It is remarkable how quickly and completely the noble ideals of the professions (medicine and law) have totally fallen to the profit motive. Now, you are a fool if you show self-restraint, because no one will notice, and your unscrupulous competitors will eat your lunch. It's the kind of pervasive corruption that can only happen when literally everyone in the system, including the victims, have given up.
The minimum viable remediation is a two-tier system in which the government takes the "or die" out of the conversation. The best approach IMO is single-payer where the government takes the "pay up" part out too, as it allows the system to be globally optimized.
At the end of the day health insurance isn't insurance, it's at best a structured payments plan. You buy insurance against things that may or may not happen. You will get sick and you will die. That's not insurance.
[1] https://corporatefinanceinstitute.com/resources/knowledge/ec...
Further there is also a general societal argument that we all benefit more from having a more healthy population than dealing with the external costs of a less healthy one.
45,000 people die each year in the US without care. Ending that would go a long way to reducing government violence. [1]
[1] https://news.harvard.edu/gazette/story/2009/09/new-study-fin...
On top of that, even "pay-up-or-die" doesn't mean that the price will be a billion dollars. Instead, it means that it's the price that maximizes total profits. Suppose that no one could ever pay more than $30,000 for the medical helicopter. Then the helicopter people would set a price that prompts people to pay as close to $30,000 as they can. Perhaps if patients see a bill for $50,000 they negotiate down to $30,000, but if they see $500,000, they go to court and only at the end pay $30,000. Similar dynamics can limit food prices in areas that really only have one food supplier - there's only so much you can charge, and if you charge more than that, you won't succeed in squeezing more out of them, but you may attract all kinds of trouble - violence, or legislation, or competitors, etc.
And you need a citation for your claim about when free markets do and don't work.
Of course you have. The first thing you did when you walked in was hand them your ID and coverage info. You think hospitals operate on the honor system?
As a Canadian I've never been asked to pay up before or after receiving treatment [edit: at the point of care].
And before you jump into taxation, Canadians pay less per capita in taxes than Americans ($13K vs $14K), and that's before you factor in the $600 per month in private tax you directly (or indirectly via employer) have to pay your insurers.
> Especially when I arrive there unconscious.
You either have insurance or you're driven into Chapter 11. Further I suspect this is not due to good will but rather government intervention.
> And Herb Cohen would say once you've received the service, you're actually in a great negotiating position.
The debt was incurred once the service was rendered, and you are now liable. 66.5% of all bankruptcies in the US are medical -- are they just bad negotiators? I'm not sure what point you're trying to make but it's not in good faith.
> People actually negotiate hospital bills all the time. Especially in those crazy stories you hear about.
That sounds the worst.
> And you need a citation for your claim about when free markets do and don't work.
Voluntary contractual exchange is one of the undisputed key pillars to a free market economy. If you're being told you will die without the service it is a coercive exchange and therefore violates one of the key tenets. [1]
If I hold a gun to your head and tell you to buy my oranges for $1000 or I kill you, is the free market price of oranges $1000? If I tell you that you have cancer and you'll die unless you get $48,000 worth of chemotherapy, is that a free market? [2]
A free market requires both the voluntary production and voluntary consumption of services.
[1] https://en.wikipedia.org/wiki/Free_market
[2] https://www.asbestos.com/featured-stories/high-cost-of-cance...
The overwhelming vast majority of people have health insurance. However, due to taxation of privately-purchased insurance but not insurance that's a work benefit, people are driven to get insurance through their job. This was the government's fault, by the way. If people lose their job, they lose their insurance along with it. People without jobs have lots of financial problems. If they have a medical problem this situation gets far worse and results in a lot of bankruptcy. You seem to think bankruptcy is worse than negotiating. Clearly, it is often preferred.
As for your oranges question, no.
For the cancer one, possibly.
Do go on. Why is dying due to an explicit action any more of a free choice than dying of an explicit inaction? Why is one any more coercive than the other?
The only point I'm making is that healthcare is not a free market due to lack of voluntary agreement between buyer and seller. Once you accept that it's not a big jump to say the system should be remediated.
Because one is coercion and the other is simply an economic system. Which by the way is also used for all the other necessities of life too. How about food?
The whole point of a free market is competition, so if you were at least arguing for emergency situations there's be something to talk about since it's rather hard to shop around. But we'd still need to compare it to how well the government handles economics of emergencies. So far we have the govt driving up the cost of emergency care by requiring the ER to provide primary care for everyone without insurance.
In functioning systems the government drives down the cost of emergency care by setting the price and insuring everyone, and the results are clear. Canada's health care system costs $5447 USD, and Americas costs $10224. That's basically all I'll say about that.
Other necessities like food are in fact subsidized or socialized.
- The freeways? Socialized.
- The schools? Socialized.
- The police? Socialized.
- The fire stations? Socialized.
- The army? Socialized.
- The post office? Socialized.
- Healthcare for 40% of Americans? Socialized. (Medicare, Medicaid, VA). Medicare is socialized medicine. [1]
Food is also very much provided for if needed. SNAP and food banks provide socialized food to the poor. Americans pay less for food than anyone else on earth in no small part because the Farm Bill subsidizes production of corn and soy to the point these staples are sold at below cost to end users.
Either way that's a distraction and a red herring. Americans pay less for food than anyone else and more for medicine than anyone else. Eyes on the prize here, and stop carrying water for the insurance companies taking advantage of you :) All we're talking about doing is moving the percent of Americans covered by socialized medicine up from 40% to 100%.
> Americans pay less for food than anyone else and more for medicine than anyone else.
Is your point then that food is cheap because it is socialized at a 100% rate as you want healthcare to be? Or that your references to socialism are all red herrings?
Poor people can get free healthcare the same ways they get free food, Govt programs and charities. Food banks are private charities, by the way.
You are not defining coercion properly. It means force or threats of force.
Freeways are not a necessity of life, though we are certainly coerced into paying for them. At least they aren't as expensive as that Army you mentioned. Apparently you define all government spending as socialism, making the only other possible form of "govt" anarchy itself?
My point is food is cheap because the government intervenes, it's not a free market as you make it out to be, and yes food is provided to those in need. However, there aren't many in need in no small part because food is already the cheapest in the world in the US. That's not an exaggeration [3].
If medicine were the cheapest in the world in the US then nobody would be calling for its socialization. The current system is an abject failure. The food market, while I disagree with it, would likely be defined as a success.
I'm saying that in other countries with socialized medicine costs are controlled far better. Medicare controls costs far better than the private sector. Canada's system costs half as much, covers everyone and is ranked better along basically ever major axis. Life expectancy is declining in the US. Healthcare in the US is among the worst in the OECD and far more expensive. [4]
I'm saying that it's not as big a leap as you make it out to be, and that there's lots of precedent, domestically and abroad.
> You are not defining coercion properly. It means force or threats of force.
Coercion (/koʊˈɜːrʒən, -ʃən/) is the practice of forcing another party to act in an involuntary manner by use of threats or force. Threats or force. Pay up or get out and die is a threat, IMO, levvied by the system.
But even if you choose not to take that definition - it remains true (the only thing I've been arguing) that health care is not a voluntary contractual agreement but one taken out of necessity on an uneven playing field. This makes healthcare not a free market under most circumstances.
> Apparently you define all government spending as socialism, making the only other possible form of "govt" anarchy itself?
"In the theoretical works of Karl Marx and Friedrich Engels and subsequent Marxist writers, socialization (or the socialization of production) is the process of transforming the act of producing and distributing goods and services from a solitary to a social relationship and collective endeavor." [1]
Socialization in a primarily capitalist economy is defined as taking a for-profit institution and transforming it into an institution collectively funded and carried out for the public benefit. If the government owns and operates a service for the public benefit it is a socialized service. It is socialism - well, democratic socialism/social democracy. It is not incompatible with freedom, or democracy, or private property rights.
Yes, these are all socialized services. Explicitly yes for Medicare, Medicaid and TRICARE. [2]
The alternative to socialized services are privately owned and operated businesses. Not anarchy, necessarily, but libertarianism.
[1] https://en.wikipedia.org/wiki/Socialization_(Marxism)
[2] https://en.wikipedia.org/wiki/Socialized_medicine
[3] https://www.ibtimes.com/us-spends-less-food-any-other-countr...
[4] http://www.oecd.org/health/health-systems/health-at-a-glance...
"Threatening to not perform a service for someone" is not coercion, and does not invalidate a free market. A market is a place where scarce products can be exchanged between buyers and sellers who meet at an agreed upon price. The ability to refuse service is a prerequisite for having a market and the idea of private property itself, not some kind of unexpected flaw. The fact that something is scarce may well be problematic for some who cannot afford to outbid others who can afford it, but no system eliminates scarcity. Ask Venezuelans, who I am sure you were dying to talk about, what happens when you try to overcome scarcity with price fixing and free money. You simply achieve shortages.
In the 1980s the US did not have a 40 percent socialized system. The fraction of people on medicare was far less. Yet it was not the most expensive system in the world then. The US system is definitely failing, but it isn't the 300-year old market system that is causing it.
The only thing convenient is you not addressing my point :) The government intervention is a desparate attempt at not letting people die of disease and pestilence literally outside a point of care. You're asking for a dystopian hellscape. And that's what much of the last 300 years was with respect to medical care.
> In the 1980s the US did not have a 40 percent socialized system. The fraction of people on medicare was far less. Yet it was not the most expensive system in the world then. The US system is definitely failing, but it isn't the 300-year old market system that is causing it.
Yes it is.
Canada had a similar system until the 1970s, and it was bad. Then it switched over and things got better. America remained on the private system and it just got worse and worse.
Venezuela is totally and utterly irrelevant to this conversation. There are so many functioning systems with socialized medicine (all of Europe, especially the Scandinavians, Canada, Taiwan, etc, etc), Venezuela is an outlier and not even worth discussing. It's a failed state.
Whether you call it coercion or a power differential (you will die, the insurer or provider won't) this precludes a voluntary meeting of the minds necessary in a free market. Period.
No it isn't. Speaking of dodging the point. The US didn't remain in the private system, it half-socialized it. And you must know Canada's system has been increasing in cost like everyone else's.
And speaking of magic single-payer economics for the good of all, what's up with that "socialized" army you mentioned? Most expensive in the world also. I expect the very same wanton mishandling of other people's money when it comes to the eventual govt takeover of healthcare. Hell they are already doing it as that 40 percent govt part is outpacing world spending all its own.
Venezuela is just a difference of degree. The same effect is seen in everyone's lack of R&D spending outside the US.
The way a market works is people find ways to serve people at a price they can afford. When you always force others to pay for the cadillac service for them, no one bothers to find cheap ways to provide healthcare.
How can you be so twisted up about this? Americas system is the expensive one, everyone else's is cheap, and controlling costs better. Medicare may not be doing a perfect job but again it's controlling costs better than the private sector. What you are saying is strictly and objectively false.
Healthcare is optimized and improved in single-payer states, because there's still budgets.
You're defending the worst system out there from a cost perspective, and not top 20 in outcomes. And you're doing so by saying the system other countries are successfully using to control costs would fail to control costs, and using this to defend American's failure to control costs? You're telling me Canada is doing a bad job of controlling costs when it literally costs half as much per capita? Because their rate of cost growth is in line with their peers while America's is way, way beyond?
Your mental gymnastics are giving me a headache.
> Venezuela is just a difference of degree. The same effect is seen in everyone's lack of R&D spending outside the US.
And that? Also false. Venezuela is a difference of degree? What on earth are you talking about.
R&D spending? Guess which healthcare companies spend the most on R&D? It's not the American ones. It's all the European ones. #1 is Switzerland's Roche. #4 is Switzerland's Novartis. #6 is France's Sanofi. #9 is the UK's AstraZeneca. #10 is the UK's GlaxoSmithKlein. [1] This is yet another failed talking point.
Guess which country developed the first COVID vaccine? Germany. BioNTech's vaccine was paid for by Germany's government. Pfizer took $0 of US money and is productionizing a Turkish immigrant in Germany's German government funded research work.
You're just not right about this one, time to move on lol.
[1] https://www.fiercebiotech.com/special-report/top-10-pharma-r...
Roche has over 8000 employees in the US. https://www.roche.com/careers/our-locations/americas/usa.htm
A handful of giant international companies who obviously make a big fraction of their money in the US market (selling at higher prices due to the lack of price fixing) do not provide a useful metric. Try overall stats, such as here: https://efpia.eu/publications/data-center/the-pharma-industr...
And that'd just pharmaceuticals. The US has far greater dominance over other areas of biotech.
But you're right, I do need to move on. This immature flaming behavior is why I avoid toxic places like reddit.
1. That's in "millions of national currency units" (except in Japan which is in "hundred millions of national currency units") so the Japan bar is in 100M JPY, the Europe bar is in 1M EUR, and the US bar is in 1M USD. It was clearly not meant for comparison against regions, just over time.
2. Not only is the currency inconsistent the values weren't adjusted for purchasing power parity, i.e. how far a national currency unit goes in that country relatively.
If we convert the values to USD adjust for PPP the picture changes completely. All values in USD, PPP adjusted:
2016 - USA: $52.4B
2016 - Europe: $46.16B (PPP factor 1.225, EUR:USD factor 1.11)
This is about a 13% delta, not the seemingly 53% delta represented on the chart. Also, this is limited to EFPIA member companies.
Privatizing these would mean anarchism as there's no longer a monopoly on force.
>- The freeways? Socialized.
>- The schools? Socialized.
>- The police? Socialized.
>- The fire stations? Socialized.
>- The army? Socialized.
>- The post office? Socialized.
It's not anarchy to pay the fire department to put out your fire. It's libertarianism. Just like paying your doctor to splint your leg.
Even if I agreed with you, whether it risks losing the monopoly on force or not doesn't make it any less a socialized service.
This might be a fun read for you: https://www.newyorker.com/humor/daily-shouts/l-p-d-libertari...
I tell you to do work, and if you don't I shoot you. It's just economics; I'm trading not shooting you for your labour and everyone comes out happy
Were you making an analogy for the economics of socialized medicine with the forcing of labor?
They mail you these paper forms known as "bills". I have examples I can show you. Insurance only pays a portion. I suppose you can call it a kind of honor system.
And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable. One's ability to pay is not a factor.
One is of course that "I suppose you can call it a kind of honor system," no, you can't, it's enforceable by law and actively collected upon. That's not an honor system.
> And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable.
Yes, the bare minimum, then ejecting them out the back door as soon as they possibly can. Of course by waiting until they require emergency care you're fleecing everyone. Minor issues that could have been addressed earlier for pennies on the dollar are instead allowed to fester until they become life-threatening, then when the poor can't pay, it's socialized across those who can at the worst possible time for the highest possible price.
Not to mention, this is an argument against the free market approach which would just be to refuse service. This is actually bolstering my case that healthcare is not a free market because of a lack of ability to form a voluntary contract.
> One's ability to pay is not a factor.
Oh come on now. Who doesn't have health insurance? The poor. Who's going to get the bare minimum treatment required be law and getting booted out the back door? The poor. Who's then going to get a bill for it forcing them to declare bankruptcy? The poor.
This is strictly about one's ability to pay.
New goalpost eh? No they generally just treat everyone fully and pass the cost on to people with insurance. Trying to transfer uninsured people out leads to lawsuits.
This was a digression and exploration of how your specific situation exists because of government intervention. The alternative is to let poor people die outside, and that's distasteful to me, and to most.
A voluntary exchange between buyer and seller prior to exchange is necessary for a free market. You're describing a failure mode where a service provider is about to be screwed out of compensation and is willing to settle for less just to get something.
It's hard to believe you're advocating so hard for something so inhumane and dysfunctional.
You really are making a lot of bold assertions. If you declare bankruptcy, the hospital gets zero. Negotiation is a process by which both sides give something to meet in the middle. Yes they do it.
https://www.cnbc.com/2020/10/28/you-can-negotiate-your-medic...
Re: waiting times, take it from the horses' mouth, you've been fed a crock [1]. Of course the system could be better, but on the whole you're just wrong. The insurance lobby has spent a lot of time, money and effort to convince you of that.
The data backs that up. A small handful of Canadians go to the US to "shop for orthopedic surgery" out of millions of visits per year in Canada. After all a hip replacement in America costs one hundred thousand dollars. Just how many Canadians do you think there are with a spare $100K USD ($128,500 CAD) kicking around in the old piggy bank for a new hip that'd be free in a few months? [2]
If you see 50-60,000 ish numbers they tend to be the 'snowbirds' - Canadians living in Florida for half the year who choose to seek care close to their winter homes. These are folks wealthy enough to have winter homes, and also maintain private insurance.
[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...
[2] https://www.vox.com/2016/10/9/13222798/canadians-seeking-med...
This is exactly the issue. You cannot seriously think that the trainwreck that is US healthcare is what it is solely because of government intereference?
Would Cigna fund and run the tiny little community clinics that serve with sliding-scale pricing? Would Kaiser willingly insure students with preexisting conditions at a fair price? (I know that in my case, they wouldn't)
What "free market" incentive is there for these insurance companies to cover people that would clearly cost them more money than they receive? Those people need help and sickness/viruses do not have any concept of money, and they effect people indiscriminately.
You are promoting a healthcare system for the wealthy and privileged, which is exactly what we have right now and what needs to be torn down.
It's an NPR interview with Cigna's former head of corporate comms, an executive in charge of pushing lies about socialized medicine. He has since come to terms with what he'd done and is working to undo the harm he has caused to the American people.
"Canada has done a better job [re: COVID], I think, because of having the kind of health care system you have in making sure that everyone who needs to be treated is treated. And so that was what prompted that. And I felt that to provide some context, I needed to describe what I used to do for a living to try to scare people away from the Canadian health care system because insurance companies fear that. They know that if the U.S. moves to a system like that, it would certainly put a real crimp in their profits."
"Our industry PR and lobbying group, AHIP, supplied my colleagues and me with cherry-picked data and anecdotes to make people think Canadians wait endlessly for their care. It's a lie. And I'll always regret the disservice I did to folks on both sides of the border."
[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...
I do not believe that is the primary driver of costs, but it definitely does not help.
For those who don't know what we're talking about, private equity looks for companies with stable revenue streams such that if you find days to make lots of cuts, the revenue stream will continue for a long time. They then strike an agreement with the current owner to buy the company by having the company take a large loan (actually issue bonds, but it comes to the same thing) to pay off the current owners. That's called a "leveraged buyout" (in finance debt is often called leverage).
They then make those cuts and use the difference between revenue and costs to pay off the debt. They then try to juice up the corpse in various ways to find someone to sell the company to before the long-term impact of the cuts becomes obvious.
This happens in any industry with stable revenue streams. And healthcare has exactly that characteristic.
See https://ourfuture.org/20120913/sick-money-how-mitt-romneys-b... for an article on this exact phenomena.
It has completely ruined hundreds of industries: driving out all of the experts, wrecking product quality, making companies unresponsive to customers, eliminating good jobs, ....
The monopoly on force which defines the state must first form before there can be any government regulation, and thus must inherently form outside of government regulation.
Once that forms, of course, there is virtually no example of anything in human society forming outside of government regulation.
But taking the absence of evidence of how things behave “outside of government regulation” for evidence of ones preferred view of the difference between life under government regulation and without it is rather unwarranted.
That's tautological statement. There is no free market without private property protections which do not exist outside of government regulation either.
Government protecting people's rights, vs. government protecting people, or government prohibiting consensual business dealings.
You don't have to fall for it, though.
There is certainly the danger of regulatory capture that increases the costs for competitor to enter a market, but that is different than regulations on how large corporations are allowed to wield their power as market leaders. You need to distinguish between regulations that increase the costs for new competitors vs. those that prevent bullying/price fixing etc. For example, it was anti-trust regulation that gave rise to popularity (not initial creation) of Unix, and interoperability regulations that further expanded competition in the telecom industry.
Does this example of a bad government regulation come from the government? Or the people voting and demanding it from the government?
No, it comes from business. DMCA is an example of the badness of private business if allowed to do what it wants.
That was a purchased law. The failure on the governments part was in allowing itself to be for sale.
So you are right, even though I bet this is just about the opposite of the conclusion you thought citing the DMCA resolves out to, we should definitely stop allowing the government to be influenced by the private sector.
Facebook has a monopoly on the social network.
[1] https://www.annemergmed.com/article/S0196-0644(13)00313-2/ab...
Cancer and other disease are extremely expensive to treat and fairly common in the population. Yet, somehow, emergency care which is a minority of health costs, eats up 10% of the spending.
Anyone that's been to an emergency room knows how excessive the price gouging going on there is. Pills that cost $0.10 OTC (or less!) routinely see 100x markup. That same pill can cost anywhere from $10->$15.
Emergency care is not actually uncommon. Heart attacks, car accidents, these are the leading causes of death. It's completely reasonable to expect this to legitimately consume 10% of healthcare resources.
> Anyone that's been to an emergency room knows how excessive the price gouging going on there is. Pills that cost $0.10 OTC (or less!) routinely see 100x markup. That same pill can cost anywhere from $10->$15.
This is just opportunism, but it isn't really the core of the problem.
Emergency care is inherently expensive for a specific reason. You need an emergency heart surgeon on premises in case anybody needs heart surgery regardless of whether anybody does at any given time. You also need a neurosurgeon and one for every other specialty, and all the supporting equipment. It's very expensive, which is why it amounts to 10% of healthcare costs.
They then try to recover some of those costs by massively overcharging for ibuprofen and band-aids, which is silly (charge insurers the actual cost for emergency heart surgery instead), but it's not going to be a source of major net cost savings just to do the accounting differently.
I was in the ER earlier this year. Had an ultrasound done and a BUNCH of labs. $500 copay for the whole visit and insurance eats the rest - regardless of where I am on my deductible.
I'd had the exact same ultrasound done "routinely" 2 days prior, at the same hospital, and similar lab the week before.. I had to pay about $1,300 for the privilege because that all falls to my deductible. (Insurance paid nothing)
So it cost me almost 3x as much to go during the day than it costs during the ER - but my insurance paid out about 6x as much for the ER visit. I wonder how many "ER Abusers" have figured out it's actually cheaper for THEM to go to the ER than "normal doctors"?
https://www.investopedia.com/ask/answers/051415/what-differe...
Most health insurance plans have a few services that are copay-limited even before you hit your deductible. i.e., the $40 for an office visit to your primary care doctor, $90 to see a specialist, and in my case $500 for the ER visit. Imaging and procedures are my problem from the start, up to the deductible though ... apparently unless they happen in the ER.
Like I said way up-thread, the way it's structured puts the incentives in the wrong place for me. Had my two visits for ER and scans been in the opposite order, I would have been out of pocket the same total.
Anyway - I'm done arguing with you. I know how my plan works and what I've paid this year, whether you believe me or not.
But then I live in Australia.
> You need medical equipment to handle all types of injury/trauma.
This is equipment that most hospitals already have for other reasons. It's not like they have ER MRIs that sit idle and then an MRI for everyone else.
Further, a lot of that diagnostic equipment simply isn't needed in most cases. For ER related problems, xray machines are commonly all that's actually needed. Those are fairly cheap in the grand scheme of things.
> You need physicians and nurses and supporting staff.
A lot of the need for that gets cut dramatically by having a single payer system. The reason we have big ERs is because they are required to treat before seeking payment. As a result, many uninsured and underinsured people are using the ER as a primary healthcare system. Give everyone 0 or low deductible healthcare and you'll see the number of ER visits drop dramatically.
I'm not saying this makes for some total solution - just reacting to rejection of the market dynamic having any worth. It's foolish to cast aside entire paradigms of approaches because they don't fully solve every corner case. (The dual would be to ask how single payer healthcare solves purely elective procedures like cosmetic surgery. It doesn't.)
Obviously any market dynamic for urgent care needs to recognize that no contract has been formed, and so hospitals can't unilaterally set charges under a fallacious idea of contract. For instance when your car gets towed under duress (accident on the highway, expired papers, etc), the state sets the rates they're allowed to charge. They're still inflated, but at least within a factor of 2-3x the usual market.
(FWIW I think single payer is a good pragmatic way forward)
Rather my point was that when you need urgent or critical medical care there should be a baseline assurance of a solution to your predicament as you may not be in a position to shop around.
Your analogy with restaurants is not a good one, since you are unlikely to be in a situation where you're about to starve to death, and the only restaurant in town has 3 Michelin stars, grocery stores don't exist, and passers-by are not qualified to give you food :)
In a different thread I pushed the lack of a contract argument, and got back a more fitting legal theory that hospitals are allowed to charge you under the idea that you not paying would be "unjust enrichment" - they treated you, incurred expenses doing so, and therefore its your responsibility to compensate them. But that still doesn't support them charging you some arbitrarily high price, rather just expecting to be reimbursed for their costs. And so such bills should actually be constrained by the lowest rate they have with contracted insurances.
As for the analogy, I've been pretty hangry to the point where I wouldn't have been able to form a contract. It was also just a more straightforward example than the overall food market still functioning even though we're all just three weeks away from starvation.
Eh, the overall food market doesn't quite fit as an analogy here. I know I'm not alone when I say I have close to a year of food storage; it's not really the same for surprise healthcare bills.
(Although maybe with the rise of big surveillance and fine grained price discrimination we'll start to see these situations in other markets get exploited more)
It seems like most people's greatest fear around hospitals is a surprise ER visit that blows through their savings.
https://www.foley.com/en/insights/publications/2019/12/price...
I believe this was fought out in court this past summer and upheld.
Posted prices, and provider always charges that price weather its paid by insurance or not. Then insurance companies can compete on how much they cover at what premiums.
1) Can you buy medicine from whoever sells it cheapest?
2) Can you hire the healthcare provider you want?
3) Are you financially punished for choosing your own health insurance?
4) Can you opt-out of government health services?
5) Can you waiver or partially waiver your right to sue the medical professional in exchange for cheaper services?
This just doesn't exist in healthcare in the US.
IMHO, healthcare should either be full retail or single payer - nothing in between. Even if you are a "free market advocate", the current system doesn't reward the customer (unless you rightfully deem Carrier's as the customers).
But that is precisely a market effect of PE being able to do this due to lack of effective regulation, isnt it?
One problem with health care in the U.S. is that prices are hidden from the customers. That interferes with a free market. Tax regulations incentivized tying health care to employment and Obamacare making it difficult to get catastrophic care both interfere with a free market, etc.
Another set of problems, as you describe, is the ability for private equity funds to collude and impeded free markets. Especially lobbyists getting laws passed in their favor, medical associations limiting the supply of doctors, doctors incentivized to prescribe opioids, etc.
The original post in this thread referred to our current health care system as a free market, and that is not accurate. That's probably just as wrong as saying that we currently have socialized medicine, and its not working.
I would say that our current health care system is a not a free market and is not socialized, it is broken mix of the two.
It won't be reformed any time soon because millions of insurance industry jobs would need to be eliminated to save any money. Good luck with that.
I'm not from US and don't have personal experience with american health system, but that would only be true if you start shopping for medical insurance when you already have broken your leg.
If you behave as a responsible adult and choose a hospital to register to, or an insurance provider to take care of you, beforehand, how are you under any kind of duress?
Basically like going to the vet. Or dentist or cosmetic surgery.
Fairly cheap, fine “most” of the time. Sometimes it’s not.
Emergency care is also inherently local. You could operate emergency rooms under the same framework as you do fire departments.
Which doesn't require a national fire department to manufacture the fire extinguishers you buy for your house or repair the damage to your car a week after a car accident.
I think diseases that take longer but are still affecting your quality of life are just as important to consider, but also think they distort decision making and fail to work like a free market as a result. The "free market" has failed to provide affordable dental care outside large insurance policies, which are inaccessible to almost a quarter of americans, for example. https://www.coloniallife.com/employer-resource-center/2018/a...
Right, so your city should operate an emergency room funded mostly by taxpayers, and then just charge a fixed deductible (e.g. $1000) for emergency care, which isn't enough to induce bankruptcy in general but is enough to deter people from using it in place of primary care.
> The "free market" has failed to provide affordable dental care outside large insurance policies, which are inaccessible to almost a quarter of americans, for example.
Your link is to the promotional material of a dental insurance company.
Dental isn't generally a market that requires insurance. You need health insurance because heart surgery or chemotherapy is a six figure expense that would bankrupt nearly everyone. Paying $1500 for dental work doesn't require insurance, it requires a payment plan. It isn't an expense large enough to require insuring against.
This is just a public option that covers little and without the bargaining power on price a state has versus a city, right? Why wouldn't the same logic go for a larger entity taking up the mantle? And if we treat only emergencies with the plan, we incentize poor people to ignore cheaper preventative care in the market based system, and to wait until it becomes an emergency that costs many multiples to fix.
> Dental isn't generally a market that requires insurance.
Also from that link, in practice most uninsured americans just don't seek dental care. This matches my personal experience of being uninsured.
I believe the Trump administration is addressing this:
https://www.hhs.gov/about/news/2019/11/15/trump-administrati...
https://www.hhs.gov/about/news/2020/10/29/trump-administrati...
> The rule requires that most health plans and health insurers not only provide easy-to-understand personalized information on enrollee cost-sharing for healthcare services, but must also publicly disclose the rates they actually pay healthcare providers for specific services.
> Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their doctor and their plan or insurer, as well as the most accurate out-of-pocket cost estimate possible based on their health plan for procedures, drugs, durable medical equipment, and any other item or service they may need.
> Consumers will also have access to accurate price and plan information that allows them to shop and compare costs between individual doctors before receiving care, so they can choose a healthcare provider that offers the most value and best suits their medical needs.
But it'll be another couple years before it's all implemented it seems
If we want the free market approach to work, we need to make it possible, easy even, to make informed decisions among competitors.
But fixing this is increasingly feeling intractable, and this pushes me further and further towards believing a single-payer (maybe not exactly, but that's the buzzword) system is the better fix.
Likely not going to happen purely out of complexity if nothing else. Look at the list of ICD procedure codes[1] and imagine all of these with a price attached. Comprehensive, sure, but comprehensible? Ehhh.. pushing it.
"Hey, we'll do CPR, but that'll will be $100, please sign here so we can save your life".
The ala cart method seems like it might work until you start thinking about the logistics. If someone goes to a doctor complaining about chest pain, do we really want them to leave because an EKG and blood test are going to cost $200. No matter how much the doctor explains to them "You might be dying" plenty of people will walk out of the hospital once the bill is presented. In some of those situations, that's going to be deadly.
By the time the anesthesiologist came around, I was drifting in and out of consciousness -- no way to ask if they were in-network. (They weren't, by the way.)
This isn't an uncommon scenario, and one where price transparency isn't really going to help.
Also, what am I supposed to do, decline the services of an anesthesiologist and request an in-network one? What if there isn't an in-network one on duty? What if they're busy? if I need a surgery now, what choice do I have?
Sure I can shop around and do a bunch of research for something that I know is coming up, but when the out of network specialist drops into my wife's hospital room as she's having an asthma attack and can't breathe I don't have the temporal luxury of vetting how much that particular specialist is going to cost out of pocket and can I please have one that's in network.
And we didn't even take an ambulance to that ER. When I had my motorcycle accident I was definitely not given a choice of which ER I was being hauled to - they stuck me on a back board and away we went.
The issue isn't just transparency it's also coverage. We can get the menu of prices from the hospital but the specialists do their own billing so won't be covered on that - you're back to an "MP" on the menu.
Even if it's a non-emergency, getting the prices up front will cause a lot of people to chose to either go untreated or to delay treatment until a problem becomes far worse.
Just having prices available does nothing to improve the costs. People with type 1 diabetes know the cost of insulin. Has that prevented it's price from moving to levels that many can't afford?
It doesn't matter if the costs are known up front when drug manufactures end up with patent help that allows them to gouge. When medical devices are often produced by very few manufactures. When hospitals enjoy local monopolies.
The thought that the only thing missing from keeping medical prices down is the price tag is just absurd.
If statistics about refused services were kept, we could see where the various providers are pricing in-demand services out of reach of those who need them. Or conversely, what services were advised above and beyond actual need.
We could see pressure on providers to bring costs in line with the benefits of each code/procedure, and the ripple effects could help reduce the premium->insurer->provider cost overages for everyone.
Mind you, I still believe single payer will be the eventual end game, but this could be a solid step in the right direction.
Why would it? They can literally just raise the price and those that have insurance are going to get it which ultimately covers the loss in those that refuse service due to price. That ultimately is reflected to the customer in the form of higher premiums which they pay regardless of whether on not they get EKGs.
Further, with less people getting services it really is as simple as cutting nursing, doctor, and lab staff because there isn't as much demand.
It may make a difference if the market was completely unregulated and insurance didn't exist at all. In that case, some guy could do EKGs out of his van at a much lower cost.
However, that's not the market we have. Doctors command high salaries and we've regulated that only those with medical licenses can practice medicine.
Medicine is not a free market and it's a bad idea to ever make it one. There are already major issues with unlicensed quacks selling placebos.
Ban all forms of community governance, municipal ownership, or a people doing something for their community without using a for profit private company middleman.
Defund and gut any form of a social safety net. Disallow people to challenge a company polluting their drinking water and shut down the agencies tasked to inspect it. Forbid places from passing clean air laws or having the power to say no to any predatory company that wants to come to town
Allow companies to sue entire countries in secret tribunals if a country decides to not eviscerate their health and safety standards. Disallow countries from preferring local industry or keeping out vulture capital doing pump and dump schemes on their water and food supply. Protect these companies by international private militias that have an authority which overrides the country's own military.
Enshrine this right in treaty law so no sovereign people can possibly override it or fight back without severe consequences. Embargo, tariff and boycott them if they don't join in.
Permit companies to hide how their products are produced, lie about abusive and child labor and hide their profits in tax shelters without any consequences whatsoever.
Allow banks to defraud customers with phony accounts, car companies to lie about emissions, energy companies to crash entire state economies, insiders to manipulate the libor rates, and create shell companies using tobashi schemes to hide losses and reverse tobashi schemes to hide profits, and then bail them out with public money when it doesn't work out.
And finally destroy public education and replace it with whatever influence peddler with deep pockets wants to pass off as curriculum so that the public doesn't ever catch on to how much they're getting robbed."
Then there's this slight of hand where the advocates talk about the theoretically heady version of free market and then do mental acrobatics to bridge the policy and theories together. It's a distraction so that all the effort to combat the chicanery is instead exhausted on debates and theory discussions so obtuse intellectualism instead of meaningful directed focussed political action occupies all the time of thought leaders.
It's just coercion exploitation and oppression based on raw capital wrapped with the union busting techniques that keep the con game going without any consequences. It's a giant hustle to snatch and grab profit while turning our back on centuries of progress all under a fraudulent banner labeled "freedom".
Even the right wingers on gab and parler are seeing this now. It's so clear.
Such a scam.
The rule of law is important for free markets and breach of contracts needs to be punished to have a vibrant market.
That's the point. "Deregulation" is code for taking hundreds of laws and dumping them in a garbage bin. "Privatization" is code for stealing tax dollars and hiding it in offshore accounts.
I only care about the actual, real world material reality that has historically factually happened. The champions politic in a way that tends strongly away from rule of law as quickly as possible.
It's a framework that gets invoked to go both ways. It's a vendor's "freedom" to not have to label, say, gmo, but then it's the vendor's "rights" to prohibit soy milk from using the label "milk".
"Freedoms" and "rights" get interchanged to rationalize the preconfigured results. The dogma is a general tool.
It was the "freedom" of agrobusiness to flood mexico with corn after NAFTA and run the local farmers out of business and then it was their "rights" to the marketplace when mexico pushed back. The farmers didn't have that same right to the marketplace, they didn't have the same freedoms, only international capital does. How convenient.
That's why the zealots always think it's the right answer - it can be reshaped like a mound of clay to justify and rationalize whatever they want.
For instance the sanctity of contract matters when it's with the gas pipeline company but not when it's with the american tribes
When instead it's a pipeline of people via a subway through a wealthy neighborhood like the purple line extension in Beverly hills, all of a sudden the free market gets invoked to guess what? Reach the opposite conclusion.
It's fundamentally a convenient power tool of capital. They used to use the Bible, now they use Friedrich Hayek. Skullduggery with the purest, most heavenly goals. Sure...
In practice, free markets are lawless raw power that bend the state to do their bidding like some feudal king, but now it's wearing a bowtie and a cardigan instead of a sceptre and a robe.
Same thing, different era.
Or regulation is taking things from the garbage bin and make them into law.
> "Privatization" is code for stealing tax dollars and hiding it in offshore accounts.
If tax dollars are being stolen, it is the government that is doing both the tax collection and allowing the tax plundering.
> For instance the sanctity of contract matters when it's with the gas pipeline company but not when it's with the american tribes
What you really want is more free markets: that is, more rule of law, law that can be applied systematically and with no discretion and discrimination. You mention the enemy over and over: the coerced state that does terrible biddings. But you then exempt government as if it were innocent first and corrupted later.
It is the mechanism by which you decide on economic matters by power that produces the vast majority of the issues you mention, way above the famous "market failures" and unaccounted externalities.
Capital and governance (CG) have been the internal organs of the body politic forever.
Hacker news, facebook, an elementary school, every institution is CG.
The theoretical framework of free markets requires the fiction that they are somehow separate and independent!
It's imaginary rubbish.
Corporations were started by the crown and modern political empires grew because of their corporate needs.
They expanded together. Every. Single. Time. Always.
The free marketeers think they can ignore all history and merely, through zero evidence intellectual exercise, derive absolute truth that needs no confirmation, measurement or testing because by logical deduction alone they know The Truth.
They use rubbish homo economicus behavioral models, rubbish ideas of clean governance and capital separation, and the rubbish assumption that companies win by playing by the rules instead of the reality where they find a new exploit.
That's why it's a scam. It's based on a classic scapegoating shell game and then uses classic cult systems to ignore evidence or question a priori assumptions.
It's the same internal logic as astrology and horoscopes. Complicated models, no reality check, cherry picked evidence, projected interpretations, same thing.
Total nonsense. It belongs in the spirituality section
In any case, I see the same corruption you see, and the question is how to go about it. If the state is powerful and corruptible, I want a smaller state, with less surface to be corrupted. And it is surprising how you can reveal most corruption by just the simple application of freedom: that's whats appealing of the free market framework.
"Smaller state, larger state" no... Those are answers without considering the questions.
Heterodoxy, material analysis, material goals, provable statements, methodologies of measurements and metrics...
That and not disconnected faith based theory opinions are what matter. Labeling things as whatever-alist is a just a silly sports game for tribalists as if it's more important to pass a purity test than it is to construct a positive functioning society.
Whether a solution makes the state bigger or smaller is irrelevant.
What is the efficacy for the effort trade-off, that's really it.
Any commitment to a theoretical purity sets one up for a blindness and bias of analysis and an easy way to be exploited.
That's why televangelists can so blatantly and openly rip people off. The purity theory blinds the faithful. This is true for socialism, capitalism, syndicalism, anarchism, all of them
The best way to beat a company that has market power is with other companies that fight in the same space or around it. And if there is one last man standing to reap profits from the victory, its again not necessarily bad. Market monopolies are overblown ghosts.
The first instinct is to buy, then shut it down, then smother it out with sheer capital, then retreat either up or downmarket.
That's why when you go in to the supermarket to look at commodities, they're often owned by either 1 or 2 companies that are mutually invested in each other.
You see a bunch of brands, but the capital ownership structure is almost entirely consolidated. Better products get dragged to court by existing players who try to shut them down or legislatives get greased palms for new regulations ("protected" terms).
In instances where this can't happen there's cartel systems which is why the dominant grocery store changes city by city.
The Austrian model of how humans work is dead wrong, how markets work is dead wrong, how capital flows is dead wrong, they're just wrong wrong wrong.
That's why they never use any examples and only have theoretical exercises, because there's absolutely zero evidence for their claims. Any observation of reality would show they're incorrect in a multitude of ways at every step.
That's why when you look at economics texts before the classical liberalism hubris, it is full of actual historical events, actual earnings and economic history to use as evidence and it's why the Chicago quacks had to tear those parts out, because their ideas don't work when you look at reality. If you look at evidence, their theories don't agree with it. They know this and that's why they don't use anything more than broad non-specific folksy anecdotal stories, because narrative fiction is the closest thing to reality they can get.
Enter any store in a free market economy and you’ll see a plethora of excellent products brought about by competition-driven innovation.
Enter any store in a planned-economy country and you’ll see empty shelves.
The ideal "free market" requires an insane level of planning.
Perfect knowledge. Perfect competition, no friction to switch loyalties, oversight of m&a to avoid the different classes of -opolies. Securing those rights are insanely complicated.
It's extremely bureaucratic and has vast overhead costs. Regulatory bodies, thousands of pages of rules, committees, it's insanely mind bogglingly planned.
That's why you need certified specialists to do anything in free market societies.
It's planned but this planning is not based on reality which is why everything keeps going crazy all the time.
The free market is a purely dogmatic ideological project, not based on any actual material evidence.
So I totally reject that bogus Hoover institute style premise.
These theoreticians set up a fraudulent spilt that doesn't exist, then states a false thing about them, and says 'ho take that'.
It's like someone trying to prove things with astrology charts. There's an internal logic to it but that actually doesn't matter because it's all disconnected fakery to begin with.
And its not binary, either. You can have it completely free, freer, free-ish, all the way to lightly regulated, heavily regulated, planned and completely locked down.
Finally, I am not talking from economists' perspective, but from that of the regular guy on the street who is just able to see policies and their result. But my conclusion is extremely simple: the freer the market is the better everybody (other than profiteers, bureaucrats and politicians) is.
The current trend in 'free-market economics' is to call captured markets free and then argue for the relatively lax regulation.
Most markets are not free markets and the healthcare definitely isn't. There's very little true choice, participants are typically under duress when seeking expensive services, and prices are hidden.
If there was ala-carte transparent pricing and no insurer lockouts things may be a bit better.
My suspicion is that Private Equity has been funneled in healthcare for two decades intentionally distorting the market behaviors for increased profitability which is why the US has such excessive healthcare costs without any apparent justification.