5 ms·

If people knew half of how consolidated their treatment was they would riot. Most Americans experience first hand how horrible health care here is. No one can

If people knew half of how consolidated their treatment was they would riot. Most Americans experience first hand how horrible health care here is. No one can get upset at whatever little details are involved, however 'cause it's beyond them. Especially, you won't get people excited about more competition in a field where markets and competition seem neither logical nor have shown any benefit. The complex referral system you describe basically results in turning regulated monopoly behavior into unregulated monopoly behavior. And this is the upshot of breaking up the original, regulated monopoly Blue Cross/Blue Shield, which provided adequate insurance in America's "Golden Era". Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system.

cyanydeez 3y ago
the healthcare complex employs millions. all these people would lose jobs. so there's really zero political will to crack the monolith, and why things like Obama care go forward, because they're bandaids. then there's the who employer leverage that businesses live having to immobilize a significant portion of their work force. it's absolutely not complicated to understand why nothing has moved the needle.
- SteveNuts 3y ago
  Right. If these huge insurance companies had to "compete" with a real universal system, there's no way they could even exist. All they do is scrape profit off the top of every healthcare procedure in the US. The most useless middleman to ever exist, in my opinion.
  - vinay427 3y ago
    I agree with your broader point, but it’s worth noting that insurance middlemen exist in many European countries with universal health insurance, so surely some form of this can exist in a more regulated health insurance/provider market.
    - rqtwteye 3y ago
      I had private insurance in Germany. The big difference is that they have to compete there instead of having a captive audience they have in the US with employer based health insurance. Your employer picks the insurance options that are convenient for them, they don't care much about what's good for you. So you are basically trapped unless you are willing to not take insurance from your employer but go on the open market which will be very expensive. A while ago I asked my employer to just give me the money they give to Optum so I can buy insurance via ACA but they wouldn't do it.
    - kevin_thibedeau 3y ago
      The problem is the US has for-profit medical insurance as well as mutual insurance (collectively owned by their members). The laws were altered in the 90s to permit mutuals to convert to for-profit. This was generally a bad move as it takes out any real incentive to manage costs when jacking them up is the only way to boost profits so the C-levels can get 8-figure bonuses.
- keenmaster 3y ago
  More competition increases the number of jobs
  - bearjaws 3y ago
    Optum has billions of dollars in profit annually, none of that is going into the employees pockets or patient savings.
- standardUser 3y ago
  Not everyone in the healthcare industry would lose their jobs, that's absurd. It would mostly be the redundant insurance staff (and redundant sets of highly-paid insurance execs).
  - NickC25 3y ago
    This! Execs would lose their jobs. Billing specialists (who do a 4 year degree in medical billing, which is in and of itself fucking absurd) would lose their jobs. You know who wouldn't lose their jobs? Doctors and nurses. The actual people who the system's outcome is dependent on.
    - FireBeyond 3y ago
      > Billing specialists (who do a 4 year degree in medical billing, which is in and of itself fucking absurd) What? I have never heard of such a thing, and I worked in the claims benefit management industry for nearly a decade. So I searched this, "bachelor medical billing" and while I got plenty of results, all of them were for certificate courses, which I'd expect. "Top rated medical billing courses" were all at community colleges. I am yet to find a Bachelor degree in medical billing. Indeed, on ... Indeed: > Can you get a bachelor's degree in medical billing and coding? > While a bachelor's degree in medical coding and billing isn't an option, people interested in pursuing this career can earn a degree in a related field instead. For example, you might consider earning a bachelor's in health care management or health information management. A certificate/diploma is going to be 9 months to 1 year. An associate diploma? 2 years. I also can't find any four year courses in medical billing.
    - lotsofpulp 3y ago
      The managed care apparatus in the United States is about allocating insufficient supply of healthcare to excess demand based on the political value of the healthcare recipient. That is why Medicare pays doctors more than Medicaid for the same work (old people are worth more since they vote more than poorer and younger people). You can endlessly bucket people into infinite changing tiers based on their political power using reimbursement, deductible, out of pocket maximum, in and out of network providers, formularies, and prior authorization protocols. For example, you can give members of the military a different quality/quantity of healthcare than US federal Senators, who have a different set of policies, who in turn have a different set of policies from a highly profitable white collar firm’s employees, and yet again different from a less profitable business with lower paid employees, and so on and so forth. You can adjust reimbursements so that some people can immediately see doctors whereas others have to go to Physician Assistants or Nurse Practitioners. The system is a thing of beauty from a political point of view, and I bet countries with nationalized healthcare like UK and Canada move closer and closer to the US system as the population pyramids go upside down and cuts have to be made. And the whole time, people will waste their time being mad at managed care organizations, when the government leaders are the ones hiring them to be the “bad guy”.
- slipperybeluga 3y ago
  [dead]
- monksy 3y ago
  They're also firing people for fun. I know of a guy who is deep in the weeds upgrading their scala libraries that just got laid off within the week. (You have to do that to stay on top of all of the cves)
oatmeal1 3y ago
> Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system. I don't trust the US government is competent enough to run healthcare. If it can do better than the existing system, let it create a new voluntary, unsubsidized insurer, free of the BS rules it has created. Competition is the source of quality and low prices. Any monopoly is an invitation for poor quality and high prices.
- bcrosby95 3y ago
  The great thing about the "50 states" model is states can try random experiments. For example, Texas has done a lot to try to bring more competition but none of them have done a thing for the high cost of healthcare.
  - oatmeal1 3y ago
    That would be great if we had real federalism. The states cannot try anything really unique, because they are hamstrung by federal law and federal subsidies with strings attached.
  - FireBeyond 3y ago
    Yup. The big one to me being capping malpractice payouts. "Healthcare costs a lot because physicians have to carry very expensive malpractice insurance because of astronomical judgments". Texas caps malpractice payments and everything stays exactly the same. Also, malpractice insurance in itself isn't typically as onerous as people believe it to be. What is onerous, and what that industry does differently to most other insurance segments is "tail insurance". Tail insurance is the concept that major malpractice suits may appear well after your claims-made liability policy has ended. In most cases it's actually DOUBLE the premium you're paying for malpractice insurance, implying the insurer believes that your coverage is less than one-third of the claims they expect to pay. What -should- happen is that you carry "claims-made and prior acts" coverage. The challenge there is that in many cases your employer will cover claims-made as part of your compensation or part of their insurance, but don't elect prior acts coverage (and because of the way they do it, I suspect it's not as simple as "let me pay the difference"). But in general capping malpractice payouts has done nothing to offset malpractice coverage costs, let alone flow-through to end consumer costs.
thatfrenchguy 3y ago
> Most Americans experience first hand how horrible health care here is I mean, no, most Americans are just upset about cost-sharing, most providers in the United States are pretty good and have pretty good facilities and equipments. You can have systems that are mostly privatized (cough, France) that are better regulated than the United States, but that'd mean doctors would get paid less money & upper class folks would likely get worse care
- AHatLikeThat 3y ago
  Maybe in large urban areas, and if you can afford insurance at all. In rural areas, even smaller urban areas, there are few physicians, long waits and not enough facilities. [https://www.krqe.com/health/new-mexico-needs-hundreds-of-health-professionals-u-s-department-of-health-says/ https://www.krqe.com/health/new-mexico-needs-hundreds-of-hea...]
  - arebop 3y ago
    It's the same in San Francisco, where we support returns to investors in residential real estate by banning new development since the 1960s and therefore doctor salaries don't afford a luxury lifestyle [https://www.nytimes.com/2017/06/03/business/economy/high-end-medical-care.html https://www.nytimes.com/2017/06/03/business/economy/high-end...] and therefore we have a shortage of physicians.
    - pyuser583 3y ago
      San Francisco is also overwhelmingly young and healthy.
      - KerrAvon 3y ago
        Between COVID and the millennial cohort in SF, that's not going to be true very much longer, if it is at all today.
  - HDThoreaun 3y ago
    This is because congress wont expand residencies so there arent enough doctors. Doctors make a bunch of money and can live anywhere they want, almost none of them want to live in bumfuck.
bearjaws 3y ago
Oh I don't disagree that the system is fundamentally broken, but we clearly need to attack from all angles.
- touristshaun 3y ago
  quicker to start from scratch
  - rqtwteye 3y ago
    That's lie rewriting a code base from scratch because the current is deemed unmaintainable. Most of the time you end up with the same number, but different problems or it's even worse. In my view Medicare for all would be a viable path but even the Democrats are not interested in tackling healthcare.
    - terr-dav 3y ago
      Let's refactor it then: The government simply takes ownership of UHC and they get a new charter to run it like the Postal Service.
      - kelseyfrog 3y ago
        Curious, how at this point could BigGov make UHC worse?
      - thallium205 3y ago
        My mailman refuses to take my stamped envelopes out of my mailbox. Can't be bothered.
        ascagnel_ 3y ago
        I’ve lived at my current address for about five years. The first year, zero issues. Starting at around the 2020 election, service dropped off precipitously, to the point where I’ve had a piece of outgoing mail in my box since Friday. I can’t trust the mail with anything time sensitive any longer. I blame this on Louis DeJoy, who was appointed Postmaster General in May 2020, and has numerous conflicts of interest.
echelon 3y ago
> State controlled medicine is essentially the only solution to the already partly collapsed US health care system. But wouldn't government control and subsidy lead to the same malinvestment and cost explosions as college tuitions? Wouldn't fierce competition at all levels be a good thing? Why not force insurers to cover everything up to a set cost on a per-disease basis? That is, let patients spend a set allowance before forcing them to use in-network? Why not adapt upfront cost estimates? Allow overages, but if a hospital goes consistently over estimate, then they get penalized? Allow patients to access cheaper doctors and services if they waive their rights to medical malpractice lawsuits. Give patients cheaper healthcare for demonstrable good health practices (taking into account diseases and existing conditions).
- worik 3y ago
  > But wouldn't government control and subsidy lead to the same malinvestment and cost explosions as college tuitions? It could do. It is hard to see how it could be worse. The USA health care system, "industry", is a case study in failure at all levels except some pointy headed technology > Wouldn't fierce competition at all levels be a good thing? Definitely not. Competition is good in some areas, very bad in others. All sides must be able to enter and leave the market, and there must be even distribution of information. Most health care does not fit well Many countries have socialised systems that use waiting lists rather than wealth to ration access to health care. The private health industry work very hard, at all levels I have seen, to undermine those systems, but in many cases they offer very good care. Some of the best health care in the Americas is in Cuba
  - throw10920 3y ago
    > It could do. It literally would. Subsidies invariably result in cost disease, because there's more money for the same amount of value in the market. > It is hard to see how it could be worse. This isn't a very useful statement - it would just literally get worse. You don't have to visualize it. > Definitely not. Competition is good in some areas, very bad in others. Where is competition bad? You haven't pointed any areas out. Competition seems obviously good to me basically everywhere. > Most health care does not fit well Which is not a property intrinsic to healthcare, but a mere result of the fact that the government hasn't legislated price transparency in that area into effect yet. > Many countries have socialised systems that use waiting lists rather than wealth to ration access to health care. ...which is obviously stupid because, unlike situations where you pay for your care, adding people to a wait list does not fund further capacity.
Gibbon1 3y ago
> Most Americans experience first hand how horrible health care here is. The little people and not so little people experience how horrible it is. All the big people get the platinum plated VIP treatment. And it's a great source of nomenklatura make work jobs for them. Anecdote: Friend worked for a billionaire. Had a seizure at the office and ended up in the ER and the head of neurology department came down to check on him.
throw10920 3y ago
> Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system. That's a wild claim that is not only completely unprovable, but self-inconsistent. We're in this mess because of the failure of the state to create (and enforce) good regulation to begin with, and you're proposing that we move the healthcare system into the state? Pure insanity.

cyanydeez 3y ago

the healthcare complex employs millions. all these people would lose jobs. so there's really zero political will to crack the monolith, and why things like Obama care go forward, because they're bandaids. then there's the who employer leverage that businesses live having to immobilize a significant portion of their work force. it's absolutely not complicated to understand why nothing has moved the needle.

SteveNuts 3y ago
Right. If these huge insurance companies had to "compete" with a real universal system, there's no way they could even exist. All they do is scrape profit off the top of every healthcare procedure in the US. The most useless middleman to ever exist, in my opinion.
- vinay427 3y ago
  I agree with your broader point, but it’s worth noting that insurance middlemen exist in many European countries with universal health insurance, so surely some form of this can exist in a more regulated health insurance/provider market.
  - rqtwteye 3y ago
    I had private insurance in Germany. The big difference is that they have to compete there instead of having a captive audience they have in the US with employer based health insurance. Your employer picks the insurance options that are convenient for them, they don't care much about what's good for you. So you are basically trapped unless you are willing to not take insurance from your employer but go on the open market which will be very expensive. A while ago I asked my employer to just give me the money they give to Optum so I can buy insurance via ACA but they wouldn't do it.
  - kevin_thibedeau 3y ago
    The problem is the US has for-profit medical insurance as well as mutual insurance (collectively owned by their members). The laws were altered in the 90s to permit mutuals to convert to for-profit. This was generally a bad move as it takes out any real incentive to manage costs when jacking them up is the only way to boost profits so the C-levels can get 8-figure bonuses.
keenmaster 3y ago
More competition increases the number of jobs
- bearjaws 3y ago
  Optum has billions of dollars in profit annually, none of that is going into the employees pockets or patient savings.
standardUser 3y ago
Not everyone in the healthcare industry would lose their jobs, that's absurd. It would mostly be the redundant insurance staff (and redundant sets of highly-paid insurance execs).
- NickC25 3y ago
  This! Execs would lose their jobs. Billing specialists (who do a 4 year degree in medical billing, which is in and of itself fucking absurd) would lose their jobs. You know who wouldn't lose their jobs? Doctors and nurses. The actual people who the system's outcome is dependent on.
  - FireBeyond 3y ago
    > Billing specialists (who do a 4 year degree in medical billing, which is in and of itself fucking absurd) What? I have never heard of such a thing, and I worked in the claims benefit management industry for nearly a decade. So I searched this, "bachelor medical billing" and while I got plenty of results, all of them were for certificate courses, which I'd expect. "Top rated medical billing courses" were all at community colleges. I am yet to find a Bachelor degree in medical billing. Indeed, on ... Indeed: > Can you get a bachelor's degree in medical billing and coding? > While a bachelor's degree in medical coding and billing isn't an option, people interested in pursuing this career can earn a degree in a related field instead. For example, you might consider earning a bachelor's in health care management or health information management. A certificate/diploma is going to be 9 months to 1 year. An associate diploma? 2 years. I also can't find any four year courses in medical billing.
  - lotsofpulp 3y ago
    The managed care apparatus in the United States is about allocating insufficient supply of healthcare to excess demand based on the political value of the healthcare recipient. That is why Medicare pays doctors more than Medicaid for the same work (old people are worth more since they vote more than poorer and younger people). You can endlessly bucket people into infinite changing tiers based on their political power using reimbursement, deductible, out of pocket maximum, in and out of network providers, formularies, and prior authorization protocols. For example, you can give members of the military a different quality/quantity of healthcare than US federal Senators, who have a different set of policies, who in turn have a different set of policies from a highly profitable white collar firm’s employees, and yet again different from a less profitable business with lower paid employees, and so on and so forth. You can adjust reimbursements so that some people can immediately see doctors whereas others have to go to Physician Assistants or Nurse Practitioners. The system is a thing of beauty from a political point of view, and I bet countries with nationalized healthcare like UK and Canada move closer and closer to the US system as the population pyramids go upside down and cuts have to be made. And the whole time, people will waste their time being mad at managed care organizations, when the government leaders are the ones hiring them to be the “bad guy”.
slipperybeluga 3y ago
[dead]
monksy 3y ago
They're also firing people for fun. I know of a guy who is deep in the weeds upgrading their scala libraries that just got laid off within the week. (You have to do that to stay on top of all of the cves)

oatmeal1 3y ago

> Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system. I don't trust the US government is competent enough to run healthcare. If it can do better than the existing system, let it create a new voluntary, unsubsidized insurer, free of the BS rules it has created. Competition is the source of quality and low prices. Any monopoly is an invitation for poor quality and high prices.

bcrosby95 3y ago
The great thing about the "50 states" model is states can try random experiments. For example, Texas has done a lot to try to bring more competition but none of them have done a thing for the high cost of healthcare.
- oatmeal1 3y ago
  That would be great if we had real federalism. The states cannot try anything really unique, because they are hamstrung by federal law and federal subsidies with strings attached.
- FireBeyond 3y ago
  Yup. The big one to me being capping malpractice payouts. "Healthcare costs a lot because physicians have to carry very expensive malpractice insurance because of astronomical judgments". Texas caps malpractice payments and everything stays exactly the same. Also, malpractice insurance in itself isn't typically as onerous as people believe it to be. What is onerous, and what that industry does differently to most other insurance segments is "tail insurance". Tail insurance is the concept that major malpractice suits may appear well after your claims-made liability policy has ended. In most cases it's actually DOUBLE the premium you're paying for malpractice insurance, implying the insurer believes that your coverage is less than one-third of the claims they expect to pay. What -should- happen is that you carry "claims-made and prior acts" coverage. The challenge there is that in many cases your employer will cover claims-made as part of your compensation or part of their insurance, but don't elect prior acts coverage (and because of the way they do it, I suspect it's not as simple as "let me pay the difference"). But in general capping malpractice payouts has done nothing to offset malpractice coverage costs, let alone flow-through to end consumer costs.

thatfrenchguy 3y ago

> Most Americans experience first hand how horrible health care here is I mean, no, most Americans are just upset about cost-sharing, most providers in the United States are pretty good and have pretty good facilities and equipments. You can have systems that are mostly privatized (cough, France) that are better regulated than the United States, but that'd mean doctors would get paid less money & upper class folks would likely get worse care

AHatLikeThat 3y ago
Maybe in large urban areas, and if you can afford insurance at all. In rural areas, even smaller urban areas, there are few physicians, long waits and not enough facilities. [https://www.krqe.com/health/new-mexico-needs-hundreds-of-health-professionals-u-s-department-of-health-says/ https://www.krqe.com/health/new-mexico-needs-hundreds-of-hea...]
- arebop 3y ago
  It's the same in San Francisco, where we support returns to investors in residential real estate by banning new development since the 1960s and therefore doctor salaries don't afford a luxury lifestyle [https://www.nytimes.com/2017/06/03/business/economy/high-end-medical-care.html https://www.nytimes.com/2017/06/03/business/economy/high-end...] and therefore we have a shortage of physicians.
  - pyuser583 3y ago
    San Francisco is also overwhelmingly young and healthy.
    - KerrAvon 3y ago
      Between COVID and the millennial cohort in SF, that's not going to be true very much longer, if it is at all today.
- HDThoreaun 3y ago
  This is because congress wont expand residencies so there arent enough doctors. Doctors make a bunch of money and can live anywhere they want, almost none of them want to live in bumfuck.

bearjaws 3y ago

Oh I don't disagree that the system is fundamentally broken, but we clearly need to attack from all angles.

touristshaun 3y ago
quicker to start from scratch
- rqtwteye 3y ago
  That's lie rewriting a code base from scratch because the current is deemed unmaintainable. Most of the time you end up with the same number, but different problems or it's even worse. In my view Medicare for all would be a viable path but even the Democrats are not interested in tackling healthcare.
  - terr-dav 3y ago
    Let's refactor it then: The government simply takes ownership of UHC and they get a new charter to run it like the Postal Service.
    - kelseyfrog 3y ago
      Curious, how at this point could BigGov make UHC worse?
    - thallium205 3y ago
      My mailman refuses to take my stamped envelopes out of my mailbox. Can't be bothered.
      - ascagnel_ 3y ago
        I’ve lived at my current address for about five years. The first year, zero issues. Starting at around the 2020 election, service dropped off precipitously, to the point where I’ve had a piece of outgoing mail in my box since Friday. I can’t trust the mail with anything time sensitive any longer. I blame this on Louis DeJoy, who was appointed Postmaster General in May 2020, and has numerous conflicts of interest.

echelon 3y ago

> State controlled medicine is essentially the only solution to the already partly collapsed US health care system. But wouldn't government control and subsidy lead to the same malinvestment and cost explosions as college tuitions? Wouldn't fierce competition at all levels be a good thing? Why not force insurers to cover everything up to a set cost on a per-disease basis? That is, let patients spend a set allowance before forcing them to use in-network? Why not adapt upfront cost estimates? Allow overages, but if a hospital goes consistently over estimate, then they get penalized? Allow patients to access cheaper doctors and services if they waive their rights to medical malpractice lawsuits. Give patients cheaper healthcare for demonstrable good health practices (taking into account diseases and existing conditions).

worik 3y ago
> But wouldn't government control and subsidy lead to the same malinvestment and cost explosions as college tuitions? It could do. It is hard to see how it could be worse. The USA health care system, "industry", is a case study in failure at all levels except some pointy headed technology > Wouldn't fierce competition at all levels be a good thing? Definitely not. Competition is good in some areas, very bad in others. All sides must be able to enter and leave the market, and there must be even distribution of information. Most health care does not fit well Many countries have socialised systems that use waiting lists rather than wealth to ration access to health care. The private health industry work very hard, at all levels I have seen, to undermine those systems, but in many cases they offer very good care. Some of the best health care in the Americas is in Cuba
- throw10920 3y ago
  > It could do. It literally would. Subsidies invariably result in cost disease, because there's more money for the same amount of value in the market. > It is hard to see how it could be worse. This isn't a very useful statement - it would just literally get worse. You don't have to visualize it. > Definitely not. Competition is good in some areas, very bad in others. Where is competition bad? You haven't pointed any areas out. Competition seems obviously good to me basically everywhere. > Most health care does not fit well Which is not a property intrinsic to healthcare, but a mere result of the fact that the government hasn't legislated price transparency in that area into effect yet. > Many countries have socialised systems that use waiting lists rather than wealth to ration access to health care. ...which is obviously stupid because, unlike situations where you pay for your care, adding people to a wait list does not fund further capacity.

Gibbon1 3y ago

> Most Americans experience first hand how horrible health care here is. The little people and not so little people experience how horrible it is. All the big people get the platinum plated VIP treatment. And it's a great source of nomenklatura make work jobs for them. Anecdote: Friend worked for a billionaire. Had a seizure at the office and ended up in the ER and the head of neurology department came down to check on him.

throw10920 3y ago

> Which to say that, imo, "restoring the free market" isn't a useful action in this mess. State controlled medicine is essentially the only solution to the already partly collapsed US health care system. That's a wild claim that is not only completely unprovable, but self-inconsistent. We're in this mess because of the failure of the state to create (and enforce) good regulation to begin with, and you're proposing that we move the healthcare system into the state? Pure insanity.