[beanjuiceII]

US healthcare industry needs to drop more non-essential workers, and invest more in workers that produce value. the industry is so bloated no wonder its costs are high. Just to get my ears checked i had to be processed by 6 different people including phone systems doing precheck-ins. one person does the actual work!

[atmavatar]

That's almost entirely due to how our private insurance industry works.

Any given health provider has to deal with thousands of different insurers, and it's not uncommon for individual patients to have primary, secondary, tertiary, and even quaternary insurers the provider then has to deal with to get paid for a procedure.

To keep health care workers focused on providing health care, providers hire a bunch of administrative workers whose job is to offload the work of haggling with insurance onto cheaper workers, but because there's so many insurers, and patients have so many layers of insurance, you end up with something close to 10 administrators per doctor.

Alas, because there's so much money sloshing around in the system, and because the US government is so thoroughly corrupt with bribes from special interests, there's no movement to correct the problem. The system is unsustainable, though, so it will inevitably collapse in on itself at some point, causing a lot of misery and probably death before anything is fixed.

[tptacek]

We know this isn't true, because CMS publishes annual numbers of the net costs of all these functions, and the total cost of service delivery absolutely dominates everything else. There is definitely annoying and pointless insurance overhead; anyone who has ever gone to the doctor for a followup appointment has seen that happen. It's just not where all the money is going.

A thing that's always worth keeping in mind: retail clinical practice for non-geriatric adults is a very small fraction of all health care costs in the US, and end-of-life care is a very large fraction. Most of us only have exposure to the former, and we generalize from it, but that's not giving us an accurate picture.

[t0mpr1c3]

The administrative overhead is not trivial: probably about 25%.

Worse is the distortion of incentives for healthcare providers. The giant leaky insurance tit is there to be sucked on, creating corruption at every level.

When you are billed for a procedure you have no idea how much you are going to get charged or what you could get billed for. There could be gigantic opaque charges for things you have never heard of. Ticketmaster could only dream of such a rip-off.

Not to mention blatant over-billing for unnecessary diagnostics, etc. Every year new kickback schemes are discovered.

[tptacek]

25% of what, and where are you getting that number? JAMA studied this on an encounter-by-encounter basis and found BIR costs were in the tens of dollars for normal visits to low (100-300) for inpatient surgery.

Price transparency is a real problem. Overbilling is a real problem, so is overprescription. Important to keep in mind that those are on the provider side, not the payer.

[t0mpr1c3]

25% is perhaps on the high side of estimates, but perfectly plausible. If you prefer citations from JAMA: https://jamanetwork.com/journals/jama/fullarticle/2785479

[tptacek]

That's all administrative costs. As the abstract says, many of those costs are intrinsic to providing services.

Here's JAMA for the BIR, based directly on cost breakdowns in specific real systems:

https://jamanetwork.com/journals/jama/fullarticle/2673148

[WizardK]

Right, most of those 6 are not medical staff, they are probably there for insurance and billing. And compared to Europe we don't even have a lot of doctors, US has fewer per capita. So the money is going to the billing layer, not to actual care.

[ramenat2am]

I think the industry itself would be more than happy to classify nurses and doctors as non-essential and drop them.

Imagine the profit margins where you don't have to pay salaries to them.

[Legend2440]

Those people may actually be saving money by offloading work from a $250/hr doctor to a $25/hr secretary.

[maxerickson]

Medical assistants and nurses work with you before the doctor to increase billable events for the doctor. You could describe this as saving money, but it's not the goal.

Phone and front desk stuff is just administrative burden, scheduling the appointment and making a paper trail.

[lokar]

Except the work saved should not be done at all.

[toomuchtodo]

It will not change on your time horizon. If you want better healthcare, move to a developed country today. It will take a half decade or more for US healthcare to improve in any meaningful capacity, assuming the necessary events take place to enable improvement in the system.

(to improve US healthcare, laws will need to change; when those laws change is a function of election outcomes and cadence; those election outcomes are a function of the electorate, who they vote for, and the rate of cohort turnover; think in systems)

[maxerickson]

Did you mean half a century? Meaningful change in 5 years would be pretty amazing.

[nozzlegear]

> It will take a half decade or more for US healthcare to improve in any meaningful capacity,

This timeline seems wildly optimistic

[toomuchtodo]

Mamdani has moved fast in NYC [1], faster change is possible when the motivated are in positions of leverage. I admit a five year time horizon is aspirational and dependent on “everything going right” with regards to election outcomes and the policy pipeline, from introduction to bill signing. I’m open to more realistic suggestions so I’m more accurate when I speak publicly on this topic (I help a non profit help US residents get out of the US, explaining the risk model of remaining in the US is a component of that work).

[1] https://www.mamdanibulletin.com/

[bpt3]

> I help a non profit help US residents get out of the US, explaining the risk model of remaining in the US is a component of that work

Congratulations, I think you just described the most ridiculous non-profit in existence.

[toomuchtodo]

Not to (potentially vulnerable) humans who want or need out. If you can self serve the information and logistics to accomplish this, fantastic, but many cannot and therefore need some help. If you are happy on US soil, you're outside of the "charity expat migration consultant" TAM.

It's actually been a fun exercise in building a gen AI solution to pour context into queries and get custom migration plans [eligible visas, employment connections at the destination, potential non traditional paths outside of work visas] out like an expat/migration plan vending machine. Output is verified by a human familiar with the problem space and away we go getting someone to where they want to go.

"Make something people want. Don't worry too much about making money." The demand, I argue, is proven. You should try to be more curious.

Record Numbers of Younger Women Want to Leave the U.S. - https://news.gallup.com/poll/697382/record-numbers-younger-w... - November 13th, 2025 ["In 2025, 40% of women aged 15 to 44 say they would move abroad permanently if they had the opportunity. The current figure is four times higher than the 10% who shared this desire in 2014, when it was generally in line with other age and gender groups."]

Americans are leaving the US at rates not seen since the Great Depression — and 5,000 even gave up citizenship last year - https://finance.yahoo.com/economy/articles/americans-leaving... - May 24th, 2026

Americans Are Leaving the U.S. in Record Numbers - https://news.ycombinator.com/item?id=47161219 - February 2026 (93 comments)

[bpt3]

Sure, lots of people have no idea what it's like to live abroad and have doomers telling them to get out because it's not their fault they aren't successful in the country where the middle class has the highest disposable income in the world. I'm well aware they exist as a person who spends some amount of time online, so you can spare me the lecture about being curious.

Those people would be better off under a more generous welfare state, but immigration policies in those nations are much less dysfunctional than our own. If you are able to offload some of these people onto another nation, I thank you, but it's a very odd focus for a charity.

If you want an example of how uninformed the people inside your TAM are, see the younger women polled in your citation. Based on other data, I strongly suspect they are motivated to leave due to actual and potential changes in abortion law and policy in the US (which I do not support for the record), and have absolutely no clue whatsoever what rights they would have in most of the rest of the world (spoiler alert, it's less than most Americans have).

[stop50]

Probably 3 of them just working to prevent you from going.