Amen! I tend to be more Libertarian than either of the 2 major parties, but I would gladly pay personally for other people's health care if it was actually being done rationally. But I've had major problems every time I've seen a doctor my entire adult life, all related to the complexity of the billing, and it got to the point where my biggest health risk was the stress of fighting it. Go for an annual physical: $1200 bill for 2 physicals, blood tests I never got the results for, and a test they never performed. Not covered by insurance because the doctor's "wellness check up" wasn't the same as the insurance company's "annual physical". Time to resolve: 8 months. Resolution: I paid because the lawyer was going to be more expensive. That's not a system I'm willing to pay for, and it's got nothing to do with whether it's my social obligation or not.

Yes it seems the complexity of billing still has something to do with Who Pays.

I had a similar issue where I was billed for a physical that my insurance provider would not pay. My wife suggested I have the Dr. office re-code the bill. Not sure what that is but I contacted the Dr. office and explained that it was not a wellness check up but an annual physical that my insurance should cover. After arguing for about 10 minutes they finally agreed to re-submit to insurance under that code... and it ended up being covered by insurance after all.

Now, imagine how much is being lost by most people having to go through that, most of whom aren't perceptive enough to notice this...

The complexity of billing is strongly intertwined with who pays and how, and adding the third-party of your employer, who actually selects the health insurance company for many of us adds yet another layer on top of the already inefficient setup.

And that's what swings me to single-payer, despite my other political leanings. The incentives system is just so screwed up. Consolidating is would make solving the remaining problems so much simpler.

Please post civilly and substantively here. Part of both of those is reading other comments charitably before commenting.

Respectfully, like 80% of HN comments, mine was not "nice", but it was neither uncivil nor unsubstantial - parent was literally an anecdote related to their billing grievances and their proposed solution was literally to let poor people die of treatable ailments. Unless you had an alternative reading?

Totally understand how you could interpret my comment as uncivil if you believe I intentionally misrepresented his argument.

Actually my proposed solution would be single payer. Reducing political issues to "x wants to kill y" is never productive. FWIW my anecdote was from when I was living at approximately half of the poverty line and after ACA took effect. Similar things have happened to me in 3 different states. So forgive me for not having confidence that required insurance is really going to do much for me, or anyone. But let me know when you're voluntarily forking over all the money you don't need to survive to help save lives in third-world countries or something.

Poor people have always had access to health care and society has always paid for it. You don't get turned away at the ER and we have Medicaid ($545B) and Medicare ($646B) [1].

The people that get hosed the most are the ones with assets, like middle-class homeowners with some savings that have a major health emergency.

It makes sense to try and force everyone onto health insurance before they need it, just like auto insurance; as it will cost a lot more to everyone if people are uninsured. But I agree that bringing down the cost should be a focus. Everyone gets a raw deal when doctors play billing games any chance they get, like giving x-rays for everything and keeping people overnight unnecessarily and charging insurance companies exorbitant multiples of the cash price.

I actually know someone carving out a business going into healthcare centers and showing them how to make more money- by not playing admin/billing games and just serving patients. That's just crazy.

[1] https://www.cms.gov/research-statistics-data-and-systems/sta...

Before the ACA, my uncle (lower-middle class, with two kids and a wife in a two bedroom apartment in Indiana), had to choose between between paying the gas bill and paying for his near-daily dialysis, which is not a service provided by emergency rooms. He had picked up Hep C as a young teenager and could not afford insurance in adulthood due to this pre-existing condition. The only "health care" he would have had access to was the ER when he inevitably suffered renal failure.

It wasn't just his doctor it is the whole system which is somewhat unavoidable.

We are lucky to have good health insurance, and a simple ER visit to get stitches or an X-Ray will invoke 5 pieces of mail from 3 different entities. You have to watch out for student Doctors who will send you a bill for being in the room. It's too much to think about when you should be focused on taking care of your health issue.

>> It's too much to think about when you should be focused on taking care of your health issue.

This is one of my biggest pet peeves. The biggest bill I've ever had get processed wrong is the only one where lawyers ended up getting involved, and what the other side's lawyers sent was a form my wife signed while in labor (was at an 8 when we got there) while I was out of the room agreeing to pay the bill however the hospital decided to bill it. They said that excused their mistake, and now that it was too late to bill insurance (had been over a year) we were on the hook.

Could you provide proof that you were charged because a student was in your room or in the operating room?

What type of proof would be good for you?

I'm a medical student, we are assured that the hospital can't bill for us. It would be enlightening to see an itemized bill showing that our presence is actually billed for. I've never heard of it happening so I think proof is warranted.

If I remember correctly, the hospital did not bill for him, he billed us separately, but the Hospital condoned this. I'm sure we agreed to it somewhere in the fine print. I'm not trying to vilify student doctors here, I understand 99% of the time they are not billing. But after this experience, we ask.

Ah gotcha. He wasn't a medical student then, most likely a resident. Residents are doctors though, if they perform a service such as anesthesia or other procedure they will likely bill.

For example, an Anesthesia resident will perform all of the procedures and monitor the patient's vital signs and response to the general anesthetics or other drugs. The Attending physician only intermittently checks on the case if the resident needs help or the case becomes too complicated.

If the resident doesn't bill for services performed, such as central line, placement, peripheral line placement, intubation, arterial lines, etc. I'm not sure who would do the billing.

Healthcare costs have ballooned for much the same reason as university tuition. There are 2 university administrators for every professor vs 10 hospital administrators for every doctor.

http://www.chronicle.com/interactives/administrative_bloat https://hbr.org/2013/09/the-downside-of-health-care-job-grow...

And most of the people in the Army don't have a rifle in their hands, and most of the people at Google don't write software. By itself those ratios don't tell you anything.

The ratio itself isn't the problem, it's the assertion that we need a growing amount of administrative vs. procedural employees. We can talk in hand wavy abstractions all day long, but for every additional person you have to pay who isn't _writing software_, you need to now pay that much more for your marginal cost of obtaining the software. In almost every other modern domain I can think of as well, efficiency is moving in the other direction. (I think, if I'm trying to be formal here, some aspects of this would seem to be described in 'Baumol's cost disease')

If we're talking anecdotes, from what I've seen of administration in healthcare and military (family is in that business) and at bigCo (my business) we could likely handle a far more lean ratio of knowledge to support workers, but that often goes against leadership incentives/risk tolerance for less conventional strategic decisions. (although I think we're seeing vestiges in this through the pushes for e.g. devops and dev/test merges)

In the Army, yes. But "every Marine is a rifleman".

To state the data you've cited in another way, there are 10 non-clinical workers for every 7 clinical roles. I'm guessing you don't personally know anyone in a healthcare administrative role, but these people are certainly not sitting around all day looking for something to do. They are hiring so many of them because the arcane administerial requirements of our healthcare system are only growing.

I echoed this idea in a comment yesterday.

The medical industry is the only industry with a broad anti-trust exemption. What this means is that they do not have to publish prices like all other industries.

How can one expect to control costs if you cannot even know how much things cost?

Removing this anti-trust exemption and allowing the public to see prices for the common procedures would be a good start.

But knowing the price of a procedure doesn't change my need for it. If I need heart surgery, I still need it regardless of whether it's $10k or $100k.

In other words, demand is inelastic.

And, most people can't afford to pay 10k or 100k out-of-pocket. So, it's not like managing your household budget. The funds have to come from somewhere else (insurance).

Also, healthcare is not easy to evaluate for a layperson. If my doctor says that I need 'procedure X', I'm relying on their expertise. Healthcare recommendations are not fungible products. If I'm buying a car, I can read reviews about the different models, reliability, etc. But my doctor's recommendation for me is highly specific to my personal health history.

So, for a lot of healthcare spending, it's not me that's choosing a medical procedure. Instead, I'm choosing to trust a doctor's recommendation. The doctor is the one that's recommending the procedure.

I think the elasticity of the demand depends pretty heavily upon the urgency of the problem.

And the demand - as you pointed out - also depends heavily on trust. That said, most health problems aren't unique enough to require a completely bespoke solution.

So at least hypothetically, it's possible to shop around IF pricing and other data were available. But they are not, at least generally.

I found this book rather interesting -- https://www.amazon.com/dp/B01DRXKWRM/ref=dp-kindle-redirect?... -- where a company compiled their health care expenditures and made the data available to their employees.

> tmaly 10 minutes ago [-]

I echoed this idea in a comment yesterday. The medical industry is the only industry with a broad anti-trust exemption. What this means is that they do not have to publish prices like all other industries.

Could you elaborate on this? I don't see what publishing prices has to do with anti-trust, and certainly I have encountered "call for prices" elsewhere.

I don't know about the anti-trust aspect, but the situation in medicine goes far beyond "call for prices." It's often impossible, no matter what you do, to find out what a procedure will cost. Billing systems are so complicated that the hospitals themselves barely understand it, and the only way they can find the cost for many things is to go ahead and do it and see how it comes out.

They provider may not even be allowed to tell you due to contracts with insurance companies.

This kind of thing is outright criminal. We need transparent pricing regulation!

Would be hard to enforce legislatively, as you're essentially forcing private companies to disclose the previously confidential pricing agreements between them and insurance companies.

What will end up happening is the equivalent of MSRP in car sales - here's the list price, but since you're such a good guy, and we're running a promotion, you can get 5% off if you act today.

Why would that be hard? I thought law takes precedence over contracts.

Even having the equivalent of car MSRPs would be a huge improvement. As it stands today, you often cannot get any price for a procedure beforehand, not even a "forget about insurance, I'm just going to pull out a wad of benjamins and start counting until you tell me it's enough" price.

Plus, car prices don't vary that much from MSRP. I can look up a car's MSRP and know that this is approximately what I'll pay. If I get a really good deal I might get away with paying 10-20% less. If the car is in extremely high demand, I might have to pay 10-20% more. But I can get a pretty decent idea. Medical pricing often varies by a factor of ten depending on whether you have insurance, and which provider it is.

I posted a link below, but some states already mandate chargemaster transparency. It's close to useless, as one quickly discovers that (a) pretty much any procedure costs a trillion dollars, but discounts apply and (b) the consumer's view of "procedure" and hospital system's view of "services provided" differ radically, as every gauze used up, every vital measurement, and every painkiller is a billing item in hospital's book (cost of goods and labor), but are integral part of the "procedure" the way the consumer sees it.

That some current laws are useless doesn't mean better laws couldn't be made. Mandate a final, guaranteed, all-inclusive price, or require disclosing every single discount made available to anybody, or even require charging the same price to everybody.

I think the real problem is that Americans mostly aren't willing to have their government going around telling businesses to cut out their shit or else.

I don't know if there are simple one-step solutions.

> Mandate a final, guaranteed, all-inclusive price

How would that work for something like birth? Depending on the amount of time spent in labor and a host of potential complications (some requiring presence of additional doctors like anesthesiologists or surgeons to perform a C-section) the costs will vary greatly.

> require disclosing every single discount made available to anybody, or even require charging the same price to everybody

That could work, as long as discounts don't evolve into kickbacks or rebates, but then why should an insurance company that signed up 10 customers receive the same discount as an insurance company that sent 100,000 people? The latter loses their leverage, which typically sends the prices up, not down.

It's definitely not simple, but I'm confident that it can be done. For something like birth, you'd have a baseline, then extras for various contingencies.

Why should an insurance company that signed up 10 customers get the same price as one that signed up 100,000? Because health care is fundamentally incompatible with free market capitalism (information asymmetry is extreme, demand curves are whacked, and there's often no competition due to time constraints) so allowing this sort of thing just leads to monopolies.

To put it another way, they should receive the same discount because if they don't, the smaller insurance company will go out of business and we'll ultimately be left with a few gigantic ones who use their market position to simultaneously squeeze hospitals and customers.

Aren't there single-payer systems where medical care is still private, and the government pays them for services? I doubt those systems would put up with "we'll tell you how much you have to pay when we're done" so I'm sure there are examples to follow.

So instead you sign a contract to purchase a car (with no take backs!) and only then do you get told the must-pay MSRP? That's about how medical pricing works today.

Some states do require chargemaster transparency, e.g. https://www.oshpd.ca.gov/chargemaster/

The ACA required hospitals to publish prices in some contexts.

http://thehill.com/policy/healthcare/204868-new-price-transp...

https://www.bna.com/hospitals-required-price-n17179910723/

Karl provides more detail in his write up than I could cover, and he links to two US Supreme Court cases in regards to the price issue

https://market-ticker.org/akcs-www?post=231949

Interesting, if ranty, hard to follow, and possibly overstated.

For one, there seems a distinction to be made between "publishing" prices and individually receiving a quote in advance of work. If there's a technical sense in which the two are equivalent, I would recommend clarifying in casual conversation.

Those requirements also don't seem (though I could've missed something) to be a part of anti-trust law, per se. The requirement that prices be consistent is, in the cited Robinson-Patman Act (although that seems to only apply if you're crossing state lines?)

Is it technical? There is a reason the US is unique in the world in both its unsocialized healthcare and in its costs. While socialized medicine now may not reverse the out of control spending, we can observe that the lack of it was the most likely cause. In the semi-private market of American healthcare that has been around since the 70s, the incentives structure has been absurdly broken for so long it should be no surprise you pay more for mediocre results.

At this point though, going with the known working solution sooner rather than later is the technically most plausible way to stop the cost expansion. It is exactly like people debating about national debt - you can't complain or argue about how to pay it off until you stop adding to it every year, often with an increasing deficit (which is how republican administrations for the last 30 years have governed).

It is crazy to argue that in the moment your house is on fire to try this untested strategy of using giant fans to blow the fire out that nobody else has done versus going with the tried and true use a fire truck to extinguish the blaze. Experiment after everything isn't on fire.

The problem isn't necessarily that it's a semi-private market, it's that for the vast majority of people it's tied to their employer.

The only for most Americans to have a choice in their health insurance is when they get to pick between the plans from either husband's or the wife's employers.

The biggest disappointment of the Republican alternative to Obamacare was not coming up with a way to sever that tie.

> disappointment of the Republican alternative to Obamacare was not coming up with a way to sever that tie.

Since that tie is also maintained by large amounts of political donations, it's going to be a hard one to break.

But tying it to an employer allows for group rate bargaining with the insurance company. I'm no expert in insurance, but I imagine there's very few instances where an individual will be able to negotiate a better rate for comparable coverage than they would get as part of a group.

Sure it cuts down on individual choice, but it should theoretically be the most cost efficient method, both for the employees and the insurance company.

It's inefficient in the first place that groups are limited to employees within a given employer instead of entire insurance customer bases or broad product based policy groups. It is very much not a cost efficiency to introduce employer sub groupings of customers.

Employer-based plans typically have lower premiums because they are, by definition, groups of working-age and (in most cases) working people. They are younger and less sick, so insurance costs are lower. (Dependents are typically more expensive.) This is the reason that companies, once they reach a sufficient size, self-insure, because they are carving out their younger and healthier population from the broader population. Plus, there are savings gained from administrative costs as well.

Selection of plans or providers is not the problem, especially with the current popularity of PPO plans.

I have a really hard time believing that somehow companies self-managing healthcare administration is more efficient than a large group consisting of the entirety of an insurers customers let alone vs. nations with universal healthcare or even ones with single payer private healthcare. And that doesn't even address the many small businesses which need to pay for "individual" plans as if there weren't larger groups with which to distribute the risk.

Even the marketing act of splitting up all these groups up as you describe is a huge waste. Now you have to shop the differences, the companies have to explain the differences, and everyone (insurance co, health provider, patients) gets to track multiple different groups with different rules. It's all a waste compared to fewer larger distributed risk pools - which is the whole point of insurance.

High marginal tax rates incentivizes employers to offer health care benefits instead of salary. This is a main reason why health care has been so closely tied to insurance. Either tax the benefits at the marginal rate, or reduce the marginal rate to liberate health care from employment.

By technical I don't mean unrelated to the question of who pays. It's certainly related. But, I think it's a mistake to spend too much time on the macro-level "medical care as a right" or "free markets."

Most medical markets (including the US') have large free market & "social" elements. I don't think moving one way or another along that axis would move the needle in a predictable way. That would be decided by the more detailed points. That's what I mean by technical

The Swiss spend about as much as the USA does on health care (as a percent of GDP) and have a similar mandated health insurance system, the main difference being that employers aren't allowed to provide health insurance as a benefit do there are no group policies (everyone is in the individual policy market).

The Swiss government spends about the same per head as the US government (and partly that's a currency problem).

However, US private spending is much higher, so the total cost of healthcare is higher.

The OECD numbers for 2013 put US per capita spending at $9,086 compared with Swiss spending of $6,325. The OECD median is $3,661.

It would be better to compare the USA with Canada, which has a universal healthcare system at a lower cost to the state ($3,974 vs $4,197).

I stand corrected, thanks! I actually liked the Swiss system when I was a part of it, even though I was a bit mad for having to pay for health insurance out of pocket at the beginning.

Switzerland also controls the max price of drugs as part of their gov't approval process.

"Drugs must be effective, cost-effective and appropriate to be listed in the positive drug list (SL/Spezialitätenliste). The federal government sets the maximal allowable public price for drugs in the SL."

https://www.ispor.org/HTARoadMaps/SwitzerlandPH.asp

It is also the most expensive of the european OECD nations...

A big problem is the U.S. is the level of profit enjoyed at the top tiers of the healthcare supplier verticals.

Which either demonstrates everything that is right or everything that is wrong with the world's leading free-market capitalist economy...

That was basically the conclusion of the widely-circulated SlateStarCodex piece [1] -- that health care (and schooling, and housing) are becoming much more expensive with no clear reason why, and if it weren't so expensive, we would all be in much closer agreement on what problems need fixing and be able to reach a compromise.

SSC in particular noted that it was not any individual salaries that were the problem -- everyone's pay seemed about reasonable. Rather, what made the US so different was how much they had to spend in near-paranoid countermeasures against the dreaded "lawsuits".

That, I think, provided the clearest clue: in Europe, it's near impossible to "sue the school", "sue for malpractice" if they adhered to the regulations, and if you can, the loser pays. On top of that, the state automatically covers the injuries, so it's much less likely for resources to get lost in the black hole of litigation and discovery.

[1] http://slatestarcodex.com/2017/02/09/considerations-on-cost-...

HN Discussion: https://news.ycombinator.com/item?id=13613687

Costs are also somewhat ideological too. A good for instance is the US belief in suing any time something bad happens. From what I can tell, 10% of every dollar spent on health care in the US goes towards malpractice insurance for doctors. A system that acknowledges that well-meaning doctors can make mistakes and shouldn't be unduly punished could cost almost that 10% less. America's health care system is designed for the %0.1 case literally at the expense of the %99.9 case.

Also, the lack of universal coverage here means that a lot of medical bills go unpaid, for many reasons including bankruptcy or even people giving the emergency room a fake name when they go in. The hospitals don't just eat that cost, they amortize it into the costs paid by patients who do pay their bills. Universal coverage would, therefore, lower the cost of care per individual by eliminating the costs of trying to collect from uninsured people who can't pay.

But the biggest ideological cost of health care in the US is our insistence on including the "free" market in paying for health care. Insurers have a ~25% profit margin. A single-payer system could be very inefficient and yet still come in far below that cost.

> From what I can tell, 10% of every dollar spent on health care in the US goes towards malpractice insurance for doctors. A system that acknowledges that well-meaning doctors can make mistakes and shouldn't be unduly punished could cost almost that 10% less.

There's no such thing as a free lunch. If you don't pay for the damage caused by doctor's mistakes, you are just offloading part of the cost of your healthcare system onto a few unlucky people. If you do pay for it but it's not paid for by the doctors, you just re-invented malpractice insurance but with a different source of funding.

Ahh...but what percent of malpractice payments are consumed by legal fees? Enough for many, many free lunches.

Also, if health care coverage were universal, we wouldn't need big medical settlements to cover future medical costs since those costs would already be covered.

But mistakes happen. How you deal with those mistakes is an ideological question. Do patients who suffer from those mistakes deserve large settlements to the detriment of the vastly larger amount of patients that receive quality care? The US system believes that while other countries choose to lower costs at the expense of those unlucky few.

The problem is not a technical one. It's about idealogy/belief.

The left believes that healthcare should be a right - that everyone should get care regardless of whether you are homeless, or a billionaire.

The right believes that it is not a right. That you should only get healthcare if you earn it. If you are homeless, too bad. You die.

Now, conservatives know that they can't come right out and say it that way, but ultimately, that's what a lot of people believe. They don't want to pay for someone else's care.

So, the arguments aren't really about 'what is the most efficient way to pay for everyone to get healthcare'.

The arguments are about the fact that half the population doesn't want to pay for healthcare for someone else.

That's certainly the standard left-wing perspective on it, yes. The problem with this is that just declaring something like healthcare a "right" doesn't give people it - you need vast numbers of doctors, hospitals, surgeons and medications and supplies, all of which have to be funded and organised somehow. You need some way of keeping the costs under control and the services operating effectively across something with hundreds of millions of customers. The American left has no more idea how to do this than the right, so they resort to emotional appeals instead.

> The problem is that getting costs down is almost impossible. Costs are salaries of doctors & nurses, a giant pharmaceutical industry, thousands of radiologists, ultrasound technicians, the machines they use (far more frequently than europeans)…

Those aren't the only costs though. A lot of the cost is on useless things like bureaucracy, middlemen and duplication.

For example, there are two very large hospitals within about a mile of my home solely because one of the insurance providers likes to build its own and providers don't like to share. You could cut costs significantly by simply demolishing one of the buildings and moving the staff to the other one.

In the US, who pays affects how much one pays.

Health insurance companies are able to negotiate lower prices for their subscribers due to leverage. Likewise, single payer would mean all subscribers would have their prices negotiated through a single entity.

Without consolidation of payment, the anti-trust exemptions for the healthcare industry means patients cannot effectively negotiate the cost for their care.

Single-payer would remedy that.

With all the leverage Medicare spending per capita (and that capita got a pretty huge boost with US population aging and baby boomers retiring) is still growing year-over-year. Their biggest claim to fame is to compare themselves to private insurers, where the growth is even more insane.

Good points but important to point out that driving down costs may not be a net negative. From Buffett's comments in the video he seems to be indicating that business are more likely to make investment and hiring decisions on the basis of high and ever-increasing health coverage costs than a change in corporate tax.

Capping or reducing healthcare cost as a % of GDP may help many other sectors to expand. On this basis politicians should first try to get the support of corporations to reduce their insurance costs, and try to change the argument - sustainable healthcare for all. This kind of corporate backing would counter the inevitable lobbying of pharma/medical corporations who will put their resources into countering any legislation that reduces their profit margins.

The problem is that healthcare is more concentrated which always helps with lobbying efforts.

Pharmaceuticals are 5 large companies. The rest of the economy is 500. So let's imagine there is a bill that would reduce the cost of drugs by 50 billion dollars. Each non drug company would stand to save 100 million but each pharmaceutical company stands to lose 10 billion. This is a classic coordination problem, and free riding dictates the pharmaceuticals win everytime.

True. I think that if Buffett wanted to address this problem his best option would be to fund an entity that could lobby on this issue and match dollar-for-dollar pharmaceutical company donations for house reps and senators that were willing to push to reduce the cost of healthcare.

Tackling healthcare is one 'big issue' that could have a huge effect on the US economy and living standards. Seems a worthy 'legacy' project for Buffett to finance.

I think cutting costs is the solution as well.

Wouldn't cutting down regulation, and reducing the AMAs monopoly on doctors help?

Less regulation = less costs.

More doctors drive costs down too.

Maybe. I don't know where the money goes to say what we can cut. Are wages our biggest cost? If so, I'd imagine salaries have to come down across the board but especially at the top. Sadly I don't know how.

The National Association of Health Underwriters have this brief, non-partisan analysis of healthcare cost drivers in the USA and some proposed solutions. (PDF warning)

http://www.nahu.org/legislative/policydocuments/NAHUWhitePap...

I haven't seen a mechanism for lowering price without collective bargaining. That's why I see a single payer system as a must for the problem you've described here. I'd like to hear more alternative views on this though.

The cost of goods (computers, phones) went down without collective bargaining, and it seems like so did the cost of services (haircuts, plumbing projects, airline tickets). Opening up the supply side seemed to do the trick.

What would happen if US (a) lowered the bar for doctor certification or (b) automatically recognized foreign doctor and nursing diplomas from English-speaking (or Spanish-speaking, to accommodate some states) countries?

More lawsuits would happen for sure. And the rulers de jour do not want any more immigration.

The problem outta not on the supply side, but at the parasitic insurer and drug supply side.

Insurance companies have a statute limit on profit margins and are required to refund excessive premiums. And prescription drugs constitute only 10% of medical bills http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%...

In other words, even if all Rx drugs were made free, current total healthcare cost growth rates would eradicate those savings in less than 2 years.

I agree with you -- the cost here is prohibitively high for many folks I know, and the politicians makes hay each election season switching groups that will take the most hit.

So HN, this field here is ripe for disruption. Like the kitchen remodeling stand at Lowe’s or Home Depot, why not a booth to connect people to competent doctors and medical specialists in Europe, Russia, or India with all medical records and diagnostics online, allowing people find the most competitive prices and options for their medical services.

Right now for a surgery if you need it, there are least three 14 hour non-stop direct flights daily to India or Dubai where well equipped hospitals and experienced surgeons will be available (added: at a fraction of the cost here)

> this field here is ripe for disruption

meaning what? that a VC funded startup should come in and start offering health insurance? what are you suggesting? what does disruption even mean in this context?

let's get away from those corner cases where it's even thinkable to fly to Dubai for surgery. that's a high cost intervention for specific (wealthy) individuals. that isn't solving the problem of providing health care for 300 million people. how do you propose we do that?

Nothing to do with insurance or VC. Think of a consumer service at Walmart or Home Depot, helping people get very competitive services at prices to fit people's need.

Yes, travel is not a total solution for all 300 million people, but think along the lines of many packaged tour companies in cities who cater for international travellers and can arrange such facilities very efficiently. (I once had dental work done in India, and people don't realize how easy it is, the same kind of thing that you get here.)

Walmart already provides a handful of services of the kind you're mentioning. They have low cost clinic services (at some locations) for flu-shots, eye exams, and prescription drugs. Expanding those services would require having MDs on staff and on location.

There are plenty of businesses trying to offer more accessible medical services also. Urgent Care clinics are becoming popular in New York City, where I live.

None of this is doing much about cost though. The Walmart style sells things cheaply that are allowed to be sold cheaply. They don't sell what they are prevented from selling due to regulations or due to non-viability of offering the service due to staffing limitations. The Urgent Care style is going through the private health insurance system like just about every other medical care provider.

So I suggested an insurance "startup" because the space that seems to lack innovation is the payment side of the health care industry.

You are just changing the problem, not solving it: the American health care would downgrade (less money to spend) and the people from that countries would complain that their access to health care got worse because of Americans.

This is a good point. If we could avoid massive expansion of arbitrary and innovation-killing biotech regulations, then the market will eventually correct the current shortcomings and will catch up and work within the current framework. This will lower costs and drive up quality of care. Silicon Valley potentially has an important role to play here.

I agree with you completely that cost reduction is fundamental, but I disagree with you that the problem is more technical than ideological. Who pays is just as important as how much it costs, because under some regimes we get spectacularly unjust outcomes because of ideological constraints on who pays.

In other words, a privatized system will always fail to adequately cover certain groups of people: the poor, those with unusually expensive conditions, the unemployed, the elderly, etc. Providing coverage for those groups, motivated by humanitarian concerns, is the reason there is so much ideological debate. The system as it is currently constructed uses a combination of limited-scope public services (medicare for the elderly, medicaid for the extremely poor) and heavy-handed regulations (various acts of Congress) to cover those groups.

That is why we have so much ideological debate and why it needs to continue. Cost reduction alone won't solve the totality of issues in the system.