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One thing to note about US healthcare is that it seems almost deliberately engineered to not be a market. I've never received significant health care in anothe

One thing to note about US healthcare is that it seems almost deliberately engineered to not be a market. I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on: 1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it. 2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time. 3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact. 4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000. 5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes. And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.

fatnoah 5y ago
All good points. In my mind, a market lets me make informed choices and choose from multiple options for something that meets my needs. As you noted, the only real choice is whatever your employer offers, or something more fantastically expensive. In terms of care, there are lots of choices but not enough information to actually choose. It's more of a choose your own adventure where you have to guess and hope you got it right.
dr_orpheus 5y ago
For #4 on your list, I remember the insane bills we got when our first child was born. It was also insane the sheer number of bills that we got. First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time. And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and... I don't remember each one specifically at this point, but I believe it was 7 separate bills. Edit: typos
- vel0city 5y ago
  I'm still getting bills from various groups almost a year after having a child. Being so far out from the event always makes me cautious about immediately paying them; I'm rather worried about getting a fraudulent bill that looks real, as many of these bills come from central billing offices several states over. It then takes me time to truly connect the dots from the service and looking at insurance history to ensure this bill is legitimate and that I technically do owe that.
buu700 5y ago
A lot of this was covered by the Libertarian Party's position on healthcare reform in the last election, which I thought was interesting: https://www.foxnews.com/politics/jo-jorgensen-big-idea-market-based-health-care-system https://www.foxnews.com/politics/jo-jorgensen-big-idea-marke... There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while: 1. Expand the government to achieve universal healthcare coverage. -- a. ACA public option. -- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.) 2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand. -- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory. -- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest. Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage). I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).

fatnoah 5y ago

All good points. In my mind, a market lets me make informed choices and choose from multiple options for something that meets my needs. As you noted, the only real choice is whatever your employer offers, or something more fantastically expensive. In terms of care, there are lots of choices but not enough information to actually choose. It's more of a choose your own adventure where you have to guess and hope you got it right.

dr_orpheus 5y ago

For #4 on your list, I remember the insane bills we got when our first child was born. It was also insane the sheer number of bills that we got. First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time. And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and... I don't remember each one specifically at this point, but I believe it was 7 separate bills. Edit: typos

vel0city 5y ago
I'm still getting bills from various groups almost a year after having a child. Being so far out from the event always makes me cautious about immediately paying them; I'm rather worried about getting a fraudulent bill that looks real, as many of these bills come from central billing offices several states over. It then takes me time to truly connect the dots from the service and looking at insurance history to ensure this bill is legitimate and that I technically do owe that.

buu700 5y ago

A lot of this was covered by the Libertarian Party's position on healthcare reform in the last election, which I thought was interesting: https://www.foxnews.com/politics/jo-jorgensen-big-idea-market-based-health-care-system https://www.foxnews.com/politics/jo-jorgensen-big-idea-marke... There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while: 1. Expand the government to achieve universal healthcare coverage. -- a. ACA public option. -- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.) 2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand. -- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory. -- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest. Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage). I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).