5 ms·

They buried the lede: > "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces" Blaming insurers and d

by timr 1y ago

They buried the lede: > "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces" Blaming insurers and drug companies is fashionable -- and employers is a new twist, I suppose -- but it feels like a desperate search for a facile answer. Nobody wants to hear the hard truth, which is that if you had to pay for it, you'd suddenly become a lot more picky about the health care you purchase. You don't see the prices, so you don't care, and you can't shop around. I'm not saying there aren't a ton of other negative incentives in the system, but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.

fzeroracer 1y ago
> but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is. Most people in the US never see a doctor outside of emergency care because it's too expensive to do so. Price shopping doesn't do shit for the majority because the people that do get healthcare get it from their job and don't have a choice anyways which doctors they can see or not.
- deleted 1y ago
  [deleted]
dghlsakjg 1y ago
This would be true if the people that do pay the prices had no influence on your purchasing decision, but the insurers maintain a massive hold on purchase decisions. And in reality, a ton of insured people do pay very directly for their healthcare in deductibles and denied coverage claims. I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything. I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance. Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here. From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
- timr 1y ago
  > From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am. You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service. > I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. ...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.
  - ceejayoz 1y ago
    > The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.
    - timr 1y ago
      Well, you're making a a series of logical fallacies (are we talking about the UK, specifically, or an unspecified constellation of "places like" they UK, so that you can avoid the false dichotomy?), but my general rebuttal would be this: "the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good." I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?
alephnerd 1y ago
> most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost. The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can. This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year (and more like $1.5k for her parents, being tenant farmers) and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore, let alone a HCMC or Hanoi where the jobs are actually located. Similar story for my cousin in India as well - he's attending a T5 AIIMS and is looking at 10 years of medical education (an MBBS doesn't cut it in 2025 anymore - you need an MD as well now) in order to get a $15k starting salary, but he is also lucky that his parents are both doctors. If he was not from that background he would have probably attempted the USMLE as well and leave. Both India and Vietnam are seeing a significant medical exodus, as is the UK, South Korea, and other countries where this kind of penny pinching sentiment is rife. HNers harp about layoffs and offshoring, but seem to only care about stagnating wages for themselves in high wage industries with no barriers to entry, relatively chill work cultures, and no risk of legal liablity. What do you guys want? Barefoot doctors and aryuvedic treatment?
- BrawnyBadger53 1y ago
  The wage of medical staff is independent to the cost of drugs
- ceejayoz 1y ago
  > This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore. I mean, people in the US pay $250k+ tuition, median income $65k/year, work $35k/year for a while, and eventually make something like that $250k/year. A house in many US markets is $300-500k. It's pretty much the same balance between each item, just more zeroes on the end of each number.
lukeschlather 1y ago
I had a procedure done recently. I was given a bill, I opted for a more expensive treatment, it was a ~$1500 total, my insurance wouldn't cover an extra $300, I paid it since it seemed worth the extra money. I received another bill in the mail for $300 a month later that my insurance had additionally decided not to cover. What is this world you live in where American health insurance means you don't have to comparison shop? Healthcare is a huge expense and not only are the prices high, they change after the fact at the whims of the people I'm theoretically paying to handle the negotiations.
- timr 1y ago
  You're describing a scenario where you bought the product without knowing the price, and were shocked by the additional bill(s) you got after the fact. At what point in your story were you able to comparison shop for a cheaper option? I know you said you chose a more expensive option, which is always your prerogative, but how many other providers did you evaluate before you made that decision?
  - etchalon 1y ago
    He explicitly said he did know the price. The price changed.
    - timr 1y ago
      He said he was presented a price. That price was not correct, so...it wasn't the price.
  - lukeschlather 1y ago
    I received a bill for the price and the price became more expensive after the fact. In my experience it's a fact of American healthcare that you always pay more than the price you are quoted. But you are usually quoted a price. I was quoted a price, I paid it, and then it increased. This is how paying for healthcare works in America.
    - 1y ago
bee_rider 1y ago
Insurance companies can’t really work as things that change the expected value of the service they insure, it just doesn’t make sense. They exist to cover massive unlikely risks. I don’t blame insurance companies for being annoying services with negative expected values (that’s just inevitable). But, whoever decided to start marketing things like low deductibles and out-of-pocket costs as a premium service, that person bears a lot of blame. They are the one that decided customers shouldn’t see most of their healthcare costs. The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups. Mixing in employer insurance also caused a skew, because it makes people see their employer insurance as a perk. A perk should be something you actually experience. Employers should dump money into your HSA, and subsidize a gym/healthy snacks for their campus instead (some do, of course).
- labcomputer 1y ago
  > The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups. Well, that's just silly. The whole point of insurance is to cover tail cases: Catastrophic costs with low probability. If there is no cap, why have insurance at all?
  - bee_rider 1y ago
    Sorry, I think I might have accidentally use a term-of-art, and misused it. I meant “no cap on how much the insurance will pay out.” But, when in the same sentence with “high deductible,” the more reasonable parse (and the one I think you read it as) is “no cap on out-of-pocket expenses.” My bad.

by timr 1y ago

fzeroracer 1y ago

> but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is. Most people in the US never see a doctor outside of emergency care because it's too expensive to do so. Price shopping doesn't do shit for the majority because the people that do get healthcare get it from their job and don't have a choice anyways which doctors they can see or not.

deleted 1y ago
[deleted]

dghlsakjg 1y ago

This would be true if the people that do pay the prices had no influence on your purchasing decision, but the insurers maintain a massive hold on purchase decisions. And in reality, a ton of insured people do pay very directly for their healthcare in deductibles and denied coverage claims. I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything. I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance. Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here. From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying

timr 1y ago
> From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am. You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service. > I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. ...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.
- ceejayoz 1y ago
  > The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.
  - timr 1y ago
    Well, you're making a a series of logical fallacies (are we talking about the UK, specifically, or an unspecified constellation of "places like" they UK, so that you can avoid the false dichotomy?), but my general rebuttal would be this: "the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good." I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?

alephnerd 1y ago

> most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost. The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can. This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year (and more like $1.5k for her parents, being tenant farmers) and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore, let alone a HCMC or Hanoi where the jobs are actually located. Similar story for my cousin in India as well - he's attending a T5 AIIMS and is looking at 10 years of medical education (an MBBS doesn't cut it in 2025 anymore - you need an MD as well now) in order to get a $15k starting salary, but he is also lucky that his parents are both doctors. If he was not from that background he would have probably attempted the USMLE as well and leave. Both India and Vietnam are seeing a significant medical exodus, as is the UK, South Korea, and other countries where this kind of penny pinching sentiment is rife. HNers harp about layoffs and offshoring, but seem to only care about stagnating wages for themselves in high wage industries with no barriers to entry, relatively chill work cultures, and no risk of legal liablity. What do you guys want? Barefoot doctors and aryuvedic treatment?

BrawnyBadger53 1y ago
The wage of medical staff is independent to the cost of drugs
ceejayoz 1y ago
> This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore. I mean, people in the US pay $250k+ tuition, median income $65k/year, work $35k/year for a while, and eventually make something like that $250k/year. A house in many US markets is $300-500k. It's pretty much the same balance between each item, just more zeroes on the end of each number.

lukeschlather 1y ago

I had a procedure done recently. I was given a bill, I opted for a more expensive treatment, it was a ~$1500 total, my insurance wouldn't cover an extra $300, I paid it since it seemed worth the extra money. I received another bill in the mail for $300 a month later that my insurance had additionally decided not to cover. What is this world you live in where American health insurance means you don't have to comparison shop? Healthcare is a huge expense and not only are the prices high, they change after the fact at the whims of the people I'm theoretically paying to handle the negotiations.

timr 1y ago
You're describing a scenario where you bought the product without knowing the price, and were shocked by the additional bill(s) you got after the fact. At what point in your story were you able to comparison shop for a cheaper option? I know you said you chose a more expensive option, which is always your prerogative, but how many other providers did you evaluate before you made that decision?
- etchalon 1y ago
  He explicitly said he did know the price. The price changed.
  - timr 1y ago
    He said he was presented a price. That price was not correct, so...it wasn't the price.
- lukeschlather 1y ago
  I received a bill for the price and the price became more expensive after the fact. In my experience it's a fact of American healthcare that you always pay more than the price you are quoted. But you are usually quoted a price. I was quoted a price, I paid it, and then it increased. This is how paying for healthcare works in America.
  - 1y ago

bee_rider 1y ago

Insurance companies can’t really work as things that change the expected value of the service they insure, it just doesn’t make sense. They exist to cover massive unlikely risks. I don’t blame insurance companies for being annoying services with negative expected values (that’s just inevitable). But, whoever decided to start marketing things like low deductibles and out-of-pocket costs as a premium service, that person bears a lot of blame. They are the one that decided customers shouldn’t see most of their healthcare costs. The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups. Mixing in employer insurance also caused a skew, because it makes people see their employer insurance as a perk. A perk should be something you actually experience. Employers should dump money into your HSA, and subsidize a gym/healthy snacks for their campus instead (some do, of course).

labcomputer 1y ago
> The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups. Well, that's just silly. The whole point of insurance is to cover tail cases: Catastrophic costs with low probability. If there is no cap, why have insurance at all?
- bee_rider 1y ago
  Sorry, I think I might have accidentally use a term-of-art, and misused it. I meant “no cap on how much the insurance will pay out.” But, when in the same sentence with “high deductible,” the more reasonable parse (and the one I think you read it as) is “no cap on out-of-pocket expenses.” My bad.