[bryan11]

As employers switch to High Deductible Health Plans where insurance doesn't kick in until one has spent a deductible of several thousand dollars, many people are delaying health care in general. A doctor's visit that once cost a co-pay of $30 is now frequently a cash price from $130 to $400, plus more for lab work. With higher costs and much of them unknown in advance, many skip getting things checked until it seems absolutely necessary.

[peteradio]

I paid 400 dollars to have a doctor tell me to neti pot my nose after having sinus infection for 3 months. Might not be rational but fuck everything about this system. Who is pocketing all this goddamn money?

[brudgers]

Through no fault of the author, this comment thread explains the trick. The article talks about US health care access but the discussion quickly goes off into the weeds of the US health insurance market. As soon as we start talking about premiums we adopt business language and metrics and abandon medical language and metrics.

All that money is pocketed by businesses run for profit. It's pocketed because it can be. It can be because untreated a sinus infection can kill you. Not a bad business to be in by the standards of business.

[heisenbit]

Exactly. German perspective here: I pay for my public health care quite a lot. Probably around $10.000 a year pre-tax which is half coming from my employer and half out of my pocket. My wife is having a private insurance and is paying a little less. That is ok, even if I don't think her option should exist and the overall system is only working due to the gating for the private option. I'm earning above average and am paying for some who earn less. Any public option that covers a large population section needs to include some redistribution aspects. Because health care is too expensive for people on lower incomes.

But it does not need to be as expensive as in the US i.e. twice as expensive as anywhere else and no better outcomes. Insurance companies are not the party that is benefiting the most. They make money and probably more than they should but this does not explain the difference. Most doctors are also not swimming in money. So where does it go?

One is Pharma companies who are then using that money to do marketing. So Pharma Marketing gets a share including doctors taking money from that source (another whole can of worms).

Larger hospital organizations and their management as one of the stronger buyers of services being able to push for high rates and low salaries.

Bill adjusters, debt collectors, partly working in insurance companies (where they contribute to insurance cost) to deal with the chaotic billing, payments and non-payments.

There are many, many who earn a good living who would not be able to get similar jobs in other advanced countries as these jobs simply do not exist. The US system is inefficient but there are powerful incentives for many to keep it going.

It is really important to separate access from payment. Otherwise small wounds will fester until it is too late or really expensive. A good compromise imho. is having some small access fee (in Germany we had a once per quarter 10 Euro fee on top of a 5€ per prescription fee. That was too much for low income and too much paperwork and the former was scrapped) as we know there is a huge difference between demand for free services and services that cost $0.01.

[AnthonyMouse]

> As soon as we start talking about premiums we adopt business language and metrics and abandon medical language and metrics.

To provide healthcare you need doctors, who need money to pay rent and student loans. You need an office to put the doctors in. You need drugs and medical devices, and researchers to come up with them. You need lawyers to keep the doctors from conducting the Tuskegee Experiment. And nurses and lab techs and janitors etc.

That is all business stuff. Paying employees and managing offices etc. If you don't pay the employees enough then they get another job and quality of care suffers. If you pay them too much then costs get out of hand.

The way you determine how much is the right amount is by letting people choose how much to pay for it. If you have a runny nose and the doctor wants ten million dollars to see you for five minutes, you blow them off as unreasonable and get a different doctor. If you demand to see them for $10 and that isn't enough to cover their costs, they blow you off as unreasonable and get a different patient. Somewhere in the middle there is a price above what it costs and below what it's worth where you neither die of a sinus infection nor sell your first born to have it cured.

There are a lot of reasons this works poorly in the US. Low deductible employer-provided health plans making consumers price insensitive, lack of price transparency, an excessively burdensome FDA approval process that impairs competition between pharma companies, etc. But those are specific failings that could be addressed.

Switching to central planning just adds a new problem without solving the existing ones. If consumers pay nothing, not even actual cost, there is even less incentive to forego unnecessary procedures. Setting prices by committee is a sure way to either overpay (and waste money) or underpay (and get supply shortages). If drug companies still set prices then costs remain high, but if they can't charge the prices they do and still have to go through the same very expensive approval process, you stop getting new drugs. And then you add another trillion tax dollars to the budget which every campaign donor in the country will have a chance to divert a chunk of away from actual medicine and into their own pockets.

> All that money is pocketed by businesses run for profit.

The significant majority of that money typically goes to employees, not shareholders. The costs are too high, but it's not because the average medical practice is turning a huge profit, it's because the existing regulatory environment causes providing medicine to be unnecessarily labor intensive (i.e. inefficient).

[Blackstone4]

The US has by far the highest pharma/biotech drug prices in the world. They are effectively paying for global R&D. Other countries use collective bargaining and government regulation to negotiate price. If I'm correct this is illegal in the US.

In the UK for instance, we do not have access to the best drugs because they are too expensive.

A large part of US insurance expenditure goes to pharma...

[heisenbit]

They are not paying for R&D but they are paying for drug pushers and doctors bribes. Seriously, the marketing budget exceeds the R&D budget.

[AnthonyMouse]

They are paying for R&D and marketing. Even if you subtract out the difference in marketing budgets, the US is still paying for a disproportionate share of the R&D.

Moreover, ban drug marketing if you like, but keep in mind two things. One, the marketing is primarily so "worthwhile" because of the price insensitivity. Patient requests equivalent but better-advertised drug even if it costs $75,000 more dollars, when they're not the one paying. So fix that and the marketing budgets drop along with drug prices. Two, marketing increases the number of "customers" by more than the cost of the marketing (or why do it?), and the extra money is what both encourages and pays for more R&D.

[brudgers]

And yet, here we are talking about business instead of health.

[AnthonyMouse]

Because it's a business problem. The problem isn't that doctors don't know what to prescribe when you have an infection, it's that healthcare is so expensive that people can't afford it.

[brudgers]

The problem is that people don't get healthcare. Price is just the rationalization for denying it.

[asdf333]

if a law was passed requiring procedures to advertise the price like restaurants, it would solve most of the pricing issue. insurance systems obscure the price so the system doesn’t work.

[LifeLiverTransp]

Because its a scam to extract the maximum amount of wealth from people with no real choice options out. And the ilusion, that in this stick-up of scenarios, the individual is to be able to engage in a free-market decision.

[AnthonyMouse]

If you have some cold symptoms, you can't call around to find a doctor who will diagnose it for a reasonable price, because they won't give you one.

But that's not a stick up, it's a lack of price transparency. So how about we get a price transparency law?

The "stick up" scenario is limited to emergency care, and there is an argument that emergency services should be provided by the city for that reason. But most healthcare is not emergency services, nor would having your city do that require any kind of national policy -- you can go implement that right now.

It's the exact thing that works perfectly at the local level, because the stick up scenario itself is what prevents arbitrage. People in Houston can't vote to cut local emergency services and then go to the emergency room in Boston when they have a heart attack, because it's too far away.

[ikeyany]

You neglect to bring up culpability of insurance companies.

[tomjen3]

But so is food, and while I probably won't die in the next 6 months from lack of medical attention, if the groceries shut down I would.

Yet the US medical system is a giant clusterfuck of burned money, and the US food system can provide food at some of the lowest prices in the developed world. US chicken is half what I have to pay in Europe.

[apexalpha]

That is a choice regarding animal welfare and food standards, though. Not because the EU doesn't know how to produce chickens efficiently.

[samirillian]

You make it sound like the business isn't run by humans. Do you consider price gouging sick people and ethical business to get into? If not, please make that a bit more clear in your comment.

[joering2]

Being run by humans doesn't mean there is empathy built-in; to the contrary because its run by masses of humans, its out of touch with reality and majority of involved will tell you someone else makes final decision, while the rest will simply follow others. Its as numb as long hand of government can be. They don't see human patients with names and families, they same charts and graphs with numbers and profit/loss cells combined.

Its not ethical business but ethics doesn't matter much these days (devil's advocate here); heck one can argue even legality doesn't matter, as for example Wells Fargo has been getting away with daylight theft that would put a single person in prison for one million years.

[samirillian]

So we have a problem:

1. assume businesses cannot be ethical. 2. so, telling a business to be ethical is pointless 3. to encourage prosocial behavior amongst businesses, they must, therefore, be regulated 4. but, since businesses cannot be ethical, they can use their power to control regulation

how to stop this hellscape? is it possible that assuming businesses cannot possibly act ethically was a lie spread by said companies?

tldr; then what's the solution, assuming regulatory capture is a thing?

[war1025]

I just paid $1436 because we took our 1 year old son in when he had a stomach bug and they decided they needed to keep him for 24 hours for observation after giving him an IV to re-hydrate him. Glad he's okay, but if I knew we would be out $1500, I don't know that we would have taken him in.

[asdf333]

this exactly. we need to change the system so prices are up front and something you can look up on the internet just like restaurant menus

[colechristensen]

Malpractice lawyers and insurance, administrative juggling of data and insurance claims, medical equipment manufactures and certification, doctors (by proxy medical schools and loan providers), practices recovering unpaid bills, and real estate owners.

[sexyflanders]

Not to mention pharmaceutical companies charging astronomical prices for prescription meds.

[mattigames]

Does it matter who? They charge you because they can, America decided your survival (AKA health) is just another business an you can be charged as much as you are willing to pay for it; and those companies -with the help of cultural baggage- have convinced a significant chunk of the population that this shady business is part of the "freedoms" you have as American, because controlling the prices would be "communism" or "socialism", words we all were taught to associate with evilness and enemies.

[bequanna]

The armies of administrative workers:

1. https://www.advisory.com/daily-briefing/2018/07/23/administr...

2. https://www.athenahealth.com/insight/expert-forum-rise-and-r...

[usaar333]

> many skip getting things checked until it seems absolutely necessary

True, but isn't that the entire point of hdhps, to minimize unnecessary visits?

They still provide no additional cost annual physicals, so you'll get the required yearly screening.

Additionally, many offices have no cost phone or email advice.

I'm personally quite happy with my family HDHP - and it is nice to have additional retirement savings.

But you have to have a savings mindset; many people don't which is what leads to medical spending increases when a refund comes in.

[JonGarfield]

Just because something is minor does not mean it isn't urgent or best tended to sooner rather than later. Strangely enough, those of us with universal health care don't make it a hobby to go to the doctor's office because it is "free" at point of use. We only go when necessary, we just don't have to weigh the possible trade off of food, shelter or savings in the equation that turns minor, easily treated conditions into major, life threatening ones.

[rootusrootus]

> They still provide no additional cost annual physicals, so you'll get the required yearly screening.

Well, until you find out that you can only get the physical for free, and physicals are really not worth much. If you discuss anything at all with your doctor that is outside a routine physical, ask any questions, get any advice, and he codes it when he submits the bill -- it won't be free at all, it'll cost you a couple hundred bucks. So there is incentive not to bother.

[usaar333]

If that happens, honestly it is time to get a different doctor. :) Good primary care doctors should be incentivized not to do that as it is a great way to churn patients.

[rootusrootus]

That is a good point. My current doctor hasn't yet done this to me. Past doctors for sure, but my current GP is pretty laid back.

[stevenwoo]

The co-pay was $10 for me in 1989. I had outpatient arthroscopic knee surgery in 1993 and it cost me nothing including X-Rays/MRI/CAT scan (the ortho was having trouble diagnosing it). All the pricing stories I hear today scare the heck out of me.

[JumpCrisscross]

> High Deductible Health Plans where insurance doesn't kick in until one has spent a deductible of several thousand dollars

HDHPs are a great deal for anyone who can set aside the deductible’s value in cash. They are a bad default. But a good thing to consider if you can set aside some cash.

(The problem with HSA-compatible plans is they have a maximum deductible. They’re thus almost as expensive as non-HDHP plans.)

[maxxxxx]

There is definitely a psychological problem. When I had a high deductible plan I always set the max aside but considering the potential cost of a doctors visit I often hesitated. 1000 dollars is still 1000 dollars even if you have set them aside beforehand.

[mgkimsal]

why is it a problem to have a maximum deductible?

Relatedly, it seems like there's roughly some 'max' insurance expects you to pay each year, and you can decide whether to take the risk using a high deductible plan, and potentially not have many expenses, but lower premium, or have higher premium up front.

8 years ago, our HDHP was ... $280/month. It's now north of $800, and the deductible went up. Yes, we're a bit older, too but it's still a bit crazy.

$280/month, with high deductible, meant that, in a bad year, we might have $15k in expenses before the insurance covered everything else. Now, it's more like $10k per year in premiums, and another $10k+ before insurance really would kick in. Catastrophic need? It's fine - I don't want to have to face a $400k bill. Day to day? This stinks.

[learc83]

8 years ago insurance was allowed to have yearly and lifetime policy limits. They could deny coverage for preexisting conditions and increase your premiums if you developed new conditions. You were also 8 years younger, which makes a big difference despite being only a few years.

Many people had policies with $100k yearly limits, any serious condition and they basically didn't have insurance.

[rootusrootus]

And these are the folks who complain now that they weren't allowed to keep their plan. So many people had (and have) no idea that they had basically no real coverage, just a policy that looked good on paper.

[JumpCrisscross]

> why is it a problem to have a maximum deductible?

Because it means I get to choose between $500 a month with a $6,500 deductible, and HSA-compatibility, and $150 a month with a $8,000 deductible. The latter is a better fit for my risk profile.

[mgkimsal]

those are just deductibles - i didn't understand what "maximum deductible" meant in that context.

Unfortunately, my experience, at least in my state, is such that none of the premium options are remotely affordable now. $2000/month with a $1000 deductible per year, or $1300/month with an $11000 deductible. Neither of these are anywhere near 'affordable' in my book.

[exabrial]

Actually I find that with my high ductable Health Plan, my visits did not change price. And you failed to mention how you get to save/grow/spend your money tax free. I made 12% on my HSA last great and didn't pay a dime of tax.

[usaar333]

A lot of folks are in California on this board which hurts the investment case for HSAs (state taxes investment and contributions). New Jersey similarly doesn't recognize HSAs.

[chaosbutters314]

I'm even researching medical tourism. The unknown financial risks are too high

[derblitzmann]

And if I am wrong please correct me, but I recall high deductible health insurance became more common/prominent since "obamacare". Which i viewed as at best a half measure at the time.