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.
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.
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.
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.
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.
>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.
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.
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.
Hmmm, interesting. I wonder to what level this is an actual threat vs. something the media came up with? It being such a hot button for people in that region would seem to also make it a potent way for politicians to gain support.
> 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 ?
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.
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.
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.
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.
> How exactly? Since it would do the same thing as ER, it would cost as much to operate as ER.
No. The ER and its expensive specialists (e.g. trauma/accident specialists) can be reserved doing their actual specialized jobs (taking care of patients injured in car crashes, for example) without being clogged by some dude with a toothache. The ER only handles the real hardcore cases that can escalate to death in a matter of seconds, and the urgent-care facility only handles the "everyday" harmless stuff, which needs less and especially less-certified/experienced and thus cheaper staff.
The ERs should already be doing this: if they have too much toothache cases for one trauma surgeon, they clearly won’t add a second trauma surgeon to the shift, they will add a general practitioner. If the trauma surgeon is not busy putting car crash victims together, he can handle the toothache just fine: he is already getting paid anyway, so it doesn’t make sense to keep him idle.
> Those behavioral changes resulted in 35% lower health-care spending than when the same employees were enrolled in traditional health insurance. Even better, the study found that employees enrolled in the deductible security plan were going in for mammograms, annual check ups, and other forms or preventive medicine at the same rate as when they were enrolled in traditional insurance. Thus, these cost savings are real and not due to people delaying necessary care in order to hoard their HSA balances.
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.
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.
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.
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.
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.
Here's how it went when I tried to do it upfront. My wife was pregnant, so we had 9 months of routine, scheduled visits. I asked "how much will this cost ignoring any unexpected costs." My insurance had a helpful PDF showing $650 as an out of pocket example with an asterisk saying not to use this number for reference. Reading up, some places offer a "package deal"--our's didn't. I was told to call the doctor's office and write down their itemized list of procedures. Then call their billing office to get an itemized list of billing codes. Then call my insurance to get the out of pocket cost. The final cost was a few multiples of that cited value (although there were additional, unexpected costs).
In my experience during a time when I had no insurance, they often can't even tell you after the fact. Everything has to go through a dozen or more layers of bureaucracy before you get a bill.
I agree with everything this article suggests, but to be fair to hospitals, they can't really tell you what some procedures will cost for obvious reasons. A delivery may ordinarily cost $x, but if a caesarean is required it may be $x + $y.. etc. A car mechanic will give you an estimate for what it will cost you to fix something, and then call you if it turns out to be more expensive. In a delivery (or a surgery) they can't really ask you if you are OK with an additional cost that may be required, they have to just do it.
However, a hospital could provide a list of prices that are commonly billed. What a list of prices would do is give you a sense if one hospital costs a lot more than another in general. If you knew you might change which hospital you go to and.. you know markets etc.
Your first example is funny, considering that the hospital where my son was delivered sent us a letter about a month before his due date with an estimate of the cost for both normal delivery and caesarean.
Of course it didn't cover every possible contingency... That's what an "estimate" means by definition. But that doesn't mean that it's impossible or even unreasonable to provide a baseline price, along with some of the more common events that can modify that price.
Most billing departments won't provide prices without the billing codes for the procedures. How do you get the billing codes? You have to see a doctor and get a treatment plan. How do you find out how much seeing the doctor is going to cost to get your treatment plan? You call the billing department for a quote.
We went through this during a very stressful time when my SO found a lump in her breast, and it took the kindness of a nurse that worked between the doctors and the billing department to give us a possible list to get a ballpark of what to expect. She called us after hours to tell us because she didn't want to get in trouble with her manager.
Once we had that information, we called several hospitals for quotes and ended up being offered 40-70% discounts. It went from thousands to hundreds to ultimately having some of the tests comped... all because we had a little information and asked the right questions about the process.
This is a disgrace and not how you treat people's health.
> But is there room to distinguish emergency from non-emergency services?
There absolutely must be, IMO. Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for. IIRC, emergency healthcare spending accounts for around 2% of our annual totals. I just don't think we can justify our full medical pricing system on the basis of emergency care needs alone.
For everything else, though, I'd be much happier if I could just have a price list up front and shop for the provider of my choice. I did it with Lasik, and it was easily the best medical experience I've ever had, not just in terms of "knowing what I'll pay", but the outfit I had it done by was actually competing to win my business. I felt like a customer they wanted to win, not just an account number that they were going to throw at my insurance company.
By means of analogy, we carry car insurance in the case of accidents, but we don't expect car insurance to pay to refill our gas tank (even though gasoline has a lower price elasticity of demand than heathcare!) or pay for oil changes. Food has a lower price elasticity of demand than healthcare, too, but it's still cheap and we don't carry grocery insurance. Insurance makes sense to cover the unforeseen and unexpected. Why do we obfuscate prices and billing practices for routine, elective, and foreseeable care?
"Don't have insurance cover routine care" is obviously insane if pricing were to remain unchanged, but I absolutely think the fundamental problem with the affordability of healthcare in the US isn't the availability (or lack thereof) of insurance, but the way we've completely separated services from prices. Hiding the prices doesn't mean they don't exist and don't get charged - they just eliminate the forces that would otherwise exert downwards price pressure. If we could get pricing transparency on everything, and then see providers start competing on uninsured pricing, I think that could open the door to "actual insurance" plans (at far lower cost than exists today), while actually reducing prices for everything else across the board.
The problem with this is in how you classify different types of care. For example, is end of life care voluntary and thus should not be covered by insurance or is it emergency? If you say it’s the former and go to a national healthcare setup, people lose their minds shouting about death panels. If you say it’s the latter, healthcare costs go up 10-12%.
Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though.
On the one hand, you do really want people to be relatively insensitive to the cost of medical care they actually need. When you need it, you get it. On the other hand, that price insensitivity, applied indiscriminately, leads to the massive ballooning costs we've all seen. I don't think there's a way to have full price insensitivity and to keep prices in check - which means that we either just spend whatever our doctors ask (I'm not interested in that), or we start making people more price-sensitive to allow those downward pricing pressures to be exerted.
Fundamentally, you don't get away with increased price sensitivity without someone yelling about death panels. Prices are how we allocate scarce resources, which means they determine who doesn't get things. We can either pretend prices don't exist (and get the status quo), or we can acknowledge that they do and that sometimes, people can't or won't pay those prices. Neither is emotionally attractive, but I think being realistic about the existence of prices and allowing consumers to actually exert some market pressures is preferable than just being held hostage to whatever the insurers demand we pay this year, just so that we don't have to think about costs at the point of service.
> Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though.
They are solvable, but with regulation, and they will sometimes get an edge case here or there wrong, which will inevitably result in a low-effort, sensationalist news article which will decry the situation, degrade people's support of the systems, and damage the institution.
Well, I don't think other countries have achieved actual price insensitivity, in the sense of "fully inelastic demand". Fundamentally, for any scarce resource, supply, demand, and price are necessarily linked. Medical care is scarce - consuming a unit of medication or a time slot with a doctor precludes someone else from consuming the same. The allocation mechanism can be monetary (price), temporal (wait times/backlogs), or regulatory (restriction from certain services or treatments), but there must be an allocation mechanism. As far as I know, there's no country in the world where you can get all the medical care you demand when you demand it without consideration of price; if you're not paying monetarily, you're subject to rationing or restrictions that otherwise limit the demand you can place on the system.
In Singapore, for example, Medisave only covers drugs that the government has deemed cost-effective. Need a high-cost experimental medication? Not permitted. Denmark has notably bad cancer survival rates, much a consequence of long wait times for screenings and treatments. The US, by comparison, has some of the highest cancer survival rates in the developed world, arguably because Americans can (and do) spend on tests and screenings at far higher rates than other countries. IIRC, Americans get medical imaging scans at a rate roughly 100-1000% higher than patients in other first-world nations. Most of those scans don't find anything, and if you're a government bean counter deciding how to allocate this year's medical budget, they're going to be high on the list to cut or ration - but when they find something, those early warnings and immediate access to aggressive (and expensive) treatment make a significant difference.
What if you offer the option of a lump sum payment upon death to anybody who is faced with a disease that will most likely end in imminent death? So, if it costs $250k for treatment of a cancer where the patient is going to die in, at most, a few years, then offer them $125k payable heirs upon their death (where it would then go to heirs). In return, they elect to have only end-of-life care performed.
I bet there's a lot of people who would take this. And it would both save money and make a pretty big difference in the lives of people who still have a lot of life left to live.
> Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it.
Agreed.
> Wouldn't that discourage preventative care?
At the margin, yes. OTOH, paying less in insurance premiums and known/lower costs for services would leave more money for elective care (or whatever else you wanted to spend it on), which would apply pressure in the other direction. Most routine preventative care doesn't have to cost particularly much. Additionally, there's no reason why we couldn't have pooled cost systems for routine care like our existing insurance plans today for those that prefer to amortize their costs, but IMO, they should be separate from emergency care. Emergency care insurance isn't practically optional.
What I don't get is how hospitals can justify the costs for a lot of the shit they charge for...
Example if you have a baby and ask for an itemized list you might see something like $49 for chest to chest time with baby... they're fucking charging you to hold your damn baby.
Or $35 for a single ibuprofin for pain. Seriously? 100x markup? I can get a bottle of 100 ibuprofin's for < $10.
Some things should just be free because it's a hospitality industry right? I mean you go into a restaurant and ask for extra napkins they just give them to you. They don't charge $2/napkin. Or at the very least - at cost.
Can you explain the metaphor "hiding the umbrella"? Google didn't turn up any obvious meaning.
If I had to guess, it's a reference to the joke about turning in your expense report, after being told they won't reimburse you for the umbrella you lost, and so you overstaet expenses enough to cover the umbrella's cost. But that never made sense to me, since they demand receipts anyway...
Your guess is correct. And perhaps the metaphor isn't perfect (though many places don't require receipts below a certain value) but it gets the point across.
The justification is that hospitals have enormous fixed costs, and somebody has to pay for care for people who don't pay and people on government plans that pay below cost. Also, nobody actually pays those prices, so hospitals have no incentive to give a shit about making them make sense.
I can see if the chest to chest time is between the father and baby. The breast tissue of a mother regulates its temperature to maintain the baby at the proper body temperature. A father's chest does not and a baby can easily become overheated. When father to baby chest to chest time happens best practice is for nurses to regularly check on the status of the baby during this time. This means you are utilizing additional staffing resources which is what the charge is for.
I think Lasik is an outlier example. I couldn't find out how much of the population is a good candidate for Lasik, but 61% need corrective eyewear. The process is basically a commodity, it's almost exclusively a quality of life elective procedure, and it's basically a one-shot deal (I know people who traveled for it).
I completely agree emergency care is one thing insurance is for, but I think more generally it's "catastrophic costs" which often includes ongoing things. A lot of issues require follow up costs (I've heard insurances are switching from itemized costs to a fixed cost for the whole procedure. Similarly, I see a lot more "continuity of care" in healthcare).
As an example, let's say someone had vision loss for a couple minutes. An emergency room visit finds them to be ok in the immediate term, but it was because of a blockage in the heart causing a minor stroke. Which means there's a lot of follow up, with large costs. How do you best incentivize this? It's not "emergency care," there is time to research cost, but putting the cost burden on the patient is more than they can handle (hence insurance). Insurance tries to use cost signals like co-pays. An ongoing cost like dialysis will be optimized around convenience if you don't expose the cost, but exposing the cost may bankrupt them.
I think tying healthcare to employment and pushing it as a benefit is the worst offender for the skewing of the market--masking the cost of routine care. Fixing that alone would make me much happier (I also think it would be an economic benefit because of people tied to their jobs and the drag on starting a small business).
I think this misunderstands the point of insurance. Insurance covers rare, but high-cost situations by spreading the risk around to the entire population that's subject to that risk. It's not necessary that the situation be a surprise.
People with chronic diseases aren't subject to an emergency, but they're far more expensive to provide medical services for than otherwise healthy people because they need so much more medical care. Same with people with cancer: cancer is not an emergency in the sense you're describing, but no amount of comparison shopping is going to make cancer treatment affordable for one person. What does make it affordable is that a huge pool of people are paying for it.
> It's not necessary that the situation be a surprise
setting aside the american/healthcare market with the inflated prices for the sake of the argument, wouldn't be more cost effective, for planned expenses, to go with savings or a loan?
No? Most people would struggle to save up hundreds of thousands of dollars to pay for the cancer or any chronic diseases they plan (?) to get at some point. Aside from that, you have no idea what medical conditions you're going to get, and when. Even if you can save the money, it's a massive amount of money sitting around in cash (can't invest it because you could need it any time), which would be a huge waste. And some people would save it all up and never end up needing it.
> a diagnostic test like an MRI can often cost that much
In non-emergency situations where you can do advance planning MRIs are cheap. It all started around 15 years ago when some college professor set up a company a2zimaging I think it was called that sold idle MRI capacity to anyone. I believe he eventually shut it down but there's now several other companies willing to do a full MRI for anywhere from $320 to $1500. Google "cheap mri" and choose one.
If you are brought into a hospital after a car accident and use their scanner without making arrangements, you can end up paying $10-$20k for the exact same scan.
But are "Asians" who live in the US a representative sample? Or might there be some distinguishing characteristics of immigrant families, compared to those in their home countries? Also, Singapore has two main ethnic and socioeconomic groups with different culture, cuisine, genetics, religious habits, and so on, which is almost certainly not the same composition as "Asian-Americans" however that is defined.
This is why direct primary care is becoming a thing. Doctors are opting out of the insurance system in order to see fewer patients and reduce overhead. For $50-$75 a month, you get unlimited access to your physician, including via video call, access to wholesale meds and labs, and reduced cost diagnostics.
These costs and incentives are often ridiculous. I got a Teledoc pamphlet from my insurance last year. Awesome! Often, when something happens or if I'm sick, I never know when to go to the ER, Urgent Care, or make an appointment. If I feel terrible for 5 days, should I wait it out or see someone? Especially with young kids, I've made the wrong call in both directions. It turns out a video/phone appointment is way more than seeing someone in person. I figured my use-case wasn't what they were targeting and couldn't imagine a scenario I would prefer it.
The price differential for the same procedures depending on whether I go to an urgent care center, or my primary care, or a hospital ER is what makes me insane. Urgent care is a flat fee $50, whatever they do, whereas the hospital starts at something like $800, and goes up from there.
I forget what the primary care costs, although I think it is more than urgent care; I can't get an appointment with my primary care without a couple months of lead time, so it's pretty much moot.
Alternatively, you could have a system like a lot of the rest of the world, where medical care is simply provided as needed, hospitals are public entities, and health-care has no price (since there is no market), just a cost, that is payed for from taxes.
This way, all the money going into the system is actually spent on healthcare, instead of having profit extracted from it. You also get rid of the stress of money from the already bad situations of major disease, and the complex bureaucracy that insurance brings with it.
> Alternatively, you could have a system like a lot of the rest of the world, where medical care is simply provided as needed, hospitals are public entities, and health-care has no price (since there is no market), just a cost, that is payed for from taxes.
Almost no countries have such a model. The closest one is the UK. But the U.K. still rations care aggressively to control costs. (The government uses formulas to decide whether the benefit from a treatment is worth the cost.) In Germany, where the government subsidizes multi-payer insurance, more than 2/3 of hospitals are private. Even in Sweden, which had a system like you’re describing until 1995, more than a quarter of hospitals are private.
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.
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.
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.
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.
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.
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/p60-26...). 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.
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.)
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!!!
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.
Exactly. If you have insurance, you should never receive surprise bills that are higher than your out of pocket maximum. Bad insurance might mean a higher out of pocket maximum, but that should mean what is says...maximum.
You're conflating in-network, out of network with HSA -- as these also apply for POS and HMO plans - only traditional plans don't get the plan cost savings, tax deduction, (or if they're lucky the employers savings into an HSA account)
Your bicycling example isn't far off though (as someone who had an HSA and was in a bicycling accident). I had a ~$3600 deductible, and that was spent between an ambulance ride, ER visit, blood test, and MRI.
So, at that point, all costs would be on my insurer and I would theoretically no longer care to price discriminate for follow up visits (to get stitches removed)
I still have an HSA, though I make sure I get the lower deductible now.
Wellll no one unless you somehow make it into an out of network situation. You know, like in an emergency. High deductible plans typically have much more constricted networks than the more traditional plans. Good luck figuring out what’s in and out of network while your appendix may be bursting!!!!
It's so odd that the claim of efficiency is based on HSA, when you look at Singapore, and say the UKs NHS have similar price performance at less than half per capita costs vs the US. As far as I understand, the NHS doesn't have any sort of HSA/deductible fees, nor price tag signals. What is in common between the low cost health systems of the UK and Singapore is significant government ownership of the service outlets as well as government negotiation of prices of input materials (drugs, etc..) for those services.
Can confirm we don't have any sort of HSA/deductible fees.
You just phone the doctor and make an appointment. Stuff happens. Pay for nothing. Ambulance turns up to help you? No payment. 5 days in hospital? No payment. Major surgery? No payment.
15 years ago, I went to the doctor with a back pain, turned out it was an pilonidal abscess, got told not to eat anything, sent directly to hospital, surgery next morning, next 2 days in hospital, then nurse came round to my house once a week for the next 8 weeks to change the dressings. I paid? Nothing. No-one even mentioned cost. I filled in no forms. It just happened.
Only thing we have to pay for is prescriptions, a fixed fee regardless of the drug of £9 ($12). And only people who can afford it, people like pensioners and people on benefit get prescriptions free. Oh, and a fairly small charge for dental checkups (£40 every 6/12 months) and if you want non-standard dental work (you used to have to pay for white fillings, otherwise you got the cheaper amalgam ones, but now you can get either I believe).
They'll usually tell you if it's a lot cheaper to buy for prescriptions yourself, i.e. if they reckon simple painkillers is the best thing, the doctor will tell you to go buy £0.40 paracetamol from the supermarket, instead of giving a prescription for the same drug at £9.
Nor do most US doctors, what's your point? And programmers in the UK don't regularly make $250k+ a year either.
Different countries, different pays.
TBH, if you feel doctor pay is somehow too expensive in the US, you're probably thinking about the wrong thing.
I would confidently expect the profits all your health insurance companies dwarf the difference in doctor salaries (an activity which is economically and socially worthless rent-seeking), let alone the salaries of all the utterly pointless health insurance company employees.
The median is over $300k for most of the fields in my link, and from my doctor friends, most easily clear it. The point is that healthcare costs less in other countries. Doctors’ labor costs less, medicines cost less, lawsuits cost less.
There’s no way to attack this problem than to lower the costs. And that means lower pay. Insurance companies have 20% margins at most, by law. Their activity is not socially worthless. The NHS performs the same activity as insurance companies, but US voters don’t want the government to do that.
I don’t know what you thought I was arguing, but my intent is to point out that things with NHS are cheaper because everyone in the healthcare chain earns less in the UK.
I never mentioned the US way is the right way, I actually think taxpayer funded healthcare is the way to go if we are going to force hospitals to provide care to anyone that shows up at their doors.
There is a lot of overhead from insurance companies that isn’t needed IF the US had taxpayer funded healthcare, but there isn’t, so they do serve a purpose of vetting a provider’s care and negotiating pricing.
Americans are being pumped full of divisive rhetoric from every angle and their politicians have been swinging to the right for something like forty years. The right wing realized the population elects R or D with something like a coin toss rate independent of what platform the party runs upon decades ago. As a party, the Rs decided to just always push their party platform to the right at every election, regardless of win or lose. It worked, and we’re four decades into the practice. All the while, the Ds also moved right in response to the center moving and not knowing the same premise. This is for national elections.
Health insurance companies in the US absolutely ARE socially worthless. They’re the singular reason we have this crazy price inflation. Doctors raise prices as a direct way to impact what they actually get paid from insurers. Insurers have “market power” (read that as-unilateral power to tell their customers and providers which way they can shove it) over providers incomes. In order to get price X from insurance providers charge X+e where e is an inflation factor to noisily correct for the kick in the pants from the insurance company. But by law providers then have to charge that price from everybody. This is a failed market.
Prices clear when supply curves meet demand curves. A plumber can’t charge $1,000 per hour because another equivalently plumber is willing to work for $200 per hour.
Doctors can charge high prices because they have low supply and high demand for their services.
No one is stopping a doctor from offering their services at $25 or even $50 per 30 min consultations. If doctor A was offering their services for X + e to insurance just to get X, and doctor B was offering their service for Y, and Y is less than X, then insurance would still go with doctor B even though there was no “e”.
Insurance companies solve the issue of a buyer having no knowledge about what they are buying since they also employ doctors to check others’ work, and to negotiate pricing as a group. Some countries don’t need this since the buyer is the government, but the government is still performing the same functions of negotiating prices and verifying doctors’ work.
> 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.
While I agree the HSA is an ineffective solution, what you're describing isn't accurate.
The HSA savings segment is not for major medical expenses. The savings portion is for minor medical expenses. The HSA savings account is paired with a high-deductible insurance policy that covers major medical expenses.
That thread also misinterprets the study. The question asked is multiple-choice, so you can't just add up the numbers the way he does (what's weird is that he acknowledges this, and then adds up the numbers anyway…) Depending on how you imagine the percentages to overlap, you can kind of have it say whatever you want.
No, he adds the numbers up to accurately provide a maximum value that's low enough that his point is proved regardless of how far below it the real value is.
The survey design, reduced to a trivial example:
Select all that apply
- A: 100% select
- B: 50% select
- C: 12% select
Suppose there were 100 people. There is no way to imagine overlap that leads to more than 12 people selecting C, as you claim.
Usually I see HSA’s combined with a high deductible plan so that the six figure medical bill is protected. We were on one when my daughter needed surgery (~$50k). We also had another child the same year ($20k), and all we paid was the $6k deductible which also came out of pre-tax money AND my employer contributed $3k to cover the premium. There were no bank fees involved. i am now self employed. Unfortunately I can not buy a high deductible or a HSA plan in my state post Obama care and my premiums in 2018 where $38k and this year have dropped to $32k. To be honest I kind of miss that $6k deductible.
I bought marketplace insurance from 2013 to 2018 in Ohio. The number of HSA-eligible plans dropped in that time period. For 2019 there were no HSA-eligible plans available in my county.
Gold means a “typical” population is expected to pay 20% while insurance company pays 80%. A plan can be gold and HSA eligible at the same time, it will just have lower out of pocket maximum and coinsurances.
If you have enough cash to afford the deductible, you should always go for HSA as you can earn the tax free investment returns on the HSA funds.
A gold non HSA and gold HSA both are designed for the insured to pay 20% and insurance company to pay 80%, but the HSA will let you invest $3,550/$7,100 single/family, and that can add up over the years.
If you started it around 10 years ago, you could realistically have over $100k in the HSA for family plans.
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.
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?
> 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.
That's not how any other insurance works. Providers charge the same amount regardless of coverage, insurance, etc. and whatever your insurance covers (including nothing at all) you are responsible for. But they also tell you up front what they are going to charge you and you acknowledge that you accept responsibility for making sure they get paid that amount either out of your own pocket or by covering the gap of what insurance pays.
The idea that having insurance changes the cost is sort of a misdirection. There's a chance my plan doesn't cover some or all of things that will be billed. So there is always a risk of non-payment or partial payment. Yes, they sometimes do pre-approvals for specific procedures but that doesn't always translate to proper billing/coding that gets covered.
The vast majority of healthcare are not ER visits which means people have a chance to review and accept the responsibility of payment. But that would also mean they would know what the hell they would be charged. There's no good reason for a hospital to say "oh you don't have insurance so we're going to basically mark your bill up 3x just to be safe. Marking the bill up 3x, for example, doesn't change the fact that they are really only seeking 1x so the people who can afford to pay 3x are legally required to do so because for some reason this is viewed as a legit practice and not fraud. And the people that can't settle for something less than 3x, usually much less. Maybe 1x...in which case the providers gets what they were after anyway and just indicates further that this is a sort of fraud and extortion.
>That's not how any other insurance works. Providers charge the same amount regardless of coverage, insurance, etc. and whatever your insurance covers (including nothing at all) you are responsible for.
This is incorrect. It's absolutely the other way around.
You're talking about something outside of healthcare charging different prices to people based on which insurance they have and said practice is legal? I've never heard of such a thing.
You're not referring to the common practice of bill inflation are you? For example, a tree falls onto your house and the damage is covered by insurance but the contractor knows insurance is paying for it so he jacks up the price once he finds out what you are getting from the insurance company (they tend to ask so that they can "plan" accordingly to stay within budget, but really they just want to make sure to capture the entire insurance check). This is 100% illegal but very hard to prove, hence it goes largely unenforced. With healthcare it's well-documented but still unenforced.
If you are referring to something else I would be very interested to know what else operates in such a manner.
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.
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.
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.
Insurance is regulated by state. You can have insurance in say Texas and visit your doctor in Oklahoma but as a Texas resident you cannot buy Oklahoma insurance. This is why for example there is not one national Obama care market but fifty. And this is also why for example we don’t have uniform compliance with Obama care across all states and why it may cost many billions more in federal aid to help states set up exchanges. If I go any further in the explaination I’m risking being downvoted for making this a political posting (quite honestly I’m pretty happy I haven’t already been downvoted).
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?
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?
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.)
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:
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.
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.
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.
The problem is your incentives breed more bureaucracy and its exactly that bureaucracy that leads to higher costs and a system where nobody knows the price of a procedure. Laws get passed with good intentions, but with bad overall outcomes on the system as you pile on more and more mandates. You have to back off from these requirements and let the market work. Imagine if anyone could get a MRI or a CAT scan or a blood draw anytime just by walking into a small private clinic in a strip mall. No requirements to go through a primary or a specialist, a registered nurse can and should be able to do this with minimal licensing. No insurance company forced to be involved. No over regulation mandating that "thou must do the following". Imagine next if health insurance was like car insurance, with companies blaring ads about how much you could save if you switched to them. No mandates that it must be employer provided. No hospitals being forced by law to fit the bill for the uninsured, thus driving up the cost for the insured.
My point is you need to back off the list of mandated incentives and let the market do its thing. Then, once it appears that things are stable and there is healthy price competition, you can maybe pass a few laws to take care of the edge cases and bad actors.
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.
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.
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.
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.
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.)
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.
> 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.
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.
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 There is an email address in the footer for honest feedback.
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.
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?
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[ 2.0 ms ] story [ 184 ms ] threadThe 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://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.
https://www.thegreenhead.com/imgs/xl/netsmen-wearable-mosqui...
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.
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-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.
Yeah, people avoid care when they have those plans. Is that a good outcome ?
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.
No. The ER and its expensive specialists (e.g. trauma/accident specialists) can be reserved doing their actual specialized jobs (taking care of patients injured in car crashes, for example) without being clogged by some dude with a toothache. The ER only handles the real hardcore cases that can escalate to death in a matter of seconds, and the urgent-care facility only handles the "everyday" harmless stuff, which needs less and especially less-certified/experienced and thus cheaper staff.
Note the article is about reducing health care costs, not patient outcomes. These are usually two separate goals.
> Those behavioral changes resulted in 35% lower health-care spending than when the same employees were enrolled in traditional health insurance. Even better, the study found that employees enrolled in the deductible security plan were going in for mammograms, annual check ups, and other forms or preventive medicine at the same rate as when they were enrolled in traditional insurance. Thus, these cost savings are real and not due to people delaying necessary care in order to hoard their HSA balances.
> 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.
Overall it would plausibly help, but it's a pretty strong claim that these are the only important differences.
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.
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.
In my experience hospitals and surgery centers can't or won't tell you what something will cost up front.
However, a hospital could provide a list of prices that are commonly billed. What a list of prices would do is give you a sense if one hospital costs a lot more than another in general. If you knew you might change which hospital you go to and.. you know markets etc.
Of course it didn't cover every possible contingency... That's what an "estimate" means by definition. But that doesn't mean that it's impossible or even unreasonable to provide a baseline price, along with some of the more common events that can modify that price.
We went through this during a very stressful time when my SO found a lump in her breast, and it took the kindness of a nurse that worked between the doctors and the billing department to give us a possible list to get a ballpark of what to expect. She called us after hours to tell us because she didn't want to get in trouble with her manager.
Once we had that information, we called several hospitals for quotes and ended up being offered 40-70% discounts. It went from thousands to hundreds to ultimately having some of the tests comped... all because we had a little information and asked the right questions about the process.
This is a disgrace and not how you treat people's health.
There absolutely must be, IMO. Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for. IIRC, emergency healthcare spending accounts for around 2% of our annual totals. I just don't think we can justify our full medical pricing system on the basis of emergency care needs alone.
For everything else, though, I'd be much happier if I could just have a price list up front and shop for the provider of my choice. I did it with Lasik, and it was easily the best medical experience I've ever had, not just in terms of "knowing what I'll pay", but the outfit I had it done by was actually competing to win my business. I felt like a customer they wanted to win, not just an account number that they were going to throw at my insurance company.
By means of analogy, we carry car insurance in the case of accidents, but we don't expect car insurance to pay to refill our gas tank (even though gasoline has a lower price elasticity of demand than heathcare!) or pay for oil changes. Food has a lower price elasticity of demand than healthcare, too, but it's still cheap and we don't carry grocery insurance. Insurance makes sense to cover the unforeseen and unexpected. Why do we obfuscate prices and billing practices for routine, elective, and foreseeable care?
"Don't have insurance cover routine care" is obviously insane if pricing were to remain unchanged, but I absolutely think the fundamental problem with the affordability of healthcare in the US isn't the availability (or lack thereof) of insurance, but the way we've completely separated services from prices. Hiding the prices doesn't mean they don't exist and don't get charged - they just eliminate the forces that would otherwise exert downwards price pressure. If we could get pricing transparency on everything, and then see providers start competing on uninsured pricing, I think that could open the door to "actual insurance" plans (at far lower cost than exists today), while actually reducing prices for everything else across the board.
On the one hand, you do really want people to be relatively insensitive to the cost of medical care they actually need. When you need it, you get it. On the other hand, that price insensitivity, applied indiscriminately, leads to the massive ballooning costs we've all seen. I don't think there's a way to have full price insensitivity and to keep prices in check - which means that we either just spend whatever our doctors ask (I'm not interested in that), or we start making people more price-sensitive to allow those downward pricing pressures to be exerted.
Fundamentally, you don't get away with increased price sensitivity without someone yelling about death panels. Prices are how we allocate scarce resources, which means they determine who doesn't get things. We can either pretend prices don't exist (and get the status quo), or we can acknowledge that they do and that sometimes, people can't or won't pay those prices. Neither is emotionally attractive, but I think being realistic about the existence of prices and allowing consumers to actually exert some market pressures is preferable than just being held hostage to whatever the insurers demand we pay this year, just so that we don't have to think about costs at the point of service.
They are solvable, but with regulation, and they will sometimes get an edge case here or there wrong, which will inevitably result in a low-effort, sensationalist news article which will decry the situation, degrade people's support of the systems, and damage the institution.
Maybe I've misunderstood you but how can there be no way to achieve what almost every other country has achieved?
In Singapore, for example, Medisave only covers drugs that the government has deemed cost-effective. Need a high-cost experimental medication? Not permitted. Denmark has notably bad cancer survival rates, much a consequence of long wait times for screenings and treatments. The US, by comparison, has some of the highest cancer survival rates in the developed world, arguably because Americans can (and do) spend on tests and screenings at far higher rates than other countries. IIRC, Americans get medical imaging scans at a rate roughly 100-1000% higher than patients in other first-world nations. Most of those scans don't find anything, and if you're a government bean counter deciding how to allocate this year's medical budget, they're going to be high on the list to cut or ration - but when they find something, those early warnings and immediate access to aggressive (and expensive) treatment make a significant difference.
I bet there's a lot of people who would take this. And it would both save money and make a pretty big difference in the lives of people who still have a lot of life left to live.
Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it.
> Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for.
Wouldn't that discourage preventative care?
Agreed.
> Wouldn't that discourage preventative care?
At the margin, yes. OTOH, paying less in insurance premiums and known/lower costs for services would leave more money for elective care (or whatever else you wanted to spend it on), which would apply pressure in the other direction. Most routine preventative care doesn't have to cost particularly much. Additionally, there's no reason why we couldn't have pooled cost systems for routine care like our existing insurance plans today for those that prefer to amortize their costs, but IMO, they should be separate from emergency care. Emergency care insurance isn't practically optional.
Example if you have a baby and ask for an itemized list you might see something like $49 for chest to chest time with baby... they're fucking charging you to hold your damn baby.
Or $35 for a single ibuprofin for pain. Seriously? 100x markup? I can get a bottle of 100 ibuprofin's for < $10.
Some things should just be free because it's a hospitality industry right? I mean you go into a restaurant and ask for extra napkins they just give them to you. They don't charge $2/napkin. Or at the very least - at cost.
Contracts prohibit them from raising prices on some items, so they shift price increases to other items sometimes in the ridiculous ways you list.
If I had to guess, it's a reference to the joke about turning in your expense report, after being told they won't reimburse you for the umbrella you lost, and so you overstaet expenses enough to cover the umbrella's cost. But that never made sense to me, since they demand receipts anyway...
I completely agree emergency care is one thing insurance is for, but I think more generally it's "catastrophic costs" which often includes ongoing things. A lot of issues require follow up costs (I've heard insurances are switching from itemized costs to a fixed cost for the whole procedure. Similarly, I see a lot more "continuity of care" in healthcare).
As an example, let's say someone had vision loss for a couple minutes. An emergency room visit finds them to be ok in the immediate term, but it was because of a blockage in the heart causing a minor stroke. Which means there's a lot of follow up, with large costs. How do you best incentivize this? It's not "emergency care," there is time to research cost, but putting the cost burden on the patient is more than they can handle (hence insurance). Insurance tries to use cost signals like co-pays. An ongoing cost like dialysis will be optimized around convenience if you don't expose the cost, but exposing the cost may bankrupt them.
I think tying healthcare to employment and pushing it as a benefit is the worst offender for the skewing of the market--masking the cost of routine care. Fixing that alone would make me much happier (I also think it would be an economic benefit because of people tied to their jobs and the drag on starting a small business).
People with chronic diseases aren't subject to an emergency, but they're far more expensive to provide medical services for than otherwise healthy people because they need so much more medical care. Same with people with cancer: cancer is not an emergency in the sense you're describing, but no amount of comparison shopping is going to make cancer treatment affordable for one person. What does make it affordable is that a huge pool of people are paying for it.
setting aside the american/healthcare market with the inflated prices for the sake of the argument, wouldn't be more cost effective, for planned expenses, to go with savings or a loan?
In non-emergency situations where you can do advance planning MRIs are cheap. It all started around 15 years ago when some college professor set up a company a2zimaging I think it was called that sold idle MRI capacity to anyone. I believe he eventually shut it down but there's now several other companies willing to do a full MRI for anywhere from $320 to $1500. Google "cheap mri" and choose one.
If you are brought into a hospital after a car accident and use their scanner without making arrangements, you can end up paying $10-$20k for the exact same scan.
I forget what the primary care costs, although I think it is more than urgent care; I can't get an appointment with my primary care without a couple months of lead time, so it's pretty much moot.
This way, all the money going into the system is actually spent on healthcare, instead of having profit extracted from it. You also get rid of the stress of money from the already bad situations of major disease, and the complex bureaucracy that insurance brings with it.
Edit: tone and some extra details.
Almost no countries have such a model. The closest one is the UK. But the U.K. still rations care aggressively to control costs. (The government uses formulas to decide whether the benefit from a treatment is worth the cost.) In Germany, where the government subsidizes multi-payer insurance, more than 2/3 of hospitals are private. Even in Sweden, which had a system like you’re describing until 1995, more than a quarter of hospitals are private.
Unless you know the average outcomes and standard deviations choosing procedures based on cost is suboptimal.
I've never met a pre-op individual that knew how to properly choose LASIK procedures. They all use price signaling and word of mouth from post-ops.
The same is true for me in medical areas where I do not have expertise.
I think that reducing procedure selection to cost and expecting competition to fix it is an error.
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.
> 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.
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.
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.
Suppose you're in a bicycling accident, you're knocked unconscious, and an ambulance takes you to a hospital that isn't in your insurance network.
Boom. Out-of-network charges.
If your bicycling accident was so bad that you need surgery, a five figure bill is a certainty. A six figure one is rarer -- but absolutely possible.
What's really messed up is that, even if you end up at an in-network HOSPITAL, you might get care from an out-of-network provider.
In this bicycle surgery hypothetical, for instance, your hospital and your surgeon might be in your network - but the anesthesiologist isn't.
Boom. Another out-of-network charge.
(Thats called Surprise Billing, btw)
At median income levels, there's no amount of HSA savings money that can insulate you from costs like that.
The current US insurance system asks consumers to walk an insane tightrope of cost controls.
It's no wonder a lot of us fall.
Yes, and in some states, it's starting to be illegal.
https://www.nytimes.com/2019/09/26/upshot/california-surpris...
Your bicycling example isn't far off though (as someone who had an HSA and was in a bicycling accident). I had a ~$3600 deductible, and that was spent between an ambulance ride, ER visit, blood test, and MRI.
So, at that point, all costs would be on my insurer and I would theoretically no longer care to price discriminate for follow up visits (to get stitches removed)
I still have an HSA, though I make sure I get the lower deductible now.
You just phone the doctor and make an appointment. Stuff happens. Pay for nothing. Ambulance turns up to help you? No payment. 5 days in hospital? No payment. Major surgery? No payment.
15 years ago, I went to the doctor with a back pain, turned out it was an pilonidal abscess, got told not to eat anything, sent directly to hospital, surgery next morning, next 2 days in hospital, then nurse came round to my house once a week for the next 8 weeks to change the dressings. I paid? Nothing. No-one even mentioned cost. I filled in no forms. It just happened.
Only thing we have to pay for is prescriptions, a fixed fee regardless of the drug of £9 ($12). And only people who can afford it, people like pensioners and people on benefit get prescriptions free. Oh, and a fairly small charge for dental checkups (£40 every 6/12 months) and if you want non-standard dental work (you used to have to pay for white fillings, otherwise you got the cheaper amalgam ones, but now you can get either I believe).
They'll usually tell you if it's a lot cheaper to buy for prescriptions yourself, i.e. if they reckon simple painkillers is the best thing, the doctor will tell you to go buy £0.40 paracetamol from the supermarket, instead of giving a prescription for the same drug at £9.
https://www.medscape.com/slideshow/uk-doctors-salary-report-...
https://www.medscape.com/slideshow/2019-compensation-overvie...
Different countries, different pays.
TBH, if you feel doctor pay is somehow too expensive in the US, you're probably thinking about the wrong thing.
I would confidently expect the profits all your health insurance companies dwarf the difference in doctor salaries (an activity which is economically and socially worthless rent-seeking), let alone the salaries of all the utterly pointless health insurance company employees.
There’s no way to attack this problem than to lower the costs. And that means lower pay. Insurance companies have 20% margins at most, by law. Their activity is not socially worthless. The NHS performs the same activity as insurance companies, but US voters don’t want the government to do that.
A lot of countries have universal healthcare and, shock, horror, it is cheaper per capita.
A lot of countries have strict gun laws and, shock, horror, they don't have mass killings.
But no, you're American, of course you're way is right because, um? You say so! You've have some compelling "arguments", despite all the evidence.
It would be funny if it wasn't causing so many preventable deaths, both from a lack of affordable healthcare, and mass murder sprees.
I never mentioned the US way is the right way, I actually think taxpayer funded healthcare is the way to go if we are going to force hospitals to provide care to anyone that shows up at their doors.
There is a lot of overhead from insurance companies that isn’t needed IF the US had taxpayer funded healthcare, but there isn’t, so they do serve a purpose of vetting a provider’s care and negotiating pricing.
Doctors can charge high prices because they have low supply and high demand for their services.
No one is stopping a doctor from offering their services at $25 or even $50 per 30 min consultations. If doctor A was offering their services for X + e to insurance just to get X, and doctor B was offering their service for Y, and Y is less than X, then insurance would still go with doctor B even though there was no “e”.
Insurance companies solve the issue of a buyer having no knowledge about what they are buying since they also employ doctors to check others’ work, and to negotiate pricing as a group. Some countries don’t need this since the buyer is the government, but the government is still performing the same functions of negotiating prices and verifying doctors’ work.
While I agree the HSA is an ineffective solution, what you're describing isn't accurate.
The HSA savings segment is not for major medical expenses. The savings portion is for minor medical expenses. The HSA savings account is paired with a high-deductible insurance policy that covers major medical expenses.
The minimum deductible for an individual is $1,350.
So, yeah, one problem is that an ambulance + ER visit will blow through any person's deductible quite easily.
https://mobile.twitter.com/p_millerd/status/1118071142311288...
The survey design, reduced to a trivial example:
Select all that apply
- A: 100% select - B: 50% select - C: 12% select
Suppose there were 100 people. There is no way to imagine overlap that leads to more than 12 people selecting C, as you claim.
You can move HSA funds to an HSA at Fidelity and put it in FSKAX or FZROX at no fee.
If you have enough cash to afford the deductible, you should always go for HSA as you can earn the tax free investment returns on the HSA funds.
A gold non HSA and gold HSA both are designed for the insured to pay 20% and insurance company to pay 80%, but the HSA will let you invest $3,550/$7,100 single/family, and that can add up over the years.
If you started it around 10 years ago, you could realistically have over $100k in the HSA for family plans.
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.
"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?
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.
The idea that having insurance changes the cost is sort of a misdirection. There's a chance my plan doesn't cover some or all of things that will be billed. So there is always a risk of non-payment or partial payment. Yes, they sometimes do pre-approvals for specific procedures but that doesn't always translate to proper billing/coding that gets covered.
The vast majority of healthcare are not ER visits which means people have a chance to review and accept the responsibility of payment. But that would also mean they would know what the hell they would be charged. There's no good reason for a hospital to say "oh you don't have insurance so we're going to basically mark your bill up 3x just to be safe. Marking the bill up 3x, for example, doesn't change the fact that they are really only seeking 1x so the people who can afford to pay 3x are legally required to do so because for some reason this is viewed as a legit practice and not fraud. And the people that can't settle for something less than 3x, usually much less. Maybe 1x...in which case the providers gets what they were after anyway and just indicates further that this is a sort of fraud and extortion.
This is incorrect. It's absolutely the other way around.
You're not referring to the common practice of bill inflation are you? For example, a tree falls onto your house and the damage is covered by insurance but the contractor knows insurance is paying for it so he jacks up the price once he finds out what you are getting from the insurance company (they tend to ask so that they can "plan" accordingly to stay within budget, but really they just want to make sure to capture the entire insurance check). This is 100% illegal but very hard to prove, hence it goes largely unenforced. With healthcare it's well-documented but still unenforced.
If you are referring to something else I would be very interested to know what else operates in such a manner.
For example, they've already started mandating drug pricing transparency in advertising: https://www.nytimes.com/2019/06/14/health/drug-prices-tv-ads..., but are being opposed by industry groups obviously.
E.g. on one of my old plans I got a $300 visa gift card just for going to a checkup.
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.
Is there anything preventing people from buying plans across state lines other than the insurance companies themselves?
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.
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?
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/?c...
[1] https://www.nber.org/papers/w3557
https://en.wikipedia.org/wiki/Healthcare_in_Singapore
http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf
https://www.vox.com/policy-and-politics/2017/4/25/15356118/s...
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/...
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.
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.
My point is you need to back off the list of mandated incentives and let the market do its thing. Then, once it appears that things are stable and there is healthy price competition, you can maybe pass a few laws to take care of the edge cases and bad actors.
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.
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.
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.
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.)
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.
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.
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.
(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 There is an email address in the footer for honest feedback.
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.
Is there any other example of an industry that operates like that?