jersey!), quite a bit longer than the 82 years in Singapore.
- criddell 7y ago
  > if I had an incentive I could’ve price shopped for it In my experience hospitals and surgery centers can't or won't tell you what something will cost up front.
  - ska 7y ago
    That is one of the main points of the article.
  - maximente 7y ago
    most in the US won't, although some do e.g. https://surgerycenterok.com/pricing/ https://surgerycenterok.com/pricing/
  - gremlinsinc 7y ago
    I'm pretty sure though they have to supply an 'itemized' list if you ask for one, which you can contest anything on the list and a lot of times take them to court over if they don't budge. Often they will because they know $35 for an ibuprofin is absurd but most people don't think they can win against a big bad hospital.
didibus 7y ago
Couldn't you do both? Provide HSA deductible Medicare for all. And force price tags on everything? Then you get government offered health care. Negotiating power of a big single bulk payer. And competition from patients trying to keep some of the insurance money to themselves by avoiding unnecessary care or hunting for a better deal.
codingdave 7y ago
As U.S. the election season warms up, it is important to recognize a political piece when you see it. This starts not with presenting the problem, but with implying that the changes proposed by Democrats aren't what is needed. And later on calls out data gathered by Republican office holders. Even if the topic is health care, those bits of the writing should indicate the political motivations behind the article. I'm not going to tell anyone where to fall in politics, and HN is the wrong place for it anyway... but I do encourage everyone to be aware of it over the next 12 months.
- orhmeh09 7y ago
  It’s nice of you to underscore the issue, but I suspect most readers would catch on based on the first line of the article, wouldn’t you? > As the Democratic presidential candidates argue about “Medicare for All” versus a “public option,” two simple policy changes could slash U.S. health-care costs by 75% while increasing access and improving the quality of care.
  - codingdave 7y ago
    I hope so. But HN typically shuts down political articles fairly quickly, and this one made it to the front page and had comments on it as if nobody had noticed, so I thought it was worth a mention.
  - anticensor 7y ago
    Is Medicare for all going to be a premium-funded, premiums enforced one like we have in Turkey?
- noelsusman 7y ago
  Yeah, these are standard conservative talking points. The best part is they would riot if we actually tried to implement Singapore's health system in the US. In Singapore the government forces you to put a certain percentage of your income into a health savings account, and then the government tells you what you're allowed to spend that money on. You can't use that money to buy a drug that isn't on a special government list, for example. The government also owns most of the hospitals, and most doctors are government employees. Hospital stays are mostly paid for with government subsidies. Drugs are also directly subsidized by the government, but only the drugs that government bureaucrats approve. But none of that has stopped them from spending decades pretending that transparent pricing is the sole reason why health spending is lower in Singapore.
smacktoward 7y ago
I bristle when I see health savings accounts presented as a solution to the health care crisis. The median household income in the U.S. is about $64,000 a year (see https://www.census.gov/library/publications/2019/demo/p60-266.html https://www.census.gov/library/publications/2019/demo/p60-26...). When a single major medical procedure can result in a six-figure bill, there's just no way that the average person could ever save enough. You end up with people who are lucky enough to never need to tap their HSAs, and people who are unlucky enough to get sick, whose HSAs just present a speed bump on their slide into bankruptcy. There's only one thing HSAs are really good at, and that's creating a huge new tranche of money for Wall Street to suck fees out of.
- nradov 7y ago
  HSAs are part of high deductible insurance plans with out-of-pocket maximums. No one with such a plan would ever receive a six-figure bill. (With the possible exception of surprise billing from out-of-network providers, which we ought to ban.)
  - irrational 7y ago
    To the best of my understanding, you are 100% correct. Why are you being downvoted? Do other people know something you and I don't know?
    - op00to 7y ago
      Yes. Look at the in/out network for your high deductible plan. None of the providers I use on a traditional plan are considered as in network for the same employers high deductible/hsa plan. Our high deductible plan does not cover out of network. Not at all. Fun!!!
      - irrational 7y ago
        That's not the case with my plan at all. We can use all the exact same providers as the traditional plan on our high deductible/hsa plan. We just switched to the high deductible plan a few years ago (after doing the math and realizing how much better of a deal it is), but we've kept all of our same doctors and specialists as we used before.
Goronmon 7y ago
But the annual gifts do more than ensure that participants are financially secure; they give people skin in the game. Participants spend prudently because they know that any unspent HSA balances are theirs to keep. The result? Massively lower health-care spending without any decrement to health outcomes. HSA also discourage you from doing any preventative care because that's money you can probably find a use for in other ways. Thus inflating long-term healthcare costs as people only go to the doctor when it's an emergency. Anyone who supports HSA accounts is either an idiot or has suspect motives. Those may be a strong opinion, but it's one I stand by in this particular case.
turc1656 7y ago
First off, if something this large can drop by 75% in price then you're being bamboozled, extorted, or potentially both. "Under our current system, it’s nearly impossible for people with health insurance to find out in advance what anything covered by their insurance will end up costing." It's worse than that. Not only can you find or figure out how much everything will cost, most places (particularly hospitals and outpatient centers) will not even tell you how much they charge for their services. Some news outlet did a study and called the top 25 hospitals in the country and asked them how much a hip replacement would cost. Only around 3-5 actually gave a number and it varied wildly. The rest refused to pin down any number at all. That's one of the most common surgeries there are and they don't know what they will charge for it? On the moral/philosophical side - how can a person be held financially liable for something they cannot possibly know the cost of in advance, even if they try to find out? Such practices are illegal everywhere else in this nation. And there is no legal exception for healthcare providers. How do I know that? Because a few years ago Rand Paul tried to pass a law that would exempt healthcare providers. It failed - which means it is still currently illegal to be doing this. Yet not one of these providers or operations has been charged accordingly. If you went to a mechanic and they took a look at your car and you asked how much it was going to cost to fix it and they responded with "which insurance do you have?" or "I don't know until I'm done" they would get shut down and charged, and rightfully so. Because the logical conclusion is to say it costs some extravagant amount of money and then "settle" for something less. Which gee, doesn't that happen a lot in the medical industry when people can't pay their bills? People face bankruptcy and can't afford a $10,000 bill but somehow the hospital is just fine accepting $3,000 instead?
- mschuster91 7y ago
  > Not only can you find or figure out how much everything will cost, most places (particularly hospitals and outpatient centers) will not even tell you how much they charge for their services. Some news outlet did a study and called the top 25 hospitals in the country and asked them how much a hip replacement would cost. Only around 3-5 actually gave a number and it varied wildly. The rest refused to pin down any number at all. That's one of the most common surgeries there are and they don't know what they will charge for it? Because in the US model the insurances negotiate with the hospitals what they pay, and you will almost always be given a number that is way higher than the highest insurance amount - as when you pay yourself the hospital has a high risk of never being able to (even partially) collect the bill. Also, it must be higher than the highest insurance amount so that if you were an undercover agent of your insurance you would still believe you pay less than others.
zip1234 7y ago
Why is price transparency not a thing already? The government should do that immediately and see what happens before doing anything extreme.
- tathougies 7y ago
  President Trump has already started that process, and has asked Congress to help: https://www.npr.org/sections/health-shots/2019/06/24/735432387/trump-administration-pushes-to-make-health-care-pricing-more-transparent https://www.npr.org/sections/health-shots/2019/06/24/7354323.... For example, they've already started mandating drug pricing transparency in advertising: https://www.nytimes.com/2019/06/14/health/drug-prices-tv-ads.html?module=inline https://www.nytimes.com/2019/06/14/health/drug-prices-tv-ads..., but are being opposed by industry groups obviously.
tempsy 7y ago
I'm a fan of M4A, but I think something the gov't could do is allow people to earn tax credits for practicing preventative care that help lower whatever tax increase would be created to fund healthcare. That creates a financial incentive to try to be healthy while not necessarily discouraging people from going to the doctor when they really need to (which can happen with out of pocket expenses, HSA or not). E.g. on one of my old plans I got a $300 visa gift card just for going to a checkup.
mattrp 7y ago
This article misses one other potential savings — allowing patients to cross state lines to buy plans in cheaper states. In terms of HSA’s, I think they are a great idea. But I have a more radical solution than an HSA: Allow the first $100k of income to be contributed pretax to a unified savings plan. We would do away distinctions between 529, ira, 401k and HSA. It would just be a unified account. You could withdraw prior to 59.5 to cover health, education and first home purchases up to any amount. Anyone (employer, family member, friend, charity) could match up to 100% of whatever you contribute in a year into the account. Cash and stock contributions would be accepted. There would not be a minimum age to participate - anyone with a ss#. Like I said, there are holes in the above - I’m sure with some thought they could be addressed. The general idea would be to turbocharge personal savings and create a unified structure that helps one build and protect a savings account with utility beyond just retirement.
- Goronmon 7y ago
  This article misses one other potential savings — allowing patients to cross state lines to buy plans in cheaper states. Is there anything preventing people from buying plans across state lines other than the insurance companies themselves?
  - jsmith45 7y ago
    In order to sell insurance (basically any type) to people in say New York, you need the to follow the insurance laws of that state. This will have all sorts of weird paperwork and rules that are different from any other state in the country. Having to jump through all those hoops will mean you need a few dozen employees minimum dedicated to compliance in that state etc. But we can overcome that by having the federal government regulate interstate insurance, likely making these companies only needing to comply to the rules of their home state, or by having states set up agreements to allow out of state insurers sell under the rules of the other state. Only a few states currently do that. Even then nobody is using this ability to sell health insurance interstate. And the reason why is: You also need to develop a network in the other state, which can be a significant factor in costs. There is no way that you will get hospitals and doctors offices in New York to accept the same small amounts that you can get hospitals and doctors offices to accept in some low cost of living flyover state. Of course if you do agree to the higher prices that New York providers would charge, well now your average costs have shot up, so you need to raise your rates, making your cheap insurance not as cheap anymore.
smileysteve 7y ago
The vision vs knee surgery on price comparison falls flat on my ears. The current HSA deductible limits are $1350-$6750. So, how does knowing a knee surgery is $20k instead of $60k make the consumer, who is out of pocket $6750 (that they still can't afford) either way, price discriminate?
- cheald 7y ago
  Expecting price transparency to fix things without actually changing anything else doesn't solve anything, sure. The point isn't that prices aren't transparent, it's that prices are artificially high because they're opaque. Fixing the transparency and encouraging people to shop around should, in theory, help fix that inflation. Currently, insurance premiums cost the average American family $19.5k/year[0] (yes, this includes employer contribution, and yes, the actual incidence falls nearly entirely on the employee[1]). Much of the point is that if pricing transparency were in place, costs of both care and premiums would plummet, resulting in more money in consumers' pockets to spend how they choose. What kind of medical care might you elect for if you had an extra $15k/year? [0] https://www.kff.org/other/state-indicator/family-coverage/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D https://www.kff.org/other/state-indicator/family-coverage/?c... [1] https://www.nber.org/papers/w3557 https://www.nber.org/papers/w3557
js2 7y ago
Looking at Singapore is a bit disingenuous. They have both public and private systems, with the private system being vastly more expensive. The public system costs are regulated. (Other differences: adult obesity in Singapore is below 10%. In the U.S. it's 40%. 65+ population in Singapore was 9% in 2010. In the U.S. 65+ population was 13% in 2010. Singapore has a population < 6M.) https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://en.wikipedia.org/wiki/Healthcare_in_Singapore http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf https://www.vox.com/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained https://www.vox.com/policy-and-politics/2017/4/25/15356118/s... https://www.nytimes.com/2017/10/02/upshot/what-makes-singapores-health-care-so-cheap.html https://www.nytimes.com/2017/10/02/upshot/what-makes-singapo... If I were starting from scratch I'd go with single-payer but given where we are, it seems easier to get to a Bismarck-style regulated multi-payer system like Germany or most recently, Switzerland: https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/ https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/... Still, Singapore is an interesting system. The craziest thing about the U.S. is how many different systems we have: the V.A. is effectively a Beveridge system, Medicare is an NHI model, Medicaid is a weird Federal/State hybrid, then we have private insurance, and on top-of-that, out of pocket. There are vested interests throughout. It's 18% of our GDP. It's going to be hard to fix. I think Medicare as a public option with subsidies is a good start. Doctors and hospitals are not going to be happy with the reimbursement rates though.
helen___keller 7y ago
I support universal healthcare, but fundamentally speaking there is no reason there couldn't be a free market healthcare solution that works for a large percentage of people (IE those that can afford a reasonable healthcare insurance premium). The remaining could be covered by a government welfare program. However, rewrite laws as you want, a good free market solution would depend on the following: - Healthcare providers are incentivized to quickly and efficiently care for patients as necessary. - Every single person should be incentivized to use healthcare services regularly and as needed, without concerns such as cost. - Insurance providers should be incentivized to make things as easy, painless, and low cost as possible for both healthcare providers and individuals. The main purpose of the insurance provider is to pool risk and prevent fraud, not to squeeze dollars out of sick folk. - Regulatory bodies like congress should be concerned with regulations that can (a) ensure the above incentives exist, and (b) lower the fundamental costs associated with healthcare (e.g. prevent drug companies from price gouging and such) Current every single incentive I've listed above is misaligned in the market today. Doctors' time is wasted with billing and insurance and risk-prevention to avoid getting sued, many many people avoid using healthcare services out of fear of unknown costs and bankruptcy (which turns untreated small issues into big ones), insurance companies optimize around fleecing customers and making billing hell for doctors, and regulatory bodies are commonly more concerned with the politics & optics of Obamacare this, affordable healthcare that. On top of that, our current free market solution somehow revolves around the employer giving some kind of subsidy and bargaining for better benefits, which makes no sense whatsoever because everybody needs healthcare, not just employees of successful corporations. Anyways, this rambled on a bit, but my point is that any solution that doesn't have a way to align these incentives will fail to make a big dent on healthcare costs in this country. Period. This includes M4A or other universal healthcare plans.
- bryanlarsen 7y ago
  Theoretically the US could put together a good health care system; in practice they are way to many cooks in the kitchen to not screw it up. The US should just lift and copy a working system from elsewhere.
- noetic_techy 7y ago
gigatexal 7y ago
From an economists perspective knowing the prices could have profound effects on things as people will likely substitute either going to the doctor at all or shopping around within or without their state for treatments until a fair market price for a procedure is found. At least that’s the theory anyway.
oliwarner 7y ago
This comparison between LASIK and actual healthcare is puerile. Healthcare providers make bank off the fact you can't afford to shop around. That you need that cancer operating on. That you need that chemo. That transplant. That stay in hospital. And that they —and all like them— can charge whatever the hell they like because your only alternative is a painful death. So no, pretending that you can fix this by listing pricing things because an entirely optional industry does it, doesn't just not fix this, it's noise that confuses people. Healthcare in the US can only be fixed by hard laws on price gouging (codified limits, etc) or astronomically altruistic competition that comes in at cost, and drives everybody else out of business. And I don't see either of those happening in the US because everybody involved in US healthcare is making obscene money from the status quo.
simonblack 7y ago
Health-care costs can only be slashed by somebody missing out on their current income. Would there be strong resistance to that?? You bet! There are too many middle-men leeching away within the US health-care system. Many poorer nations can afford single-payer health-care which covers all citizens. Why not the US too? It's just a matter of determination, and removing the 'I must have my share at the trough' mindset.
Ericson2314 7y ago
I don't get how anyone. An draw conclusions from elective treatment like Lazik, when, until we get better about proactive medicine, most treatment is reactive and fairly dire. I don't think in our current state of poor health and disfunction ("deferred maintenance") is a market appropriate at all. The Oregon experiment makes sense. We need to get a few good years of people taking care of themselves in ways they never did before. It might mean more visits. (A side benefit is we can recalibrate all our statics with more healthier people visiting.) Only then could we experiment with some quasi market tricks. America is too stupid unhealthy and disfunctional for some clever market tricks to work. We need some simple stupid public healthcare and only then could try some German/Swiss/Japanese/Indianan tricks. Capitalism works best when the stakes are low, as a game for rich (or healthy in this case) people. The improvished or dying will just get screwed over without aggregate benefits for the rest.
markus92 7y ago
This could sort-of work. In The Netherlands, healthcare is billed according to a"diagnosis-threatment combination" (DBC, diagnose-behandel combinatie in Dutch), which is a government-mandated set of billing codes. Each code covers the whole diagnosis/threatment pipeline, for example "uncomplicated total knee replacement" which covers imaging, surgery, and a few days of revalidation until you leave the hospital. As these codes are standardized, it is relatively easy to know in advance what it's going to cost the insurance company. The codes are sort of overlapping, for example a breast MRI has it's own code (usually 270eu, but with outliers both ways), but there's also a code for the combination of a mammography, breast MRI + lumpectomy. Hospitals are nowadays obliged to publish these pricelists, even though insurance is mandatory etc., after some court cases involving uninsured people not knowing costs in advanced. Just having these lists could work wonders in terms of transparency.
djinnandtonic 7y ago
Article's rubbish and (probably purposefully) misses a bunch of really important points. 1. The biggest problem with American health care is access to coverage - publishing prices or helping pay deductables does absolutely nothing when your insurance company refuses to reimburse or refuses to cover in the first place. Deductables don't bankrupt people, uninsured cancer does. 2. The exorbitant cost we pay is caused by a predatory, rent-seeking insurance industry extracting value from the whole process. Only medicare for all solves both of these problems! (Finally and hilariously, the article touches on the example of LASIK, which - free of the insurance industry, as none of them cover it! - has allowed market forces to bring up the standard of care while simultaneously lowering the price on average.)
- noetic_techy 7y ago
  Uninsured people don't typically foot the bill and don't go bankrupt, the hospital has to eat the costs because no one can be turned away from a hospital. They then pass that along to the insured by jacking up their prices. Imagine if health insurance was like car insurance, with radio adds telling you how much you can save. Imagine a world where you can get MRI's or CAT scans done for cheap in a strip mall with total price transparency, something like "MRI's are us", instead of requiring people to go through a primary or a specialist. No one company could sustain predatory practice without another company lowering their price to eat their market share.
  - dudul 7y ago
    > Uninsured people don't typically foot the bill and don't go bankrupt, the hospital has to eat the costs because no one can be turned away from a hospital. They then pass that along to the insured by jacking up their prices. Too true. The few times I or a relative had to visit the ER, I got an outrageous $1,000+ bill for minor things (like suture, stuff like that). I always called them, told them to fuck off, and they basically said "If you can pay $~300 we're good". It just feels like they're desperate to get any payment because I assume a lot of people just don't pay at all, and they have to eat the cost.
lcall 7y ago
Trying various proposed solutions sounds good to me, if and only if the US federal government is not the one doing it. States could be good laboratories to try things if and as those people want to, and learn from each other etc (and not make the federal budget problems even worse while trying to solve everyone's personal problems). If there are people in need: join nonprofits or help them personally, or at the state or local level: there are many good efforts! But charity by federal force leads to too much control over our lives and huge, controlling, wasteful bureaucracies that are hard to live with, multiply laws and consume resources so limiting ability to try anything different. (edit: I know enough about history to know what happens when the government tries to solve every problem. We definitely do not want that.) In fact, we fought a war in the 1770's, partly because of faraway people having too much involvement and control in our lives. Then wrote a constitution that limited federal power, because of those problems. The principles in the Declaration of Independence and US Constitution really are important. Helping people is important! There are other, better ways to do it than increasing federal control and distracting it from its core missions. To avoid going on and on about this, I posted more thoughts including personal experiences (with even more that I haven't posted, but can, given interest), at: http://lukecall.net/e-9223372036854586100.html http://lukecall.net/e-9223372036854586100.html There is an email address in the footer for honest feedback.
noetic_techy 7y ago
Glad to finally see someone pointing out the obvious, that simple price competition would lower prices, and that Singapore does have a private insurance system that works! You can only have two out of three: Low Price, High Quality, Universal Access. Europe chose Price and Access. Singapore chose Price and Quality, and they have done some interesting things to make sure that at least their poorest have no-cost access with a tiered system. You will have a mass wave of doctors quiting the profession if everyone goes on medicare, the reimbursement rate is too low to make any money.
dudul 7y ago
I don't understand how people can be liable to pay a bill they have no knowledge of upfront, like not even a rough estimate. Even a plumber will tell you "well, I bill $150/hr and I think it will take 2 hours, but who knows". Is there any other example of an industry that operates like that?
fuqmachine 7y ago
Why look at Singapore, a tiny country akin to San Francisco and try to apply it to all of US, which is infinitely larger and more rural. Why not look at Sweden, UK, France etc. like the Dem. nominees are correctly doing?

110 points by Reedx 7y ago

The Indiana data point for this was only two years of study, a decade ago 2007-2009, and crossing the very exceptional 2008 recession year. This is a questionable time period to claim proof of savings on health care costs. The Singapore cost savings example is attributed to silver bullets of price tags and deductible scheme while completely ignoring that most care in Singapore are delivered via government owned corporations of hospitals & clinics that service 70-80% of the population. Drug prices for example are controlled essentially by government boards nationally negotiating prices with vendors. This too is ignored in the marketplace article and seems fundamental to making those silver bullets viable. I would submit that the fundamental control of pricing at work here is that the 20-30% private care needs to compete with a basic competent and majority publicly provided care delivered at gov't negotiated prices. The financial structuring of how the care is priced to the user base is a far far lower contributor to Singapore care being 75% less than the US. https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://www.vox.com/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained https://www.vox.com/policy-and-politics/2017/4/25/15356118/s... Edit: I would also say that it's a nice trick to keep some small component of private care boxed into an area where it has to compete on fundamental effectiveness. This allowance I think is a nice way to accommodate some level of private innovation maybe helping to keep a public only system from becoming too stolid.

lostdog 7y ago
It also totally ignores that a dollar saved by skipping on short-term care can be a thousand dollars lots five years later. Not sure how it's possible to show much of anything in a 2 year study.

nickgrosvenor 7y ago

This is a critical issue that could throw the whole economy into a recession. Fixing this and the recent prevalence of foreign, disease carrying mosquitos are the two biggest policy issues, that if fixed will cause a world of good.

borkt 7y ago
There is already a practical (but unsightly) solution to mosquitos - bug nets. There is nothing stopping people from wearing bug nets covering their entire body if they feel disease carrying mosquitos are a grave danger. It is irresponsible to waste the resources that treating mosquitos as the second biggest policy issue facing the world would require, and it could also cause serious consequences to the ecosystem if we get an eradication solution wrong. https://www.thegreenhead.com/imgs/xl/netsmen-wearable-mosquito-suit-xl.jpg https://www.thegreenhead.com/imgs/xl/netsmen-wearable-mosqui...
Accujack 7y ago
>the recent prevalence of foreign, disease carrying mosquitos are the two biggest policy issues This is a weird idea. Are you arguing that native mosquitos carry fewer diseases? Also... I can agree that health care is #1, but mosquitos are not number 2... more like number 900 or so. The amount of disease caused by them is tiny compared to e.g. smoking or obesity.
- maximente 7y ago
  why weird? some mosquitoes prefer to feed on e.g. birds whereas others do not bite birds at all; that makes them a vector for particular diseases.
- nickgrosvenor 7y ago
  It's more of a local policy issue for southern California residents. Of course all of this can be debated, and perhaps it's not the 2nd most important, but it's much more important to me and all my friends than most policies. Native mosquitos on the west coast (Culex) do not carry west nile or zika. The new Aedes species does and is extremely hard to control. https://www.latimes.com/science/sciencenow/la-sci-sn-aedes-mosquitoes-california-20180901-story.html https://www.latimes.com/science/sciencenow/la-sci-sn-aedes-m... Further, it caused everyone I know in the Los Angeles area to stay inside during this last summer. My kids and friends kids stayed inside all summer. It was like night and day compared to every other year. Fear of Zika has spread to pregnant mothers around my neighborhood. People are literally choosing not to get pregnant because of the fear of this new mosquito in the area. The amount of fear caused by these new mosquitos has been extreme. They are very hard to control, I think this new invasive species can only be eradicate with government intervention. There are no cost effective trapping solutions. Nets and Deet aren't 100 percent effective and is not something we should settle for being the new normal when government intervention is possible. The sooner it's dealt with the more realistic it can be fixed. I would literally vote for any local politician if this were a primary policy issue for them.

thatfrenchguy 7y ago

> The second policy—deductible security—pairs an insurance policy that has an annual deductible with a health savings account (HSA) that the policy’s sponsor funds each year with an amount equal to the annual deductible. Yeah, people avoid care when they have those plans. Is that a good outcome ?

deleted 7y ago
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partiallypro 7y ago
In many cases, I would say yes. A massive amount of ER visits are not needed for instance, and are more suitable for walk-ins and primary care. And just in my experience my Doctor will often push for various tests, which aren't needed. I've had multiple people tell me the same. Then I've gone to other doctors that wonder why such and such doctor did that other than just to gouge.
- notadoc 7y ago
  Most ERs would be well served by opening all-hour urgent care clinics directly adjacent, and triaging the roughly 70-80% of people with non-emergent and/or minor issues into that wing rather than to the ER.
  - xyzzyz 7y ago
    How exactly? Since it would do the same thing as ER, it would cost as much to operate as ER. The patients and insurance would win if this made them pay less, but the hospital would be a loser here with reduced revenues.
    - lostapathy 7y ago
      Or it might mean they'd get a lot of business that would go to another nearby ER. Where I live, it's practical for me to go to an ER in at least 3 different hospital systems. If one of them offered 24-hour "urgent care" I would definitely go there vs the one closest to my house.

partiallypro 7y ago

This would definitely help, but the 75% number is just pulled out of the air.

npongratz 7y ago
It may have been in reference to Singapore's results, per TFA: > With Singapore’s citizenry empowered by deductible security and price tags, competition has worked its magic, forcing providers to constantly figure out ways to lower costs and improve quality. The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world.
- ska 7y ago
  It is mostly pulled out of a backside though, because without much evidence it attributes that 77% decrease in spending to a couple of cherry picked difference between the systems. Overall it would plausibly help, but it's a pretty strong claim that these are the only important differences.
  - adventured 7y ago
    It ignores the 30 point gap in obesity - 6% for Singapore, 36% for the US - which is obviously a big contributor to the US healthcare cost problem. 36% obesity is an extreme elephant on the table for costs. I would be surprised if the US couldn't shave 1/5 off its healthcare costs with a 22% obesity rate (comparable to Germany, Brazil, Poland, France, Sweden, Netherlands, Finland, Norway, Austria, Spain, Russia, etc). Singapore vs Japan and South Korea is a more interesting comparison (similarly very low obesity rates) between costs in developed health care systems, if you wanted to see which worked better. Japan for example has a spiraling healthcare cost problem related to its aging population.
    - deleted 7y ago
      [deleted]

rayiner 7y ago

What I’ve always found amazing is how cheap dental and eye care is in comparison to other types of medical care. The fact that you can get laser surgery in your eyes for a couple of thousand dollars is incredible, given that a diagnostic test like an MRI can often cost that much. Clearly there is room for competition to reduce costs. Clearly that doesn’t work for emergency services. But is there room to distinguish emergency from non-emergency services? I had surgery for a deviated septum. I don’t know what it cost, but if I had an incentive I could’ve price shopped for it. There are a lot of non-emergency procedures (colonoscopies, hip replacements, knee surgery, etc.) that could be subject to competition. Also, the comparison to Singapore’s health outcomes is a bit odd: > The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world. Fun fact: Life expectancy for Asians in the US is 86 years (almost 90 in New Jersey!), quite a bit longer than the 82 years in Singapore.

criddell 7y ago
> if I had an incentive I could’ve price shopped for it In my experience hospitals and surgery centers can't or won't tell you what something will cost up front.
- ska 7y ago
  That is one of the main points of the article.
- maximente 7y ago
  most in the US won't, although some do e.g. https://surgerycenterok.com/pricing/ https://surgerycenterok.com/pricing/
- gremlinsinc 7y ago
  I'm pretty sure though they have to supply an 'itemized' list if you ask for one, which you can contest anything on the list and a lot of times take them to court over if they don't budge. Often they will because they know $35 for an ibuprofin is absurd but most people don't think they can win against a big bad hospital.

didibus 7y ago

Couldn't you do both? Provide HSA deductible Medicare for all. And force price tags on everything? Then you get government offered health care. Negotiating power of a big single bulk payer. And competition from patients trying to keep some of the insurance money to themselves by avoiding unnecessary care or hunting for a better deal.

codingdave 7y ago

As U.S. the election season warms up, it is important to recognize a political piece when you see it. This starts not with presenting the problem, but with implying that the changes proposed by Democrats aren't what is needed. And later on calls out data gathered by Republican office holders. Even if the topic is health care, those bits of the writing should indicate the political motivations behind the article. I'm not going to tell anyone where to fall in politics, and HN is the wrong place for it anyway... but I do encourage everyone to be aware of it over the next 12 months.

orhmeh09 7y ago
It’s nice of you to underscore the issue, but I suspect most readers would catch on based on the first line of the article, wouldn’t you? > As the Democratic presidential candidates argue about “Medicare for All” versus a “public option,” two simple policy changes could slash U.S. health-care costs by 75% while increasing access and improving the quality of care.
- codingdave 7y ago
  I hope so. But HN typically shuts down political articles fairly quickly, and this one made it to the front page and had comments on it as if nobody had noticed, so I thought it was worth a mention.
- anticensor 7y ago
  Is Medicare for all going to be a premium-funded, premiums enforced one like we have in Turkey?
noelsusman 7y ago
Yeah, these are standard conservative talking points. The best part is they would riot if we actually tried to implement Singapore's health system in the US. In Singapore the government forces you to put a certain percentage of your income into a health savings account, and then the government tells you what you're allowed to spend that money on. You can't use that money to buy a drug that isn't on a special government list, for example. The government also owns most of the hospitals, and most doctors are government employees. Hospital stays are mostly paid for with government subsidies. Drugs are also directly subsidized by the government, but only the drugs that government bureaucrats approve. But none of that has stopped them from spending decades pretending that transparent pricing is the sole reason why health spending is lower in Singapore.

smacktoward 7y ago

I bristle when I see health savings accounts presented as a solution to the health care crisis. The median household income in the U.S. is about $64,000 a year (see https://www.census.gov/library/publications/2019/demo/p60-266.html https://www.census.gov/library/publications/2019/demo/p60-26...). When a single major medical procedure can result in a six-figure bill, there's just no way that the average person could ever save enough. You end up with people who are lucky enough to never need to tap their HSAs, and people who are unlucky enough to get sick, whose HSAs just present a speed bump on their slide into bankruptcy. There's only one thing HSAs are really good at, and that's creating a huge new tranche of money for Wall Street to suck fees out of.

nradov 7y ago
HSAs are part of high deductible insurance plans with out-of-pocket maximums. No one with such a plan would ever receive a six-figure bill. (With the possible exception of surprise billing from out-of-network providers, which we ought to ban.)
- irrational 7y ago
  To the best of my understanding, you are 100% correct. Why are you being downvoted? Do other people know something you and I don't know?
  - op00to 7y ago
    Yes. Look at the in/out network for your high deductible plan. None of the providers I use on a traditional plan are considered as in network for the same employers high deductible/hsa plan. Our high deductible plan does not cover out of network. Not at all. Fun!!!
    - irrational 7y ago
      That's not the case with my plan at all. We can use all the exact same providers as the traditional plan on our high deductible/hsa plan. We just switched to the high deductible plan a few years ago (after doing the math and realizing how much better of a deal it is), but we've kept all of our same doctors and specialists as we used before.

Goronmon 7y ago

But the annual gifts do more than ensure that participants are financially secure; they give people skin in the game. Participants spend prudently because they know that any unspent HSA balances are theirs to keep. The result? Massively lower health-care spending without any decrement to health outcomes. HSA also discourage you from doing any preventative care because that's money you can probably find a use for in other ways. Thus inflating long-term healthcare costs as people only go to the doctor when it's an emergency. Anyone who supports HSA accounts is either an idiot or has suspect motives. Those may be a strong opinion, but it's one I stand by in this particular case.

turc1656 7y ago

First off, if something this large can drop by 75% in price then you're being bamboozled, extorted, or potentially both. "Under our current system, it’s nearly impossible for people with health insurance to find out in advance what anything covered by their insurance will end up costing." It's worse than that. Not only can you find or figure out how much everything will cost, most places (particularly hospitals and outpatient centers) will not even tell you how much they charge for their services. Some news outlet did a study and called the top 25 hospitals in the country and asked them how much a hip replacement would cost. Only around 3-5 actually gave a number and it varied wildly. The rest refused to pin down any number at all. That's one of the most common surgeries there are and they don't know what they will charge for it? On the moral/philosophical side - how can a person be held financially liable for something they cannot possibly know the cost of in advance, even if they try to find out? Such practices are illegal everywhere else in this nation. And there is no legal exception for healthcare providers. How do I know that? Because a few years ago Rand Paul tried to pass a law that would exempt healthcare providers. It failed - which means it is still currently illegal to be doing this. Yet not one of these providers or operations has been charged accordingly. If you went to a mechanic and they took a look at your car and you asked how much it was going to cost to fix it and they responded with "which insurance do you have?" or "I don't know until I'm done" they would get shut down and charged, and rightfully so. Because the logical conclusion is to say it costs some extravagant amount of money and then "settle" for something less. Which gee, doesn't that happen a lot in the medical industry when people can't pay their bills? People face bankruptcy and can't afford a $10,000 bill but somehow the hospital is just fine accepting $3,000 instead?

mschuster91 7y ago
> Not only can you find or figure out how much everything will cost, most places (particularly hospitals and outpatient centers) will not even tell you how much they charge for their services. Some news outlet did a study and called the top 25 hospitals in the country and asked them how much a hip replacement would cost. Only around 3-5 actually gave a number and it varied wildly. The rest refused to pin down any number at all. That's one of the most common surgeries there are and they don't know what they will charge for it? Because in the US model the insurances negotiate with the hospitals what they pay, and you will almost always be given a number that is way higher than the highest insurance amount - as when you pay yourself the hospital has a high risk of never being able to (even partially) collect the bill. Also, it must be higher than the highest insurance amount so that if you were an undercover agent of your insurance you would still believe you pay less than others.

zip1234 7y ago

Why is price transparency not a thing already? The government should do that immediately and see what happens before doing anything extreme.

tathougies 7y ago
President Trump has already started that process, and has asked Congress to help: https://www.npr.org/sections/health-shots/2019/06/24/735432387/trump-administration-pushes-to-make-health-care-pricing-more-transparent https://www.npr.org/sections/health-shots/2019/06/24/7354323.... For example, they've already started mandating drug pricing transparency in advertising: https://www.nytimes.com/2019/06/14/health/drug-prices-tv-ads.html?module=inline https://www.nytimes.com/2019/06/14/health/drug-prices-tv-ads..., but are being opposed by industry groups obviously.

tempsy 7y ago

I'm a fan of M4A, but I think something the gov't could do is allow people to earn tax credits for practicing preventative care that help lower whatever tax increase would be created to fund healthcare. That creates a financial incentive to try to be healthy while not necessarily discouraging people from going to the doctor when they really need to (which can happen with out of pocket expenses, HSA or not). E.g. on one of my old plans I got a $300 visa gift card just for going to a checkup.

mattrp 7y ago

This article misses one other potential savings — allowing patients to cross state lines to buy plans in cheaper states. In terms of HSA’s, I think they are a great idea. But I have a more radical solution than an HSA: Allow the first $100k of income to be contributed pretax to a unified savings plan. We would do away distinctions between 529, ira, 401k and HSA. It would just be a unified account. You could withdraw prior to 59.5 to cover health, education and first home purchases up to any amount. Anyone (employer, family member, friend, charity) could match up to 100% of whatever you contribute in a year into the account. Cash and stock contributions would be accepted. There would not be a minimum age to participate - anyone with a ss#. Like I said, there are holes in the above - I’m sure with some thought they could be addressed. The general idea would be to turbocharge personal savings and create a unified structure that helps one build and protect a savings account with utility beyond just retirement.

Goronmon 7y ago
This article misses one other potential savings — allowing patients to cross state lines to buy plans in cheaper states. Is there anything preventing people from buying plans across state lines other than the insurance companies themselves?
- jsmith45 7y ago
  In order to sell insurance (basically any type) to people in say New York, you need the to follow the insurance laws of that state. This will have all sorts of weird paperwork and rules that are different from any other state in the country. Having to jump through all those hoops will mean you need a few dozen employees minimum dedicated to compliance in that state etc. But we can overcome that by having the federal government regulate interstate insurance, likely making these companies only needing to comply to the rules of their home state, or by having states set up agreements to allow out of state insurers sell under the rules of the other state. Only a few states currently do that. Even then nobody is using this ability to sell health insurance interstate. And the reason why is: You also need to develop a network in the other state, which can be a significant factor in costs. There is no way that you will get hospitals and doctors offices in New York to accept the same small amounts that you can get hospitals and doctors offices to accept in some low cost of living flyover state. Of course if you do agree to the higher prices that New York providers would charge, well now your average costs have shot up, so you need to raise your rates, making your cheap insurance not as cheap anymore.

smileysteve 7y ago

The vision vs knee surgery on price comparison falls flat on my ears. The current HSA deductible limits are $1350-$6750. So, how does knowing a knee surgery is $20k instead of $60k make the consumer, who is out of pocket $6750 (that they still can't afford) either way, price discriminate?

cheald 7y ago
Expecting price transparency to fix things without actually changing anything else doesn't solve anything, sure. The point isn't that prices aren't transparent, it's that prices are artificially high because they're opaque. Fixing the transparency and encouraging people to shop around should, in theory, help fix that inflation. Currently, insurance premiums cost the average American family $19.5k/year[0] (yes, this includes employer contribution, and yes, the actual incidence falls nearly entirely on the employee[1]). Much of the point is that if pricing transparency were in place, costs of both care and premiums would plummet, resulting in more money in consumers' pockets to spend how they choose. What kind of medical care might you elect for if you had an extra $15k/year? [0] https://www.kff.org/other/state-indicator/family-coverage/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D https://www.kff.org/other/state-indicator/family-coverage/?c... [1] https://www.nber.org/papers/w3557 https://www.nber.org/papers/w3557

js2 7y ago

Looking at Singapore is a bit disingenuous. They have both public and private systems, with the private system being vastly more expensive. The public system costs are regulated. (Other differences: adult obesity in Singapore is below 10%. In the U.S. it's 40%. 65+ population in Singapore was 9% in 2010. In the U.S. 65+ population was 13% in 2010. Singapore has a population < 6M.) https://en.wikipedia.org/wiki/Healthcare_in_Singapore https://en.wikipedia.org/wiki/Healthcare_in_Singapore http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf https://www.vox.com/policy-and-politics/2017/4/25/15356118/singapore-health-care-system-explained https://www.vox.com/policy-and-politics/2017/4/25/15356118/s... https://www.nytimes.com/2017/10/02/upshot/what-makes-singapores-health-care-so-cheap.html https://www.nytimes.com/2017/10/02/upshot/what-makes-singapo... If I were starting from scratch I'd go with single-payer but given where we are, it seems easier to get to a Bismarck-style regulated multi-payer system like Germany or most recently, Switzerland: https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/ https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/... Still, Singapore is an interesting system. The craziest thing about the U.S. is how many different systems we have: the V.A. is effectively a Beveridge system, Medicare is an NHI model, Medicaid is a weird Federal/State hybrid, then we have private insurance, and on top-of-that, out of pocket. There are vested interests throughout. It's 18% of our GDP. It's going to be hard to fix. I think Medicare as a public option with subsidies is a good start. Doctors and hospitals are not going to be happy with the reimbursement rates though.

helen___keller 7y ago

I support universal healthcare, but fundamentally speaking there is no reason there couldn't be a free market healthcare solution that works for a large percentage of people (IE those that can afford a reasonable healthcare insurance premium). The remaining could be covered by a government welfare program. However, rewrite laws as you want, a good free market solution would depend on the following: - Healthcare providers are incentivized to quickly and efficiently care for patients as necessary. - Every single person should be incentivized to use healthcare services regularly and as needed, without concerns such as cost. - Insurance providers should be incentivized to make things as easy, painless, and low cost as possible for both healthcare providers and individuals. The main purpose of the insurance provider is to pool risk and prevent fraud, not to squeeze dollars out of sick folk. - Regulatory bodies like congress should be concerned with regulations that can (a) ensure the above incentives exist, and (b) lower the fundamental costs associated with healthcare (e.g. prevent drug companies from price gouging and such) Current every single incentive I've listed above is misaligned in the market today. Doctors' time is wasted with billing and insurance and risk-prevention to avoid getting sued, many many people avoid using healthcare services out of fear of unknown costs and bankruptcy (which turns untreated small issues into big ones), insurance companies optimize around fleecing customers and making billing hell for doctors, and regulatory bodies are commonly more concerned with the politics & optics of Obamacare this, affordable healthcare that. On top of that, our current free market solution somehow revolves around the employer giving some kind of subsidy and bargaining for better benefits, which makes no sense whatsoever because everybody needs healthcare, not just employees of successful corporations. Anyways, this rambled on a bit, but my point is that any solution that doesn't have a way to align these incentives will fail to make a big dent on healthcare costs in this country. Period. This includes M4A or other universal healthcare plans.

bryanlarsen 7y ago
Theoretically the US could put together a good health care system; in practice they are way to many cooks in the kitchen to not screw it up. The US should just lift and copy a working system from elsewhere.
noetic_techy 7y ago

gigatexal 7y ago

From an economists perspective knowing the prices could have profound effects on things as people will likely substitute either going to the doctor at all or shopping around within or without their state for treatments until a fair market price for a procedure is found. At least that’s the theory anyway.

oliwarner 7y ago

This comparison between LASIK and actual healthcare is puerile. Healthcare providers make bank off the fact you can't afford to shop around. That you need that cancer operating on. That you need that chemo. That transplant. That stay in hospital. And that they —and all like them— can charge whatever the hell they like because your only alternative is a painful death. So no, pretending that you can fix this by listing pricing things because an entirely optional industry does it, doesn't just not fix this, it's noise that confuses people. Healthcare in the US can only be fixed by hard laws on price gouging (codified limits, etc) or astronomically altruistic competition that comes in at cost, and drives everybody else out of business. And I don't see either of those happening in the US because everybody involved in US healthcare is making obscene money from the status quo.

simonblack 7y ago

Health-care costs can only be slashed by somebody missing out on their current income. Would there be strong resistance to that?? You bet! There are too many middle-men leeching away within the US health-care system. Many poorer nations can afford single-payer health-care which covers all citizens. Why not the US too? It's just a matter of determination, and removing the 'I must have my share at the trough' mindset.

Ericson2314 7y ago

I don't get how anyone. An draw conclusions from elective treatment like Lazik, when, until we get better about proactive medicine, most treatment is reactive and fairly dire. I don't think in our current state of poor health and disfunction ("deferred maintenance") is a market appropriate at all. The Oregon experiment makes sense. We need to get a few good years of people taking care of themselves in ways they never did before. It might mean more visits. (A side benefit is we can recalibrate all our statics with more healthier people visiting.) Only then could we experiment with some quasi market tricks. America is too stupid unhealthy and disfunctional for some clever market tricks to work. We need some simple stupid public healthcare and only then could try some German/Swiss/Japanese/Indianan tricks. Capitalism works best when the stakes are low, as a game for rich (or healthy in this case) people. The improvished or dying will just get screwed over without aggregate benefits for the rest.

markus92 7y ago

This could sort-of work. In The Netherlands, healthcare is billed according to a"diagnosis-threatment combination" (DBC, diagnose-behandel combinatie in Dutch), which is a government-mandated set of billing codes. Each code covers the whole diagnosis/threatment pipeline, for example "uncomplicated total knee replacement" which covers imaging, surgery, and a few days of revalidation until you leave the hospital. As these codes are standardized, it is relatively easy to know in advance what it's going to cost the insurance company. The codes are sort of overlapping, for example a breast MRI has it's own code (usually 270eu, but with outliers both ways), but there's also a code for the combination of a mammography, breast MRI + lumpectomy. Hospitals are nowadays obliged to publish these pricelists, even though insurance is mandatory etc., after some court cases involving uninsured people not knowing costs in advanced. Just having these lists could work wonders in terms of transparency.

djinnandtonic 7y ago

Article's rubbish and (probably purposefully) misses a bunch of really important points. 1. The biggest problem with American health care is access to coverage - publishing prices or helping pay deductables does absolutely nothing when your insurance company refuses to reimburse or refuses to cover in the first place. Deductables don't bankrupt people, uninsured cancer does. 2. The exorbitant cost we pay is caused by a predatory, rent-seeking insurance industry extracting value from the whole process. Only medicare for all solves both of these problems! (Finally and hilariously, the article touches on the example of LASIK, which - free of the insurance industry, as none of them cover it! - has allowed market forces to bring up the standard of care while simultaneously lowering the price on average.)

noetic_techy 7y ago
Uninsured people don't typically foot the bill and don't go bankrupt, the hospital has to eat the costs because no one can be turned away from a hospital. They then pass that along to the insured by jacking up their prices. Imagine if health insurance was like car insurance, with radio adds telling you how much you can save. Imagine a world where you can get MRI's or CAT scans done for cheap in a strip mall with total price transparency, something like "MRI's are us", instead of requiring people to go through a primary or a specialist. No one company could sustain predatory practice without another company lowering their price to eat their market share.
- dudul 7y ago
  > Uninsured people don't typically foot the bill and don't go bankrupt, the hospital has to eat the costs because no one can be turned away from a hospital. They then pass that along to the insured by jacking up their prices. Too true. The few times I or a relative had to visit the ER, I got an outrageous $1,000+ bill for minor things (like suture, stuff like that). I always called them, told them to fuck off, and they basically said "If you can pay $~300 we're good". It just feels like they're desperate to get any payment because I assume a lot of people just don't pay at all, and they have to eat the cost.

lcall 7y ago

Trying various proposed solutions sounds good to me, if and only if the US federal government is not the one doing it. States could be good laboratories to try things if and as those people want to, and learn from each other etc (and not make the federal budget problems even worse while trying to solve everyone's personal problems). If there are people in need: join nonprofits or help them personally, or at the state or local level: there are many good efforts! But charity by federal force leads to too much control over our lives and huge, controlling, wasteful bureaucracies that are hard to live with, multiply laws and consume resources so limiting ability to try anything different. (edit: I know enough about history to know what happens when the government tries to solve every problem. We definitely do not want that.) In fact, we fought a war in the 1770's, partly because of faraway people having too much involvement and control in our lives. Then wrote a constitution that limited federal power, because of those problems. The principles in the Declaration of Independence and US Constitution really are important. Helping people is important! There are other, better ways to do it than increasing federal control and distracting it from its core missions. To avoid going on and on about this, I posted more thoughts including personal experiences (with even more that I haven't posted, but can, given interest), at: http://lukecall.net/e-9223372036854586100.html http://lukecall.net/e-9223372036854586100.html There is an email address in the footer for honest feedback.

noetic_techy 7y ago

Glad to finally see someone pointing out the obvious, that simple price competition would lower prices, and that Singapore does have a private insurance system that works! You can only have two out of three: Low Price, High Quality, Universal Access. Europe chose Price and Access. Singapore chose Price and Quality, and they have done some interesting things to make sure that at least their poorest have no-cost access with a tiered system. You will have a mass wave of doctors quiting the profession if everyone goes on medicare, the reimbursement rate is too low to make any money.

dudul 7y ago

I don't understand how people can be liable to pay a bill they have no knowledge of upfront, like not even a rough estimate. Even a plumber will tell you "well, I bill $150/hr and I think it will take 2 hours, but who knows". Is there any other example of an industry that operates like that?

fuqmachine 7y ago

Why look at Singapore, a tiny country akin to San Francisco and try to apply it to all of US, which is infinitely larger and more rural. Why not look at Sweden, UK, France etc. like the Dem. nominees are correctly doing?