[Lagged2Death]

You can price shop if you put a great deal of effort into it.

I'm glad this worked out for you, but if one is visiting the doctor because of some symptoms, rather than visiting a technician to have a specific, prescribed, and highly standardized service (like an MRI) performed, I'm sure you'd agree that situation is different.

It's simply not in the nature of medical care to have price-tags (although the situation could certainly be better that what we have in the US today).

I'd argue this is the case with all sorts of expertise-based services, actually - auto mechanics, lawyers, consultancies of all kinds, etc. You can't know how much a visit to your lawyer will cost unless you know exactly what you need - but much of the time you don't know what you need. You're visiting the lawyer so he can figure out what you need.

Yet every time I see an article that involves economists pondering medical care costs, this fundamental uncertainty (at the personal level) is just elided, as if the economists never thought of that. As if they never actually deal with the health care system themselves.

[aggieben]

Lawyers, accountants, and mechanics all have to provide estimates to a client precisely for this reason. I see no reason why medical practitioners should be any different.

As an anecdote, I have found that price comparisons are perfectly feasible in a non-emergency situation. My son broke his arm, and instead of just driving to the nearest emergency room, I called around to a handful of urgent-care clinics and found one that was able to quote me some prices that were reasonable, so we went there to get him treated. Easy.

In any case, I think the ACA is a train wreck, piling on more of the crap that makes our system suck: the disconnect between consumer and producer. If we ever want to make our healthcare market sane, we will have to largely cut out the middleman ("insurance"), and the only way to do that is have patients pay for their own care (particularly routine care).

[kaitai]

How long were you on hold while your kid was clutching his arm?

On the one hand, on the other hand. Many people are not good at judging what is an emergency and what isn't when it comes to health care, especially since vast swathes of the public no longer have more than rudimentary home health-care skills. So breaking your arm -- emergency or not? Concussion -- emergency or not? Falling out of a tree or off a ladder and having lots of bleeding, but not sure what happened -- emergency or not? Chest pain -- emergency or not? And what if you're the one sick? Say you've got what you think is a gallstone and you're in a lot of pain. How do you shop around? How can you evaluate for yourself how long it is ok to wait, and how do you deal with it when you go to see the cheaper internist for an evaluation but want the surgery done at the cheaper surgery but the internist looks at you and says, "Holy )(&! you're going in now" and they take you to the expensive surgery? And then how do you make sure some specialist doesn't visit you while you are unconscious and then charge for that "consultation"?

A fun read with respect to the last question is on pregnancy in the US [1].

I agree with you in many ways -- it would be reasonable to give estimates, the ACA is insurance "reform" rather than health care reform, insurance is not health care. One big problem is that if your car doesn't work you can put off repairing it for a bit until you find a decent mechanic, but when you get acutely ill you can't put off care. (Well, you can try, but it just costs more later unless you die quickly.)

[1] http://www.nytimes.com/2013/07/01/health/american-way-of-bir...

[aggieben]

> How long were you on hold while your kid was clutching his arm?

None at all. Possibly less time than I would have spent with a 911 operator asking me my address and whatnot.

> Many people are not good at judging what is an emergency

Perhaps, but I think in the main emergency care is an outlier in relative terms. I have no citation for you, but I just can't imagine that emergency care (i.e., you don't have time to make decisions about who to see, etc) is a very large proportion of healthcare dollars spent (and is also where insurance can actually make sense).

I think the goal should be to optimize the system for non-emergency care by making it a consumer-oriented market. As long as third parties are spending most of the money it can't be that, and until we have price transparency, the control of expenditures can never be with the patient.

[karmajunkie]

There's a law called The Funeral Rule[1] that, among other things, requires that funeral homes provide a General Price List and quote prices over the phone without the consumer being required to give contact information.

The equivalent is sorely needed in healthcare. One of my biggest (indeed, one of my only major) complaints about the ACA is that neither the GOP nor Democrats saw fit to make any moves towards requiring pricing transparency in the law. Its a travesty. This is a free-market reform that would have completely on its own transformed the economics of the industry, even for consumers that couldn't do the research under acute circumstances.

Even without that, the ACA is far from a trainwreck. I'm guessing you didn't have to spend a lot of time dealing with procurement of individual policies prior to the ACA. I did, and its a godsend.

[1] http://www.consumer.ftc.gov/articles/0300-ftc-funeral-rule

[aggieben]

> I'm guessing you didn't have to spend a lot of time dealing with procurement of individual policies prior to the ACA. I did, and its a godsend.

A lot? I guess not, but I did shop for individual (+family) insurance plans before the ACA, and I much prefer the before to the after. I absolutely despise the stupid metal-color tiers, in which every single plan is a cookie cutter of another within the same tier. Nevermind that plans that before ACA could be obtained relatively cheaply are now quite a lot more expensive - in some cases, more than double. So there is far less consumer choice, and everything is more expensive. If that's not a trainwreck, I don't know what is.

P.S. - I 100% agree about price transparency. I'm ambivalent whether the way to accomplish it is through a regulatory rule.

[karmajunkie]

Well, I did it a lot, every 12-18 months for about ten years before the ACA, and between trying to find out if a given plan actually covered something like maternity care (and under what circumstances), trying to gather and provide medical records for as much as ten years prior to initiation of coverage, and dealing with the first attempt to get a claim covered (when invariably the company in question would start making attempts to claim a condition was preexisting), there is absolutely no doubt in my mind that what we have now, while imperfect, is absolutely better than pre-ACA.

[candu]

Or we could, you know, follow the rest of the developed world and nationalize healthcare.

[aggieben]

Right, and we'd just be headed over a cliff like the rest of them. Nationalized healthcare is a disaster economically and in patient outcomes, not to mention patient and physician autonomy.

[jjoonathan]

> Nationalized healthcare is a disaster economically

If this is what an economic disaster looks like, where do I sign up?

https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

> and in patient outcomes

Back when I was taking a health care policy class and actually digging up these stats on a semi-regular basis, I typically saw the US in the middle of the OECD 20 pack. PDF page 46 of this report, for instance:

http://www.rand.org/content/dam/rand/pubs/technical_reports/...

Exceptions: we do really well at treating breast cancer and diabetes. But sometimes we're at the bottom of the pack, too. Overall it's a wash.

> patient and physician autonomy

Like the freedom to go to any hospital in the country and know that it will be covered? The freedom to know that calling the ambulance won't cost you $12,000 which is somehow not covered by your plan? Or the freedom to have a claims adjuster who isn't financially incentivized against you? What about the freedom to spend half of the money you are forced to spend on our continued experiment with private health care? There are many kinds of freedom not provided by choosing between megacorp A and suspiciously similar megacorp B.

[dragonwriter]

> Nationalized healthcare is a disaster economically and in patient outcomes

In the rest of the developed world, universal healthcare (both nationalized and on other models) is consistently cheaper (per capita and per GDP) than the US system, and produces overall comparable to better outcomes than the US system. So, if it is fair to say that "nationalized healthcare is a disaster economically and in patient outcomes", it is only in a sense where nationalized healthcare is still significantly less of a disaster in those areas than the US system is.

[maxxxxx]

The US has by far the most expensive health system as percentage of GDP and I haven't seen any statistics that show that the outcomes are superior. In some areas outcomes are very good, in other areas not so much.

One place where health care is an economic disaster is the US.

[Gibbon1]

That is because economists are either academics or work for large blue chip companies and have gold plated health insurance policies. They actually never have to deal with this on a personal level.