[TuringNYC]

The problems are so vast it is difficult to even describe to outsiders. For example, if I purchase a particular medication at a local pharmacy, it costs $25. However, my insurer mandates that I purchase it via their Pharmacy Benefit Managers (PBM) Optum, which charges $125. Easy enough right, you price shop? Well then it doesnt count towards your deductible. The whole thing is an elaborate trap to not pay.

Sometimes it is easier to just pay cash without insurance altogether. You need the medication today and dont have two weeks to fight it out with letters and forms, then it definitely doesnt count towards your deductible (and also, what is the purpose of the pharmacy coverage insurance?)

[cmiles8]

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers.

When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, they’re just cutting out all the middleware bloat and selling you the meds at a defensible markup plus their logistics costs. Love what these guys are doing.

The fact that something like that even exists highlights how corrupt and broken the health insurance companies have become. It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse that Joe Blogs off the street can get with cash.

In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion, but the US’s challenges are all rooted in massive administrative overhead. If we got rid of that and had a lean system where healthcare providers can do their job without interference there would be plenty of money to go around for amazing care at lower cost.

[anon7000]

> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse

Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible

[nsvd2]

In no way shape or form is the medical industry in the US a free market, it's one of the most heavily regulated sectors in the economy. Remember when the government wanted to make purchasing health insurance mandatory? Forcing employers to pay for their employees health insurance greatly distorts the market. And many other things...

By the way, as much as people complain about the profit seeking motives of insurers, many of them have been performing abmysally in the last six months. As it turns out, our current system is bad for just about everyone.

[ciupicri]

In Romania the employer takes a cut from the employee's salary and gives it to a government agency for the health insurance (some thing with income tax, social security (pension), etc). I think this is happening in other European countries as well.

Some employers also offer as a bonus a sort of subscription at a private clinic, so you can see a private doctor or have an operation for a lower price or even for free.

[simonh]

Same in the UK.

In the USA the government health programs for people in low incomes, children and pensioners cost about as much as a typical European single payer health system. Then tax payers get to pay to be gouged by health insurance companies to get any cover for themselves.

[rectang]

> In no way shape or form is the medical industry in the US a free market, it's one of the most heavily regulated sectors in the economy.

If any regulation at all makes a market not "free", then there are no free markets as soon as we have any laws.

Like all free markets, this one is regulated. There are degrees of freedom.

[shaftoe]

In this market, neither the producer nor the consumer are responding to price signals and often neither knows what anything costs. The Payer (literal healthcare industry terminology) does but isn't producing nor consuming the service.

This is why this isn't a free market. It's not about regulation, it's about the system being divorced from responding to market dynamics.

[alistairSH]

There are degrees of freedom, but within the American framework, medical care is on the less-free end of the spectrum.

Aside all the insurance stuff, you cannot open an MRI imaging lab or similar without a letter of need from the local government. The supply side is quite literally gated by existing players in the market (via campaign bribes and similar).

[nickff]

Just to tack on, dentistry is an example of a somewhat freer market than 'healthcare', and veterinary care is an example of an even freer (though somewhat different) medical service.

[FireBeyond]

And pharmacy vertical integration is an easy way for them to get around regulated profit margins. While if your profits are capped at 15%, the only way to increase them is to increase premiums as a result of increasing providers costs (which the insurers can and absolutely are doing, of course), if you own the pharmacy supply chain, you have freer reign to increase those prices.

Healthcare is one where vertical integration can be really profitable, even at the smaller scale. I used to work as a paramedic, both local agencies and private. The private ambulance company I worked for started when a man who owned a nursing home realized how much money the facility was paying for ambulance transports, so he started an ambulance company. He realized how much his ambulance company was paying to industrial/medical gas companies for oxygen, so he started a medical gas company. And so on. And went from his one small nursing home to his daughter having a $100M empire by the time he died 30 years later.

[ethbr1]

> The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible

For-profit health insurance. Which imho should be illegal.

A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by:

1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too)

2. Tying financial incentives and disincentives to outcome-based KPIs

[LorenPechtel]

Big problem here: You get more KPI, not better outcomes. Things like no doctor being willing to risk working a high risk patient.

We have already seen it with things like Medicare Advantage plans doing sign-up meetings on the second floor of buildings without elevators etc.

[rexroad]

Fair point about KPI gaming, and it's a real problem in value-based care. But the fix in Issue #3 (commercial reference pricing at 200% of Medicare) is a price cap, not a quality incentive structure, so it doesn't directly create the risk-avoidance problem you're describing.

Montana Medicaid has used 200% Medicare reference pricing since 2015. Published evaluations haven't shown measurable quality deterioration or patient-selection effects in that program. The RAND Round 5.1 study underlying the savings estimate controlled for case mix, so it's comparing equivalent procedures at equivalent acuity. Risk adjustment is still genuinely hard at the individual level, and the concern is well-founded for P4P schemes. It's a separate question from whether commercial payers should pay 254% of Medicare rates for the same surgery at the same hospital.

[ethbr1]

Medicare Advantage is a clusterfuck from start to finish (denying more claims than Medicare while also costing taxpayers more), precisely because it tries to micro-manage KPIs.

If you want to look at them done correctly, look at the FEP program. High-level KPIs that are difficult to game (without actually improving service & outcomes) tied to financial incentivizes.

[alistairSH]

Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?

[evandijk70]

It doesn't.

The Netherlands has a system with both not-for-profit and for-profit insurers, that works reasonably well.

- Transparent, identical rules for minimum coverage and strict rules on minimum and maximum deductible for all insurers and insurees. - Mandatory coverage for everyone (just like liability insurance is mandatory for cars in the US) - Insurers do not have the right to refuse any applicants based on pre-existing conditions - Insurers directly negotiate with hospitals on rates. Emergency care has to be covered regardless of whether hospitals are in network or not.

[rexroad]

The Dutch model is a useful counterexample to the argument that you need a single-payer structure to contain costs. Netherlands uses regulated private insurers with community rating and risk equalization, yet achieves per-capita spending well below the US (roughly $7,200 vs. $14,570 in 2023 OECD data). The direct insurer-hospital negotiation you describe is also how Germany's sickness funds operate.

The US equivalent would be all-payer rate setting. Maryland has run a statewide all-payer hospital rate system since 1977 with documented cost containment. Issue #3 of this series focuses on a lighter-weight near-term version: capping commercial hospital payments at 200% of Medicare (already used by Montana Medicaid and thousands of self-insured employers). The Dutch model shows a stronger structural fix is feasible. The question is political path, not technical feasibility.

[throw0101c]

> Does "not for profit" actually solve anything?

Ask the Swiss and/or Germans? AIUI there are (aspects of) their health insurance that are mandated to be non-profit.

Perhaps someone from one of those countries can give more details.

(IIRC, the Swiss only 'recently' moved to universal coverage: in the 1990s?)

[ethbr1]

In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al.

Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit).

And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}.

Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?

[adrianN]

Human well-being should reduce medical expenses, so at least in theory it should be a goal of insurance companies.

[Turskarama]

> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion

How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.

[youknownothing]

As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK.

Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault.

The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.

[nicoburns]

I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for less private finance).

[eitally]

I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.

[nicoburns]

Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone.

I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on whether you can pay). Except for some particularly expensive treatments (think CAR-T for cancer) which are not available at all in the state funded system. But you can still pay for those privately if you want to.

[gopher_space]

> With state funded healthcare you get rigid rulebooks and policies.

We could just not do that. If you change the flow of control certain problems solve themselves. Think about a landscape where government funding multiplies the patient dollar, for example.

[LorenPechtel]

The problem is that it always happens. There's no such thing as comparable funding.

[gnz11]

I'm sure there is a lot of nuance but long term healthcare outcomes are generally lower in the US compared to other countries. https://www.healthsystemtracker.org/chart-collection/quality...

[alistairSH]

Personal anecdote... My uncle is an auto mechanic in Scotland (Scottish NHS) and my brother-in-law is an auto mechanic in WV, USA.

Both have similar health care outcomes - they have ready access to quality care, specialists, etc. ER/A&E is available. The biggest difference is the perceived cost and stress incurred by that cost. My uncle doesn't give much thought to health care - he can work, retire, whatever and be assured a reasonable level of care. My BIL will work to 65 or beyond, fighting red-tape the entire time, then retire and still have to deal with supplemental programs.

Looking at another uncle, who was a small business owner in Scotland vs my father (also small business owner), it's similar to above, just with more money at stake. Uncle also purchased additional insurance on top of NHS for faster access to selective care, still cost less than insurance in the US, even after accounting for tax differences.

American's kid themselves when they say the Western Europe has higher taxes. Once you account for medical care, college funding, and other similar things, it's pretty close.

[rexroad]

The RAND Round 5.1 study (2023) puts US commercial insurer payments at 254% of Medicare rates for identical procedures. That's the mechanism behind the international gaps — it's not complexity or quality, it's that commercial insurers negotiate against chargemaster list prices rather than against cost. The HCRIS cost-to-charge analysis (3,193 hospitals, FY2023) puts median markup at 2.6x actual costs.

[bandofthehawk]

I think this difference mostly disappears if you group Americans by wealth. So wealthy Americans have similar life expectancies to those in other countries. It's really the poor that are most affected by our dystopian healthcare system, which is probably a big part of why it never gets fixed.

[rexroad]

The obesity adjustment is worth quantifying. US adult obesity: 42% (CDC). UK: 28%, Australia: 31%, Germany: 22%. Those gaps are real, but they don't explain a 2.5x per-capita spending differential. The Commonwealth Fund's 2021 analysis controlled for age, income, and chronic condition burden; the US still spent roughly $5,000 more per capita than the next-highest spender (Switzerland).

Obesity also matters less than assumed in hospital pricing: a hip replacement costs $29,000 commercially in the US regardless of patient BMI, vs. $15,000 in Germany and $9,000 in Spain (iFHP 2024). The cost structure is in the pricing system. Johns Hopkins researchers estimated eliminating US obesity would reduce healthcare spending by about 12%, real but not 2.5x. Repo with methodology: https://github.com/rexrodeo/american-healthcare-conundrum

[dinkumthinkum]

Hvae you considered that America is a much larger and much more diverse country that these other countries and and it is very different social norms? Obesity is a major problem in America and it is not the fault of the doctors. I wonder if this has anything to do with it?

[LorenPechtel]

So we do better at actually delivering care, they do better at getting it delivered to everyone.

[avhception]

Yet, living in Germany, the problems I hear about our healthcare system from friends or in the media are an absolute far cry from the insanity that I hear about the US system. Maybe some of it is sensationalism, but I very much doubt that would account for the whole story.

[9x39]

What's usually missing from anecdotes is class cohorts - so, US working class with Medicaid or a crappy marketplace plan vs working professional with an amazing plan vs retiree with Medicare vs...

Nothing's perfect, but the plan differences seem stark. For example, my wife had a crappy marketplace plan and I had a plan through my employer. For her, an MRI was denied, denied, then finally approved with many calls. For me, it was approved immediately. For her, pre-auth to a specialist was denied until her doctor went and tried a different referral strategy. For me...well, I haven't been denied yet. It goes on - same city, same hospital, some of the same referrals, etc.

I've come to think the price discrimination really does mean we have class-based care which seems to allow for the sensationalism. Combine a dire scenario with a working or indigent class American, and they don't have to exaggerate much at all.

[titzer]

Having lived in both Germany and the US, my experience with the German system is that there are a lot more, smaller hospitals and private practices, the care is good, and all I ever paid for out of pocket was prescription medications. I didn't have to wait long for an MRI (two weeks) versus months in the US. I had a number of things that would have been hundreds or thousands of dollars in the US that I never paid a penny for in Germany. I'll also say that hospitals are absolutely crazy about sending bill collectors after you. I had a handful of small charges--like $10 or $20 things--that I hadn't realized were even there and two months later they freaking inundated me with bill collector notices.

It does make a big difference exactly where you are in the US, however. Some places have a glut of healthcare providers and other places don't.

[matwood]

> I didn't have to wait long for an MRI (two weeks) versus months in the US.

Where in the US did you have to wait months? There seems to be an MRI/imaging location in every other shopping center in the US right now. I've never had a problem getting a same day MRI when needed. Perhaps you were waiting for the 'free' one your insurance would accept?

[rexroad]

Personal experience with specific interventions reflects something real: US cancer survival rates, cardiac procedure outcomes, and access to cutting-edge treatments are genuinely strong for people with good coverage. That's not disputed.

The cost-outcome tradeoff shows up at the population level. US life expectancy: 77.5 years. Spain: 83.6. UK: 81.6. Infant mortality: US 5.4 per 1,000 vs. Spain 3.4, UK 3.7 (OECD 2023). The US spends $14,570 per capita. Spain spends $3,300, UK $4,100. If the premium were buying 10 extra years of life expectancy and half the infant mortality, it might be worth the argument. The data shows the opposite at population scale.

The newsletter's framing isn't that US clinical quality is poor. It's that the US is paying $3T more per year than Japan (same life expectancy, lowest infant mortality in OECD) for aggregate outcomes that are worse.

[youknownothing]

The cost and life expectancy differences are indisputable, but the rationale may need more nuanced: that's not necessarily a problem with the healthcare industry, but with lifestyles, safety regulations, food standards, and a long et cetera of reasons. For instance Spanish people, on average, have more balanced diets and are more active than American people. They also lead much less stressful lives. That's a big factor.

[pnutjam]

"And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you."

This happened to us with private healthcare. There is basically one specialty group for the procedure my family member needed so any 2nd opinion request just got routed back to the same doctor, "Oh, your Dr X's patient". Also, we could barely afford the procedure so we missed out on some follow up testing that would have verified things worked properly and basically got blacklisted from that practice so hopefully it's resolved...

[biophysboy]

There are other public healthcare models besides Beveridge though. Some countries do the payment & financing via gov, but the actual service is a mix of public/private. Not a perfect solution, but in my opinion better than what we have now. Maybe more achievable than Beveridge too.

[ninalanyon]

Norway funds health care through taxation, seems to work pretty well here. But we don't have PFI, instead there are fully private healthcare companies that act as suppliers of services such as MRI, CAT scans, etc. So if your GP orders an X-ray or MRI you will most likely get it done by a private company rather than the local hospital. The patient doesn't really see any difference most of the cost is borne by the state, the patient pays a small egenandel (like copay in the US, excess in UK insurance terms) wherever it is done.

I'm not sure how the other Nordic countries do it but I think it's probably similar.

[cherryteastain]

You can also get private medical insurance in the UK. The cost is usually much lower than the US and quality is decent. NHS acts as an anchor keeping down premiums.

[alexfoo]

I guess that's because many/most countries don't have the concept of a private emergency department.

It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment.

I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years.

But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!"

After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need.

(I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)

[dabiged]

Australia reporting in.

We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required.

I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.

[glenngillen]

Also Australia reporting in.

I've unfortunately had a number of emergency visits over the past few years. I'm a bit torn on the public vs private situation. For certain classes of issue (e.g., broken bones) my friends who work in hospitals have repeatedly said they'd go public purely because the volume of patients those surgeons have to treat daily means the teams in the public systems are typically incredibly experienced. And yet, I smashed my hand to pieces mountain biking on a holiday weekend and when I arrived at the ER the place was absolutely rammed and it was going to be a many hours wait to even get triaged. We got straight back in the car and drive to the private ER 5 minutes down the road and were seen immediately.

In the moment I was incredibly appreciative of that option. It does make me feel uncomfortable that it was only an option because I could afford to pay to jump the queue though.

[Aeolun]

Does it make sense to get an x-ray for that? I’m sympathetic to the desire, but isn’t the end result for pneumonia always antibiotics anyway?

[SoftTalker]

If it's not pneumonia, antibiotics might not help.

[LorenPechtel]

Simple test: The reports saying the UHC systems are better always are using statistical games. If they were really better why would they put their thumb on the scale?

Things like making 20% of the score "fairness"--as in UHC. And hiding the fact that most of the life expectancy difference is infant mortality and most of the difference in infant mortality is a reporting issue: infant mortality + stillbirth produces a far flatter plot. Thus much of the difference is whether it's considered to have died before birth or after birth.

[dsr_]

There are certainly locations in the US where the standard of patient care -- ignoring cost -- is world-class.

And there are certainly locatioms in the US where the standard of patient care is nowhere close to that, and would be easily beaten at any major hospital in any other first-class economy.

[some_random]

There are people who have lived in multiple countries, and speaking with them the only place that seems to be comparable (until you factor in private healthcare of course) is Switzerland.

[adrianN]

Patient outcomes should provide reasonably hard data for comparisons. Life expectancy at least is not vastly better in the US, how about other metrics?

[samiv]

"In many ways the quality of care in the US is far better than what folks get elsewhere"

This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.

[realo]

"... quality of care in the US is far better ..."

Care starts when you need it, at the ambulance level.

Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later.

So no. Quuality of care in the US is not that good.

[PaulHoule]

See https://pharmacy.osu.edu/news/prescription-discount-cards-wh...

[rexroad]

Thanks for sharing the OSU piece, good read. A few things it surfaces that complicate the "discount cards help patients" narrative: discount card companies still contract with PBMs to set pricing, they don't bypass them entirely. The savings often come out of the pharmacy's margin rather than the PBM's: the article shows a pharmacy receiving $5 on a drug it acquired for $15, with the PBM still collecting a transaction fee either way. GoodRx was also fined by the FTC for selling patient health data to advertisers without authorization, so there's a second extraction happening on the data side.

The deeper point the card market reveals: a profitable arbitrage layer can consistently undercut the insurer's "negotiated" rate, which tells you the negotiated rate isn't really a discount. Generic apixaban costs £1.16 per 30-day supply in the UK. Medicare's gross cost for Eliquis (same molecule) is $862.

[fragmede]

The catch is that Mark Cuban is now the one capturing the rewards instead of the now-unknown-to-me-in-the-wake-of -Luigi-Mangione healthcare tech company CEO

[dsr_]

https://en.wikipedia.org/wiki/Stephen_J._Hemsley

You're welcome.

[hammock]

People are waking up and a lot is happening to counteract some of this.

In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own

Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off.

Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers

[rexroad]

The rebate pass-through rule (effective 2028) is a real step, and worth tracking. But rebate retention is one of six extraction mechanisms the Big 3 PBMs use. The FTC's Interim Reports I and II (2024-2025) documented $7.3B in specialty drug markups alone, separate from rebate games. The Ohio Auditor found PBM spread pricing extracted $224.8M from a single state's $2.5B Medicaid drug budget in one year.

The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum

[pnutjam]

TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsite...

[Aeolun]

> In many ways the quality of care in the US is far better than what folks get elsewhere

Or so people keep telling themselves to not feel completely fucked?

[onlyrealcuzzo]

Health care is so broken that I think it will unbreak itself.

You can eliminate most of the problem by mandating true cost billing by hospitals (get rid of their insurance mandated 500%+ markups to make it look like your insurance does anything at all besides make your care as costly as possible).

As you said, it's oftentimes cheaper to buy drugs without insurance.

The average person would quickly find out that insurance doesn't pay for anything at the hospital (most of the time).

~80% of healthcare spending is already at the tail end, and the state already covers most of that through Medicare and Medicaid.

The bottom ~50% of spenders (healthy people) only spend ~3% in total of healthcare (~$900 per year per person, about 1 month's PREMIUM).

Health insurance is a MASSIVE tax on the bottom ~3% of spenders (~50% of the population), when the state ALREADY covers the vast majority of people that need covered for tail end expenses.

Think about this: the MEDIAN adult in the US pays <$1k in personal income tax! Yearly health care premiums (that do nothing) are 3x that! 75%+ of the median person's true tax is going to health insurance that does NOTHING for them.

We already have the European model. Health insurance as it is is a tax. It just could not be designed to function more poorly than it does for the average healthy worker.

It benefits literally no one besides the health insurance industry which does not employ that many people, and is not strategically important for national security.

If the state completely covered the tail, and we had true billing at hospitals, almost no one would need or want insurance besides people that already have it through Medicare and Medicaid.

[mekdoonggi]

You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old.

If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health insurance.

[Taikonerd]

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it

Most Medicare recipients do get supplementary private insurance though? It's called "Medigap."

Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people get Medigap coverage.

[mekdoonggi]

By "the insurance" I was referring to Medicare. I'm a working, healthy person and rarely use healthcare outside of preventative care. You could raise my Medicare taxes by hundreds monthly and still be less than what I pay for private insurance.

In a Medicare-for-all scenario, the individual price of a given procedure doesn't need to be so high, because the reimbursement is guaranteed. Right now, the "list" price of the procedure has to be high to subsidize the uninsured and Medicaid who lose money.

I'm sure there are single payer health insurance countries in which people still purchase insurance, which should inspire debate about the universal insurance cost-sharing.

Regardless, the only viable solution in the US is a single payer insurance model.

[SoftTalker]

Your private insurance isn't there (ideally) to pay for your preventative care, which you can easily pay for out of pocket. It's there to pay for the low-probability but very expensive scenarios, such as cancer, major accident/injury, etc. that would otherwise bankrupt you.

[mekdoonggi]

I understand how insurance is supposed to work. The problem is that private insurance captures all of the value I pay in during my working life, and doesn't have to pick up the tab when I inevitably get old and sick.

To use car insurance as an example, it would be like if we had a government program for cars over 150k miles. You have to pay for both private and government insurance. The private company collects more money than the government, but the government pays for all the expensive stuff because that's when cars break down. It's completely pointless.

If you want a medicare-for-all scheme where working people have a higher cost-share than children/retirees, fine, that's reasonable. Having private companies rake in profits from a system that has no business being a profit enterprise is insane.

[LorenPechtel]

Paying for the preventative is because it's been demonstrated that doing so reduces costs overall. The amount involved isn't all that much, it's not the driver of the costs.

[onlyrealcuzzo]

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old.

I strongly think that covering everyone in the existing system is not the best way to go.

The existing system is designed to cost as much as possible, and we have way too much demand for treatment (as is) and not enough supply. ER wait-times aren't 2-4 hours just because.

First, that needs to break.

Then, you can cover everyone.

We simply do not have enough doctors for how many old and unhealthy people we have. We should be thinking about how to keep people from going to the hospital that don't really need to be there. Do you really need to go to the ER because you stubbed your toe? If you didn't have insurance, you'd go to a low-cost clinic and get the same treatment for 1/10th the price.

We are slowly getting there already. Low cost clinics weren't widely available, but they are becoming more and more available as the cost of health care even WITH insurance is too high for most people.

The infrastructure for the bottom ~50% of people needs to exist to break free from a system that is not designed for them BEFORE they can move off it.

It's almost there.

Since One Medical became widely available, I basically have not gone to the hospital in 5+ years. Before, you kind of needed to go even for routine things (or at least I didn't know of a viable alternative). More and more places like this are springing up all over the US.

[b_t_s]

>ER wait-times aren't 2-4 hours just because.

ER wait times are long because ERs are the only place in the country where we effectively have medicare for all, albeit in a particularly perverse and dysfunctional form. Everyone gets treated at the ER even if they're broke & uninsured as long as they're willing to wait long enough. Now imagine if those folks could go to any primary care doc or even use One Medical, CVS walk-in clinic etc. That would go a long way toward fixing our overloaded ERs. We've legislated quazi-medicare for all but only in the most inappropriate part of the system.

[mekdoonggi]

Agreed. We all collectively understand that we can't allow people to die in the streets because of their lack of health insurance. We already have universal healthcare, we just have the worlds dumbest way to pay for it.

[teeray]

> Do you really need to go to the ER because you stubbed your toe?

Where else are some people supposed to go? Maybe that toe is starting to change colors… is it broken? Do I need to have it set? Is that possible for toes?

People have valid medical questions and don’t want to wait weeks to see their primary care. They might not live near an urgent care. The urgent care may have terrible hours, or they made the mistake of mentioning chest pain for their heartburn incident and now they are forced to the ER.

It’s a chicken and egg problem. Faster medical answers will lead to reduced ER wait times. Reducing ER wait times lead to faster medical answers.

[throwaway173738]

Who would you choose not to cover? The sick?

I hate to break it to you but insurance is meant to be a tax on the entire risk pool. What changed after the ACA is we couldn’t kick anyone out of the risk pool for getting sick.

[onlyrealcuzzo]

> Who would you choose not to cover? The sick?

You didn't read the post.

The sick are mostly the old (if you're looking at total spending), and they are already covered by Medicare.

The sick young are a minority, and are often times covered by Medicaid.

If the state covers the tail end and assuming they aren't covered already by Medicaid, there just isn't that much spending remaining.

They can get private insurance to cover the under $10k per year - but there's not really a product that covers that effectively - so unless a new insurance evolves, it still wouldn't make much sense.

The sick, young, non-medicaid tail is VERY small compared to the rest of the tail the state already covers. Just add it in. A 1% global tariff could easily cover it. You've still got 9-14% left to spend on more bombs, tax breaks for the rich, paying people to get underwater basket weaving degrees, whatever.

[LorenPechtel]

The premium charged for the sick, young is high enough that your math doesn't make sense. ACA plans have to pay out 80%. Since I'm paying $11k/yr for my ACA plan they are clearly paying out at least an average of $9k in claims for the average member of my cohort. (And the reality is worse as they are limited in the ratio between young and not so young, this effectively makes the young subsidize us not so young.)

[throwaway173738]

I’m not understanding how this is better than just putting everyone in one risk pool and having the young and healthy subsidize the old and sick? You’re basically saying if you’re healthy don’t carry any insurance and just rely on the government and taxes for catastrophic coverage. And then as soon as you get sick you’re supposed to apply for this coverage that only applies when you’re sick? The biggest problem with Medicaid is that you have to prove you can’t get the means to pay for healthcare which is essentially impossible without paying for healthcare.

So now you have this huge apparatus for intake and for rejecting people who are not sick enough or old enough but who can’t conventionally afford care. And you have to pay for that apparatus. Why would that be any better for the young people, other than seemingly using their taxes to make cruel decisions about a portion of the old and sick instead of simply providing care?

And what’s worse is a lot of those sick people wouldn’t have gotten that sick if they could pay for preventative care. So now in your system you have this huge group of people who have through lack of means let their illnesses and maladies get so severe that they can’t afford to treat. The whole point of preventative care is to keep people healthy so they don’t become a cost burden to the insurer. That’s why we pay more relative to what it costs. And it’s a hedge for us. We might find ourselves among the desperate ill some day without the means to pay for treatment.

[rickydroll]

Breaking the existing system will be extremely difficult. I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting. New doctors don't know me, they don't know my history, and haven't seen the medical shit show you've been through and why your treatment is the way it is. Then they think they can change your treatment to something that has already failed because "I didn't give it a long enough trial" or "That's a rare side effect," it won't happen to you.

I highly recommend you read the book "We've Got You Covered." It's an economist's view of health systems and how we can rearrange government spending to provide coverage for everybody and prevent medical bankruptcies.

One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized? Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists? Are they servicing only the young and healthy?

Their senior care plans tell an interesting story. They only work with Medicare Advantage plans, specifically those known for up-coding, excessive pre-authorization requirements, and high rates of care denials. Medicare Advantage is an interesting failure in the marketplace in that it costs the government significantly more than classic Medicare and provides worse-quality care.

For the rest of us, we can skip the ER by going to an urgent care. But around here, urgent care offices are owned by private equity, have deceptive billing and are part of the reason why medical care costs so much.

[onlyrealcuzzo]

> I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting.

You are clearly not in the bottom 50% of health care spenders. You would be in the group that would keep private insurance and be happy.

> One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized?

No.

> Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists?

The vast majority of their "doctors" are Physician's Assistants. You can see whoever you want for whatever you want (that they provide).

> Are they servicing only the young and healthy?

Mainly. It's a clinic. You can't go there for Open Heart Surgery and cancer treatments. They'll just (cheaply) refer you to a specialist (who will be expensive and require insurance).

What you can do is avoid huge wait times and get good enough treatment for ~90% of what the mostly healthy group of ~50% of the population needs for fair up-front prices - which previously did not exist.

[rickydroll]

That's a mighty big assumption you're making. I've had private insurance for years, and I've always been unhappy with it because of treatment delays, Treatment denials, pre-approvals, and unrealistic copay limitations.

Many of my health needs are not expensive, but my body's reaction to treatments is. Frequently, cheap drugs are all side effects and no benefit. Also, private insurance has bizarre coverage gaps. For example, ambulance costs. When I had a heart attack, I drove myself for 45 minutes to the nearest hospital with a cath lab rather than take an ambulance and end up with God knows how many thousands of dollars in uncovered ambulance fees. Then there are things like cardiac rehab, which go a long way toward restoring cardiac health. 12 weeks, three times a week at $50 copays, was an expense I wasn't counting on. When I qualified for Medicare, the quality of care improved significantly. Usually, wait times for service are much lower than with private insurance.

I also resent private insurance because my premium dollars go toward enriching stockholders rather than providing care for all policyholders.

[UncleOxidant]

> We simply do not have enough doctors

We're going to need to make more doctors. To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

[onlyrealcuzzo]

> To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

We could import them.

We have tons of options. But the medical industry likes a shortage, because they like high wages, so I won't hold my breath.

They pick the rules. The rules favor them.

That's going to remain true for the foreseeable future, and on the list of problems, that's at the absolute bottom of things to fix that would actually move the needle.

The cost you spend on DIRECT HEALTHCARE is only ~20-30% of all spending. The rest is administration, drugs, insurance overhead, profits, ACTUAL insurance costs, cost overruns due to insurance making everything as expensive as possible to scrape 15% off the top, fraud, legal fees, etc.

The biggest benefit to moving to a centralized insurer is that fraud is centralized.

If you're a Republican and skeptical of government, you might assume the government will let massive fraud slip through to insiders, and you don't like that.

If you're a Democrat, and think the government can generally be good, you think the government can catch a lot of the fraud and cut total costs by 10% to get to fraud levels that are similar to other advanced countries (with similar systems).

[throwforfeds]

Or, like, not haze kids in their 20s for residency and make them take hundreds of thousands of dollars in debt. Whereas in Europe and other countries, residents work something like 50 hours per week and graduate with zero debt.

I've watched friends go through it here in the US and I have zero interest in working 24 hour shifts and sleeping in break rooms, working 80+ hour weeks for years. There just is no need other than hazing and keeping artificial scarcity of doctors for inflated wages. There are plenty of brilliant, scientifically minded, hard working people that care about others that probably could be great doctors, but the US training system is just hostile towards most people.

[46493168]

The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people.

See, for example, “Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland” by Jonathan Metzl

[onlyrealcuzzo]

> The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people.

This subset does exist, but is smaller than the percentage of people who think the system is broken - and the solution is not to just open up the floodgates and make it even more broken and even more expensive.

You FIRST have to fix the system before you open up the floodgates.

I am on your side that I think it would actually cost LESS to move all high-cost patients off of the ER and onto Medicaid.

But that's not a big enough problem to actually move the needle. In the rosiest scenario, you might save 2% per year. That's still like $20-40B, so nothing to scoff at - but in realistic scenarios, I'm doubtful it would save >$10B.

Even if they had Medicaid, they're so conditioned on going to the ER for everything, a lot of them might still go there instead of somewhere cheaper. For one, they might be convinced they get better care there (and maybe they would).

There's way bigger fish to fry.

[46493168]

>You FIRST have to fix the system before you open up the floodgates.

I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out. There's things that the top 5 US states for healthcare have in common, and there's things that the bottom 5 US states have in common [0]. They know how to talk to each other if they want to know more.

[0]https://www.commonwealthfund.org/publications/scorecard/2025...

[onlyrealcuzzo]

> I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out.

It's a problem because the nation already ineffectively covers the tail.

The state shall not fix what is not a problem for the state.

[jkestner]

But they’re a subset. It can happen.

The more critical, and yet smaller, subset is the people making bank from the current system. Get their money out of politics and watch resistance crumble.

[46493168]

Yes, precisely. The smaller subset that make bank from the current system directly benefit from us poors (aka non-billionaires) from blaming the person lower on the ladder.

[Projectiboga]

Medicare's admin cost is around 5%, private insurance is around 33% of claim dollars. There are around 27-28% uninsured. The money is already there who pays needs to be moved to the Billionaire and Multimillionaire class to reduce the annual costs for those who work for a living.

[onlyrealcuzzo]

> private insurance is around 33% of claim dollars.

The Medical Loss Ratio (MLR) requirement established by the Affordable Care Act (ACA) is 20%.

Typically it's closer to 15%.

As these are private companies, some percentage of that is obviously profit.

It doesn't cost that much more to run private insurance than Medicare.

The problem is the incentive of insurance to drive up cost to get a larger fixed cut, and the lack of a public option (which would require private insurance to actually be worth it).

[rexroad]

Those figures are in the right range, and the full picture is larger. The CMS NHE 2023 data puts total US healthcare administration at roughly $1.1-1.7T annually (depending on methodology), building on Woolhandler and Himmelstein's 2020 Annals paper ($812B in 2017 dollars). The per-capita comparison against 10 OECD peers: US $4,983 vs. a peer average of $884. That 5.6x gap is the number Issue #5 of this series will examine in detail, covering three separate computation methodologies and why the estimates range so widely. All source code will be in the repo: https://github.com/rexrodeo/american-healthcare-conundrum

The policy lever that addresses this is billing standardization, not just insurer reform. Countries like Germany and Switzerland run much lower admin under private insurance through standardized claims formats and all-payer rate setting.

[WarmWash]

The actual true problem is that there is a mismatch between the value the average person generates in their life, and the value of them staying alive. A handful of SOTA treatments can easily blast through a year of someone's total earnings. And this isn't even some kind of gouging or scam, anything SOTA tends to be the most expensive.

Insurance is the natural solution to this, but to be effective it requires most people to not need it while still paying into it. This is what Obamacare tried to fix by mandating insurance, but healthy/young people got sticker shock and bailed.

[onlyrealcuzzo]

> Insurance is the natural solution to this, but to be effective it requires most people to not need it while still paying into it.

Yes, and you can fix it by the state covering ONLY tails - which it ALREADY essentially does, just as expensively as humanly possible.

Democrats and Republicans spend all their time arguing about whether to have sweeping changes that won't drive down costs or do nothing (which obviously won't bring down costs).

You could spend less money and get better outcomes by officially covering the tails instead of un-officially.

Instead of ~50% of young, healthy people paying a MASSIVE tax for "insurance for all" which doesn't really do what it says - you could just officially cover the tails, use the existing tax dollars, and accept that instead of ~30% of people "not having coverage" everyone would have tail coverage and ~50% of people wouldn't have "coverage".

You get a better, fairer system - that costs less overall, and that I think the American people could actually vote for.

Republicans would like it because it costs less and doesn't cover abortions or whatever they bitch about.

Democrats would like it because it officially covers everyone and prevents medically bankruptcies, and it doesn't FORCE anyone off insurance, and it would bring down private insurance costs significantly. They'd bitch that we should just do Universal Healthcare instead, but it's hard to argue it's a step in the wrong direction.

Pipe dreams don't pass. Reality does. You're never getting anything passed that massively fucks over a huge relatively popular special interest (like doctors).

You might be able to pass things that piss off unpopular powerful special interest like Health Insurance (or, previously, Fossil Fuel companies).

[LorenPechtel]

And this is supposed to be an answer?

1) In many cases you are paying that high "markup" for the handling rather than the product.

2) Hospitals are typically not making much money. Available 24/365 costs. Deadbeats cost.

3) Yes, most people don't pay much healthcare in any given year. But you don't know what year they are going to.

4) I like the idea of it as a tax--but in the real world this always ends up with the fox guarding the henhouse. Because most people don't need much care in a given year it's easy to satisfy the majority of the population with poor quality care. The ones that see the failure aren't enough to change the outcome of the ballot box.

[thayne]

Another example, I needed to rent some medical equipment which was pretty inexpensive. But for some unfathomable reason the insurance required that if that was rented, I also had to rent some other equipment that was like 20x as expensive that I didn't need at all. As well as purchase some disposable stuff, that I would not use, and could not be returned or used by someone else. And paying for just the things I actually needed myself without insurance wasn't an option.

[alexfoo]

This always baffles me.

There’s so much rampant profiteering in the US healthcare system it’s unbelievable. Other countries look at it from afar in utter disbelief. I’m glad I had no serious health problems when I lived there 25 years ago (and I had health insurance via my employer).

In the UK prescriptions are effectively capped at about USD125 per year:

https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-pr...

I recently collected 4 prescriptions from my local pharmacy (3 for temporary conditions, the other one was ADHD meds which I’ll be on for the foreseeable future) and the pharmacy didn’t even want to see proof of my prepayment certificate, I just said I had one and they ticked the relevant box and handed me the prescriptions.

(The implication is that the NHS will check this and come after me if I was lying.)

Don’t get me wrong, there’s lots wrong with the UK healthcare system but the access to regular medication has very few barriers.

[1234letshaveatw]

What an amazing system! Poof! just like magic you can pretend that sophisticated medicines, that are years in development, should cost nothing just because! And then you can act all smug about it!

[pjc50]

Cost nothing to the user, yes. You can then have the state, a sophisticated purchaser, decide what it's willing to pay.

[1234letshaveatw]

Sure, sure, “sophisticated”

[alexfoo]

Not at all. The majority of the cost is subsidised by the Government who acts as a central purchaser to minimise profiteering and keep prices down.

Everyone pays a little bit towards it all via general taxation but if you prefer a system where individuals have to front the vast majority of their own costs, much of which is just being extracted as profit, then you are welcome to that. I prefer the option that leans a lot more towards socialism than rapacious capitalism.

[1234letshaveatw]

Ok, but that wasn’t part of the discussion was it? Just “lol drugs only cost a nickel here, silly USA” seems disingenuous

[rexroad]

The NHS prices in the Issue #2 analysis are not subsidies. They are the generic reimbursement rates from the UK Drug Tariff after patent expiry on each molecule. Apixaban (Eliquis) costs £1.16 per 30-day supply on the Drug Tariff. That is what the open market charges for the active compound once patent protection expires. The NHS does not manufacture it or subsidize the price: that is the market rate for the molecule itself.

The $862 Medicare gross cost for the same molecule is not explained by active R&D recovery, either. The IRA's first ten negotiated prices (effective January 2026) cut Medicare gross costs 40-70% per drug, which does not happen if those gross costs were development-cost-justified.

[arethuza]

In Scotland and, I think, Wales there are no subscription charges at all.

[alexfoo]

Ah yes, forgot about that.

The regional differences are quite odd.

I got my ADHD diagnosis via Right-To-Choose, so it is considered an NHS diagnosis and I get my medication via the NHS (and therefore cheap). But the RTC pathway isn't available in Wales/Scotland/NI. I'd either have to wait years for an NHS diagnosis or go private and then have to pay £££ for my prescriptions privately.

The UK system has many problems but at least the general population are shielded from the exorbitant individual costs. We pay for it through general taxation but that, at least, spreads the load a bit.

[akpa1]

I got my ADHD diagnosis privately (mostly because of the length of the NHS waiting lists, and I'm currently waiting on a NHS RTC provider to transfer my care there) and I pay the trade price plus pharmacy markup (so ~£40/mo) for my medication, for whatever it's worth as comparison.

Definitely not cheap (I would prefer the £9.90 NHS prescription fee) but I get the feeling that it's cheaper than I would pay elsewhere in the world anyway.

[alexfoo]

Yeah, mine would have been £50/mo if I’d been private according to the receipts I never had to pay on RTC. Luckily I only had to wait about 9 months from referral to RTC to diagnosis and starting titration. I know some people who have only had to wait a couple of weeks, it’s another lottery based on the individual providers and the phase of the moon.

Meanwhile we’ve spent close to £7k on my kids ADHD/ASD diagnoses privately as it was a 4 year waiting list for a NHS CAHMS referral. Luckily the GP has agreed to take on the private diagnosis and prescribe the meds under a shared care agreement.

I’ve no idea what happens in a few years when my kid hits 18. I’m hoping they don’t have to back out of the SCA leaving them without access to meds. It’s something I need to research although the fallback is paying privately I guess.

[kraig911]

try being diabetic ugh. I am constantly grinding against made up barriers. 150$ in strips and about 500-700$ for insulin. Meanwhile I meet a friend and he's just buying the base insulin from walmart for about 50$ a vial.

[vablings]

It is insane to me how much diabetic test strips cost in the United States. They are a cheap mass manufactured product that cost almost nothing everywhere else in the world

[rexroad]

Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own mail-order or in-network channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year.

The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs (CVS Caremark, Express Scripts, OptumRx) in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually. This is the subject of the next issue being released this Sunday.

[rexroad]

Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year.

The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually.

[throwaway173738]

Oh you must have United Healthcare. Yeah they do this with IVF drugs too, and I’m sure with chemotherapy drugs. Plus it all has to be shipped so if you’re mid-cycle and the doctor orders a different medication you either waste the benefits or pay out of pocket. And they structure all their pricing so the fertility benefit covers a cycle but the medications aren’t fully covered so you pay out of pocket in medication that’s 3-4x as expensive as the cash price would be at a pharmacy like Alto.

[iwontberude]

If you are on UnitedHealth and reading this, switch to Kaiser HMO next open enrollment, you will not regret it. It’s worth far more than the UnitedHealth PPO, they have plenty of availability for appointments and lots of remote options. They don’t skimp on screenings and radiology, their pharmacy is fairly priced. You can go in for a single appointment and get 4 things accomplished (physical checkup, blood draw, prescription transfer, physical therapy sign up and more) in 45 minutes. The people are nice and you have tons of locations nearby.

[fearmerchant]

I pay cash for a medication because the insurance won't pay for the 90 day supply and it's a hassle to deal with it every month. It's $70 for me to pay for 90 days out of pocket versus paying a $20 deductible each month. I'm only paying $10 extra to avoid the hassle. Worth it.

[SoftTalker]

If you can pay cash without insurance, then you don't need the insurance.

Insurance is (should be) addressing the risk of unexpected expenses that you cannot afford. Not predictable, small expenses that everyone has.

[tmountain]

This ignores catastrophic scenarios.

[SoftTalker]

That is included in "unexpected expenses that you cannot afford"

[IAmBroom]

???

This explicitly addresses catastrophic scenarios.

[soupfordummies]

Free idea: AI-powered "agent" that fights health insurance and medical bills for you.

[Vrondi]

The people writing the AI agents are being paid by the insurance companies.

[estimator7292]

My new job has some kind of insurance add-on which is an entire company of people with the express purpose of negotiating with your primary insurance to get specialty medication paid for.

Sticker price on my partner's medication is $10k/mo. Insurance alone refused to pay anything. This third party negotiator managed to get insurance to pay some, the manufacturer to discount it, and a "copay card" with several thousand dollars preloaded appeared to pay the rest.

We ended up paying zero out of pocket for the medication but it took two weeks of thrice-daily phone calls with various entities.

The very notion that an entire company can exist and sustain itself solely on negotiating with your insurance provider on your behalf is utter insanity. I've heard horror stories about communist bureaucracy from Soviet-occupied European countries, but I don't think even the USSR can compete with the modern American healthcare bureaucracy. It's outrageous and unconscionable.

[jimt1234]

My Boomer mother has a mild case of shingles. Her health insurance will only pay for an expensive monthly injection. She tried it, but doesn't want it, as she says the side-effects are worse than the shingles. She prefers to apply a cream when she experiences a flare up - maybe, twice per year. Well, her insurance won't pay for the prescription cream; they keep insisting on the monthly injection. She was told if she insists on the cream, she needs to buy it on her own - cost, around $150. Thankfully, we live not far from Mexico, where I can purchase the exact same cream for around $7.

So, it seems the solution to the high cost of prescription drugs in the US is to live near a border. LOL

[georgeburdell]

I have never heard of shingles as a chronic condition. Will the vaccine not work?

[boppo1]

This kind of bureaucracy sounds like the stuff my teachers criticised communism and socialism for in school. Isn't our 'capitalist' system supposed to thwart this?