> In the US you can happy if your cost for seeing a doctor is less than 4 digits.

My wife and I have never paid four figures for a doctor visit, despite having two surgeries (one oral), a calf strain, and a dislocated shoulder (with ER visit) between us. The state of medical care in the US is bad enough as it is; you don't need to make up hyperbolic bullshit to make it seem worse.

You walked away from multiple ER visits including surgeries for less than four digits out of pocket? Maybe consider that your experience is the exceptional, not the people you call hyperbolic.

My son had a laceration glued together (dermabond in lieu of one or two stitches) and that was either close to or slightly over four digits after totaling the hospital bill and doctor bill, both in network.

My son just had a laceration that needed closed up a week ago. We didn't even take him to the ER, just his pediatrician who saw him for all of 5 minutes. She didn't even use any skin adhesives to close up the wound, she just taped it together and called it good. $120 for literally putting on a bandaid that came apart before we even finished the car ride home leaving us to tape it up properly ourselves.

How much support stuff does your doctor have? Industry wide, admin expenses are now 5x the cost of the care providers. Your doctor probably needs $X revenue per hour just to keep the lights on.

You didn't pay $120 for the doctor to slap on a band-aid. You paid $120 for the peace of mind of having a "trained professional" do it and tell you that was an acceptable solution. It's the same reason people call plumbers to snake drains and pay mechanics to change brakes. Those are basic things that the least trained workers in those industries are capable of doing but you pay a premium to not have to think about it.

Nothing about the situation required an expert opinion and the pediatrician made a pretty poor decision to boot. It was abundantly clear that the wound just needed stitches, that's not something I can do myself. In the future I might just get some Vetbond, because if I had that on hand that would have been preferable to the care received from paying an expert $120. No other developed country on the planet is this backwards when it comes to health care.

I'm fine with paying a premium for trained professionals, I'm fine with paying doctors a high wage. $120 is crazy for a doctor who already has an opening in their schedule taking less than 10 minutes to glance at a wound and slap some steri-strips on it.

The US, in general, is hell bent on forcing consumers to be experts in everything if they don't want to be screwed over on prices.

One ER visit. The surgeries we're both planned, and I went to an urgent care for triage of my strain, then to a regular orthopedist.

> Maybe consider that your experience is the exceptional, not the people you call hyperbolic.

I'm not saying I'm typical. I'm saying that four-figure Mexican bills aren't. If they were, then I'm an extreme outlier, which I don't accept.

I'm certain your visits were four figures, you just have good insurance.

I fell down the stairs and had a muscle spasm in my back. Had to go an ER. I had insurance that was considered good and it still cost me $350 for 10 minutes with the doctor and a bottle of muscle relaxers.

An ER visit is not the same as a simple doctor's visit. If ER visits are necessary (questionable in this case), they are covered by insurance - by law. Your deductible still applies.

Who cares about the deductible? It’s still a ripoff. My girlfriend had an eye infection while we were in Germany. We went to an eye doctor and paid 25 Euro cash including an ointment. The US is just horribly expensive and very unpredictable.

"You should care about the deductible, cause you entered the contract, silly."

This is stupid. There is no real way to shop and bring down health insurance costs in the US. It's tied to your job, meaning you would need to get many job offers, and turn them down when you find out the actual insurance costs until you find one that's better, and ignoring other employment factors.

And then everything can change the next time open enrollment comes around. Don't like the deductible, time to start the job search again! Oh, and the deductibles are probably about the same at all the other companies, anyway.

It's just a stupid system from top to bottom, locked into place because our political representatives are completely uninterested in governing.

When I worked at HP/HPE, we had decent insurance. My family rate was average, not too expensiv. After they spun us off to DXC they claimed to be contributing the same amount, but our rates went up to about double or triple per pay period (varied some with the different plans).

Insurance isn't tied to your job. You can (and often should) forego the employer's plan and purchase insurance on the open market. Most insurances have some form of deductible, it's what keeps them affordable. Insurance should be protecting you against a huge financial fallout, not against petty expenses.

I agree it is a stupid system though and I'll tell you why: People want something for nothing. They want coverage for everyone, they don't want a tax, but they don't want compulsion to purchase and they also want to force insurers to take people with pre-existing conditions. Insurance can't work that way, the money has to come from somewhere.

If there was a compulsion to purchase, the system could work, as it does in many other countries. That's probably unconstitutional though, so it probably wouldn't stand.

Lastly you have "Medicare for all" which would basically bankrupt hospitals if you extrapolate from what current Medicare does to them financially.

You honestly can't blame representatives for dealing with voters that understand nothing and want everything. They voted for Obamacare, then they voted for Trump to make Obamacare even worse. I don't even want to know what's next...

Thanks for engaging, your comments are interesting and thought provoking.

"If there was a compulsion to purchase, the system could work, as it does in many other countries."

Wasn't that one of the major points of Obamacare, to make strides in that direction? And it did pass Supreme Court scrutiny, who decided yes it is a tax, and yes the government is allowed to tax us.

"Lastly you have "Medicare for all" which would basically bankrupt hospitals if you extrapolate from what current Medicare does to them financially."

Across our economy, competition and technology drive higher quality at lower cost. Doctors and hospitals need to have an incentive structure that rewards keeping the most people healthy at the lowest cost. "Capitation" models are meant to provide these incentives, where you don't get paid for "doing things" to patients, like ordering tests or performing surgeries. You get paid a fixed sum per patient to keep them healthy, adjusted for the "risk" associated with the patient (for example, if they have a chronic condition that needs ongoing treatment).

So an intelligent "Medicare for All" system could be designed to incentivize innovation and cost cutting and overall patient health, if implemented intelligently.

It’s tied to your job because health ins through your employer gets an effective tax discount compared to that bought through the ACA market. There is no way for latter to be as economical.

I've priced insurance outside my job. It's never even close and your employer isn't going to hand you the money they were spending on your policy. You basically pay at least 150% and give you employer money if you want to self-insure. You still won't be able to pay your policy if you get critically injured, so what's the difference.

In what way is your comment about price fixing relevant? I don't care if the lower price is because of price fixing or not.

"you're completely ignorant"

Thanks. Very stylish.

mate, the health situation in the US is a joke. the US is less healthy than Oman and Slovenia.

$359 is an order of magnitude less than four figures.

It's also about what we paid for my wife's shoulder. Which, like I said, is bad enough on its own.

What is included in that fee is malpractice insurance premiums (because it isn't that nothing can go wrong in that 10 min interaction which causes you to sue the doctor) paid by the doctor.

On the top of that, he didn't charge you for what it was, but for what it wasn't and confirming it.

Take for instance if that muscle spasm actually lead to something darn serious, the doctor ruled that out, that's why he sent you back after 10 mins. For some weird reason (or counter-intuitive economic reasoning which everyone has got), if you had a serious problem, and the doctor had identified it in that 10 mins, then you'd be ok with that billing.

See it this way, if you're tech security contractor and the CEO calls you urgently to come take a look at suspicious behavior on his computer which he thinks might be a hacker hacking his computer, but it turns out to be a quite known windows bug, that doesn't mean you shouldn't charge him your regular fee if it was an actual hacking attempt. You're getting paid for being on call.

That price has little to do with malpractice premiums. You're paying for the fact that the ER was there, fully staffed, ready to treat literally anything that you could have walked in with at a moment's notice. That and you're subsidizing people who don't pay.

I went to the ER thinking I was having a heart attack, and it turned out there was nothing wrong. The doctor who saw me afterwards thought it might have been intestinal spams. I got to pay $6,000 for that bit of entertainment.

Let me guess - your deductible is 6000$?

Is that really relevant though? That should never cost anywhere near that much.

It's relevant because the doctor probably charged EVEN MORE than $6,000, and mikeash only saw $6,000 of that because it was his entire deductible.

Did you pay the bill outright without negotiating?

Yes. I couldn’t find an angle to negotiate with. I could afford to pay, so trying to use hardship as a lever to bring down the bill wouldn’t have been honest.

Normally you just call and say youd like to lower the bill

Not so easy if you’re google-able and clearly work in tech. They won’t squeeze blood from a stone, but if they smell money, they aren’t going to negotiate. The advice frequently found on reddit about negotiating is good, but keep in mind it’s targeted at individuals with, best case, 0 net worth and worst case hundreds of thousands in debt.

Your mileage will vary depending on the bill collector, hospital system, staff etc., but keep in mind someone has to be paying the bills. American, work in tech, post on Hackernews? It’s probably going to be you.

Always worth a shot though. Worst case they’ll usually let you go on a 0% APR payment plan for years and years.

Why would they respond with anything besides “fuck you, pay me”?

When I did ask, their response was basically a more nicely worded version of that.

In my experience that doesn't work.

If you're willing to risk your credit score for a bit, just don't pay the bill. Eventually some entity down the line will accept less. If you don't want to do that, then you have to eat it; immediately or in installments.

I really don't understand this 'labor theory of value' thinking.

Just because there wasn't anything wrong doesn't mean you don't have to pay a person for their services.

That’s not what I’m saying at all. I’m saying that the cost was way too high.

How much does an ER visit like that cost in a sane country? I mean the actual cost, not the “free” that the patient might see from a socialized system. It’s nowhere near that high.

I stepped on a coal that was knocked out of a bbq grill at a 4th of July party. I went back and forth on whether I should go to the doctor, but the nurse line suggested that I should. 30 minutes, a nurse and doctor saying “don’t pop the blister”, and two Vicodin later I had a $2500 bill to pay off as a broke college student.

I guess I shouldn’t have gotten injured on a federal holiday.

Wait until you need dental surgery. I've never found a dental insurance that allows paying out more than $1,500/year. One gum graft alone is about $2,000. Dentures, replacement teeth, these all cost multiple thousands of dollars.

True. One thing I have noticed about dental though is that they give reasonable upfront estimates which is something most other doctors don’t do.

They do that to keep insurance away. Dentists have it much easier.

A basic non-complication natural child birth will cost at least a couple of thousand out of pocket for most insurances.

With insurance, more complicated births aren't that much more. We were out of pocket $4k for the birth of our twins (maxed our deductible). The total 'sticker price; was over a million USD (they spent a combined 10 weeks in the NICU).

Over a million for 10 weeks in nicu? Who sets these rates?

Our local hospital tried to charge our insurance $20k for 1 hour of the recovery room and $25k for 1 hour of the surgery room.

We have a friend whose hospital tried to charge them $15k for a delivery room they never used - never used because the doctors forgot about them and she delivered her own baby in the hallway. Talk about two major fuckups in a row.

To be "fair" that also includes the c-section delivery...

Wife passed out on the way out of the hospital after getting an IUD put in.

With insurance we paid $800 for her to lay in the Er for 3 hours.

My 6yo son went to the ER with blue lips and we ended up with a $1400 bill for a glorified strep test.

It happens with high deductible plans.

When I had back surgery I was with a public employer PPO. Total out of pocket was like $300 for about $500k of procedures. Half the people in my recovery PT were selling cars and emptying 401ks to make the mortgage.

That’s the crazy thing about the US system. For a lot of people things work smoothly like it did for you. Then you have a significant number of other people who get totally screwed with out of network stuff, billing errors and the insurance declining payment for random things. These people now have to have to negotiate often for years, fight collection agencies and often end up owing thousands and tens of thousands of dollars. It’s a big gamble and there is pretty much nothing you can do to protect yourself.

That is generally the failure mode of complex systems. Say if you made flawed software a couple of decades ago, chances were it crashed. Today flawed software will produce many different errors. Not that the former is necessarily better, just that it is something to understand about the modern world were we aren't limited by scarcity. Same thing with e.g. food or education.

> It happens with high deductible plans.

I never said it doesn't happen, which seems to be the strawman most people are responding to. However, there is a huge gap between "it happens" and

> happy if your cost for seeing a doctor is less than 4 digits

which I indicates this is common and typical.

It depends on who you are and what you do. My health insurance costs more than what a typical minimum wage workers gross compensation.

Just one of my blood tests alone cost $4,600. Surprise billing. "Out of network". Didn't even know to ask. Doctor, lab, everything all under the same roof. Why would any one even think to ask?

In fairness, the US typically does not cost $1k+ for a simple doctor visit.

> My family in Germany throws a fit when they have to pay 50 Euro for something.

Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.

> In the US you can happy if your cost for seeing a doctor is less than 4 digits.

That isn't generally true. Every insurance plan is different. Cheap plans have a high deductible. It's similar to private insurance in Germany.

It's basically like this: If you're gonna be poor, go to Germany. Everyone else will pay for you. If you're going to earn well, leave Germany, otherwise you're going to be paying for everyone else.

This is missing a few important points.

1. The 15% of income has a cap. It's something like after 60k EUR in wages you don't pay anymore. Also, only 7.5% comes out of your paycheck, the employer pays the other half. When I was there a few years ago I was self employed so I had to pay "both sides". It would've worked out to roughly 750EUR/month for health insurance which had _0 deductible_ and _0 coinsurance_ for doctors visits or ER care and would've covered my entire family no matter on my children I had. Compare that with a typical HDHP family plan offered in the US and you're looking at $400/mo in premiums, with a $3k deductible and max OOP of $6k. The final cost is comparable.

2. The 15% is only if you participate in the public system - the private is not tied to your income.

>> Also, only 7.5% comes out of your paycheck, the employer pays the other half

You might delude yourself that this "other half" is paid by the employer, but in reality your employer takes that cost into account when employing you, so they offer you lower gross salary because of that. In other words: it's still paid by you, just indirectly.

EDIT: more clear wording.

> Also, only 7.5% comes out of your paycheck, the employer pays the other half.

That distinction is imaginary. It all comes out of your total cost for employer, which either goes to you or to (possibly earmarked) taxes.

This doesn't mean the amount is not fair (it very well might be). But it's important to realize it all comes from your paycheck.

> Also, only 7.5% comes out of your paycheck, the employer pays the other half

This just means that paychecks are 7.5% lower then they would otherwise be. It is a mistake to think that the employer paid benefits are "free". The market adjusts. You find that out right quick of you are self-employed (at least in the US).

The difference is that the other 7.5% (plus a few more such line items) don't appear in your progressive tax rate, and they also don't appear in "how much do you earn in country X" comparisons.

In most countries, even the first 7.5% don't apear in your tax rate.

But still, if you count everything together, for a 2keur net paycheck you have to charge your customers 4.8k in my country (slovenia), and the government takes 2.8k (social benefits, pension, health, income tax and VAT). Say what you want, but 4.8k->2k is a huge amount of taxes.

> The 15% of income has a cap. It's something like after 60k EUR in wages you don't pay anymore.

...at which point progressive income tax starts kicking in badly.

> Also, only 7.5% comes out of your paycheck, the employer pays the other half.

Guess what, the employer pays 100% of your paycheck, including your vacation, pension, healthcare and taxes. It doesn't really matter to the employer how the cost is labeled. That's why you get to charge more when self-employed.

> The final cost is comparable.

Comparable? It's almost double if you don't take any care. Also, what if you don't have children? It's apples and oranges.

> The 15% is only if you participate in the public system - the private is not tied to your income.

Caveat: You are forced to take part in the public system unless you earn well or you are self-employed.

"It's basically like this: If you're gonna be poor, go to Germany. Everyone else will pay for you. If you're going to earn well, leave Germany, otherwise you're going to be paying for everyone else."

You should add this to your algorithm for location choice: If you get a serious health problem and want to become poor, come to the US.

You’re not that far off from reality. I’m currently in the US because career opportunities are far superior here.

However, if I were to get seriously and chronically sick I would back to my home country. Not that i couldn’t get very good care in the US, but the system here is just a massive burden compared to countries with universal coverage.

> You should add this to your algorithm for location choice: If you get a serious health problem and want to become poor, come to the US.

If you already have a serious health problem, you'll be hard pressed to find any country to take you and just take care of it pro-bono, if you're uninsured.

German public insurance only covers the bare minimum. I know enough people who are poor because of serious health issues. Sure, their medical costs were covered, but they're now welfare cases. They can't afford many treatments that would make their lives better. They would've had to buy extra insurance, but they chose not to, or couldn't afford it.

Relating that to the US: Don't skimp on insurance. Don't get an insurance that is capped at a low number, otherwise you will go bankrupt if shit hits the fan.

>Don't get an insurance that is capped at a low number, otherwise you will go bankrupt if shit hits the fan.

But shit will not hit the fan for the overwhelming majority of people. There's no good reason for someone in their 20s (or 30s) with, no dependents, no history of medical problems and doesn't partake in a dangerous lifestyle to load up on coverage. Loading up on coverage in that situation might make you feel warm and fuzzy. It might win you internet points. It is not financially sound.

> Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.

And that's kinda the point of the parents' post, I think. If I were paying 15% of my income for socialized health care, I would be pissed if I ever had to pay anything out of pocket for my own medical needs.

>>Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.

Comments like this always miss the larger point, which is that healthcare overall is cheaper in socialized systems because the government as a large entity negotiates on behalf of citizens and puts strong downward pressure on prices.

Meanwhile, US governments pay more per capita for healthcare than other "socialized medicine countries", but with terrible clinical outcomes.

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

I wouldn’t say that the govts of socialized systems negotiate rates down, it’s more of “this is what you will get paid”.

Salaries for doctors are the highest in the US. If we want to move to a single payer system they will have to take significant pay cuts.

Guess what, private insurance companies will also negotiate prices.

What happens in socialized systems is that the government does price fixing, which makes healthcare worse and it limits supply. Try getting a specialist appointment with socialized healthcare in Germany, it can take several months. Get private insurance (or pay out of pocket) and suddenly appointments become available. Doctors are leaving the country in droves.

Some of the hospitals in Germany are in an abysmal state, MRSA rates are extremely high:

https://correctiv.org/en/latest-stories/super-bugs/2017/01/1...

>>Guess what, private insurance companies will also negotiate prices.

They negotiate prices based on the size of the pool. This is why if you are a small business the rates you will get will be worse than if you were a large enterprise.

With socialized healthcare, the pool is the entire citizenry, which is what gives the government substantial leverage when negotiating.

The German government doesn't negotiate anything. They set prices, period. Set them too low and you create shortages. Guess what the German healthcare system has, it's a shortage of doctors, especially specialists. German doctors are leaving for greener pastures, like Switzerland. They are replaced by doctors from Eastern Europe. Quality suffers. Waiting times are high. Most Germans are too uninformed or arrogant to admit it (especially to Americans) but the system sucks.

That's not to say the American system is good, but I can't stand all this talk about how socialized healthcare is so great. It isn't. A lot of what people are calling "socialized" systems are actually private systems with a compulsion to purchase insurance, for example Switzerland, Netherlands, Australia. Even Germany technically has a dual system (public and private) but only the top earners are allowed to go private.

> The German government doesn't negotiate anything. They set prices, period

Incorrect. In the public system, the fees are negotiated between the GKV Spitzenverband (federal association of public health insurers) and the KBV (federal association of public doctors).

Germany still is in the top group regarding quality of care indicators.

Australia doesn't have any compulsion to purchase insurance. It's perfectly normal to skip it and receive treatment on Medicare. However, if you don't have private insurance, and have a relatively high income, you pay a tax surcharge.

You have a point. There are a lot of people comparing the worst parts of the US system with the best parts of the single payer systems.

As a Canadian, I will say there are a lot of people dissatisfied with the Canadian system. Likely to a lesser degree than in the US, but the system is far from perfect.

Health care can never be perfect unless you (personally or government) are willing to pay an indefinite amount of money towards it. The positive with an imperfect socialized system is that it's under democratic control. In other words society decides what to prioritize.