That is until you call the hospital and find out there's all sorts of "sliding" prices etc...

I had a procedure billed for one of these drastically larger "insured" codes which got denied based on the nature of the procedure from the insurance company (apparently too new of a procedure at the time, however common now).

It all got worked out in the end but what I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies. We've set the American healthcare system up to be a cat and mouse game where those in need are represented the least.

Best insurance here is "don't get sick"

Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be.

I was stuck with a charge from a doctor for 7x the price my insurance would have paid. My pre-ACA insurance refused to cover the procedure and I ended up on the hook for the inflated price. The doctor wouldn't negotiate and demanded the full fee. Neither the doctor, nor I, knew this would happen until the procedure was already done.

It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly?

Until everyone becomes a contract lawyer capable of devoting weeks to insurance shopping every 6 months, the only good insurance market is a heavily regulated one, even though heavy regulation comes with its own gigantic bag of worms.

Yeah, there's a decent amount of regulation around payouts to protect the consumer, but it pales in comparison to the regulations around making sure that the insurer has enough liquid assets on hand, that the total valuation of their assets (ie investments) remains large enough, and that they're charging a minimum amount of premium for the risk that they're taking on.

Deceit can take many forms, and I'd argue that undercapitalization is actually one of them. "There's a trap clause on page 23 of the telephone book contract" is only the simplest strategy an insurance company can use to lemon-drop. "We ask our customers to do an impossible information wrangling task and only review the paperwork if they get cancer, so that we have an excuse to drop them" is a slightly more evolved form. Loading up sacrificial business vehicles with risk and using bankruptcy to discharge obligations is the most advanced form of deceit-based insurance business models, because it provides plausible deniability. "We just tried to compete a bit too hard!" they can claim, even if they knew in their hearts exactly what they were doing: the age old practice of selling insurance that you had no intent of making good on.

Fortunately, we have a long record of historical evil tricks to draw on when crafting legislation, because I absolutely stand by my claim that the natural incentives (the ones that happen without careful legislation) in the insurance industry are overwhelmingly bleak, both on an absolute scale and relative to other industries.

The payouts regulations are still good and necessary because that's way better than requiring people to find out the hard way through shitty claims processes and denials and word-of-mouth reputation, but they're in no way sufficient.

> "Oops we invested badly and have literally no money with which to pay your completely valid claim".

It's 100% possible for this to be a genuine mistake. I'm sure that it happened as a genuine mistake more than once! However, it is also possible to do this on purpose: load up a business vehicle with increasing amounts of risk and extract as much of the premiums as one possibly can before it explodes. If this is done intentionally, it is exactly the same hustle as selling policies that one doesn't intend to make good on, it just uses a different mechanism to shirk the obligation.

Every company that does it on purpose will say that it happened by mistake, of course, and just as I am certain that it has happened multiple times as a genuine mistake, I am certain that it has happened multiple times on purpose.

Undercapitalization is the evolved form of the "sell a trash policy" hustle because it provides almost perfect plausible deniability. It makes sense that the greatest legislative effort would be spent heading it off.

Isn't the latter a strict superset of the former? No payouts is an easily predictable number. And for nonzero amount of payouts, the less those payouts sum to, the more money remains for continuous investing.

Here's some random numbers,say for a hypothetical 100,000 hypothetical year long policies low probability, low variance: E(total claims) := 20, V(total claims) := 1 low probability, high variance: E(total claims) := 20, V(total claims) := 20 higher probability, low variance: E(total claims) := 20,000, V(total claims) := 10 higer probability, high variance: E(total claims):= 20,000, V(total claims): 10,000

Premiums don't usually make their way into investing for a bit. They're used to cover claims and then business overheads and then even dividends first. First they go to claims, because there's usually regulations to prevent price gouging that require insurers to refund premium if the ratio of aggregate premium : aggregate claims gets too high (the regulation is on a state by state basis in the US). Then any remainder goes to any other outlay first, so that the invested money can be/stay invested into longer term investments. Only if those outlays can be completely covered by the premium (and i'm skipping over a few things like regulations regarding various levels of liquidity for different risk levels and other stuff) then yeah it can make its way over to the actual investment fund. But in general the business model for insurers is that underwriting profit, limited as it is by regulations, is primarily used for actually running day to day operations and isn't a reliable source for being turned over to the investing side. The investing side is primarily using the initial capitalization of the insurer and the returns from earlier investments.

One way of looking at insurance is that the insured is actually buying an option against the insured's capitalization with very limited exercise clauses, but the the insurer pays out exercised options with the money from other purchased options contracts.

...sourced from the premiums. When they pull in more premiums, they have more money to invest.

Ideally the premiums will cover payouts and day-to-day business expenses, so the invested money can just keep being reinvested, hopefully into longer term and more aggressive investments. The premiums and payouts get rolled into underwriting profit/income. And that can eventually get rolled into new investments.

Here, look at state farm for 2019[1].

Their underwriting gain was $777 million on $65.2 billion in total premium. Their investment income was $5 billion with a net worth of over $100 billion, which is more than 6 times larger their underwriting premiums.

Their profit ratio for underwriting is like 1.2% because they're not trying to maximize that profit. A large reason they're not trying to maximize it is that for admitted policies, there's usually an upper limit to how much aggregate premium can go to anything other than paying out claims (eg: [2] and [3]).

So for an insurer, they don't want to set themselves up to depend on premiums to fund the investment arm because 1) there's an upper limit on how much aggregate premium can go towards anything other than claims 2) there's no limit on how much aggregate premium can go towards claims, 3) growing premium haphazardly can result in less money available for investing due to other regulations that limit risk and require a certain amount of liquidity for claims.

[1]: https://newsroom.statefarm.com/2019-state-farm-financial-res... [2]: https://www.law.cornell.edu/regulations/california/10-CCR-Se... [3]: https://consumerfed.org/press_release/auto-insurers-reaped-n...

They don't have control over investment returns for the most part, so premiums are the only avenue for growth that they can do something about.

One of the worst offenders from the before-times was an insurance plan targeted at college students that had a 10% MLR.

Payers often get incentivized to promote certain drugs via manufacturer kickbacks and I wonder if this system is also used to run around MLR requirements.

And given that the payouts are very nearly a function of how hard the insurance company can negotiate, they can simply choose to call off the negotiations when they reach their target amount.

Private medical insurance in the US is a horridly inefficient system. Separating the claims process from insurance companies hands might help, but their incentives are never going to line up with consumers.

Money spent on paperwork comes out of the same pile as profit. The MLR cap preserves incentive to reduce paperwork, wherever premiums and payouts sit.

Of course insurance companies are also in competition so they have individual incentives to keep premiums cost competitive.

With R = revenue, P = profit, A = administrative expenses, and M = medical expenses, we have:

    R = P + A + M

    P = R - M - A

    P₂ = R - M - (A + δ) = P - δ

    P₃ = (R + δ) - M - (A + δ) = P

Does the MLR cap have an impact?

    MLR = M / R
    MLR₃ = M / (R + δ)
    MLR₃ < MLR

    P = (R + δ) - M - (A + δ)

Of course if I believe that my company is better able to handle the new paperwork than my competitors, that could help - but if the whole industry believes that's the case then most of them are wrong, and in any event I believe this incentive is weakened not strengthened by the MLR cap.

If paperwork keeps new entrants out of the market, that is something current participants can probably agree on, but that's true in any case and I don't see how the MLR cap makes it stronger.

I don't think this analysis changes if we pull executive compensation out of "administrative expenses" and treat it as something we're maximizing in addition to (or instead of) profit.

So while thinking in terms of total administrative costs seems reasonable there are two different numbers here, administrative costs for the insurance companies and administrative costs for the healthcare industry and that matters.

So again, assuming it’s the regulation not market forces limiting profits increasing Ma directly increases profits. Up to some limit rather than P < (Mm + Ma) * X% it’s P = (Mm + Ma) * X%. Thus creating incentives to increase Ma.

It is true that the MLR cap does nothing to motivate insurance companies to avoid increasing hospital paperwork. I don't see that it produces incentive to create it - yes, increasing payments to hospitals increases allowable profit, but in order to make that profit you need sufficient revenues and customers aren't paying because they want hospitals to do paperwork. I'm of a mind that (at the margin) increasing legitimate (or nearly legitimate) medical spending is typically pretty easy so there is no need to find alternative ways of paying hospitals more; if I'm mistaken about that then you raise an important point that probably deserves attention (if it hasn't got it in some way I'm unaware of).

If the payouts are dropping because there's a massive reduction in claims, then there's a pretty decent chance that paying the policy maximum on each claim still won't be enough.

Plus, profits don't come directly from the premiums anyway. They come from the investments the insurer makes with the premiums. So sure, they can try to convince policy holders to increase coverage which allows them to charge a higher premium, or they can work on their loss modeling and investment strategy to better predict their actual loss ratio (which means they can have less money in reserve and more money in investments) or get better returns on the investments. And those 2 are usually a better use of resources since increasing coverage means an individual conversation with each policy holder. That's a lot of human-hours compared to the modeling and investing.

Or they just stone wall and increase premiums anywhere they can until they hit targets. Like at a previous job I had at a 250 employee company where premiums went up $150/m one year because the previous year had two families had a kid get (very different kinds of) cancer out of the blue. You'd think that shopping around would've helped in that case, but the word got out somehow to the other insurance companies and they were giving us similar quotes.

The power relationship is very very tilted in the insurance company's favor and they can more or less dictate terms.

It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.

When employees go through big health events it's hard to keep it under wraps in a work environment... especially in this "race to the bottom" society we happen to live in. You can bang on about privacy all you want, but people talk.

I guess I'm shocked it happened in an office of ~250 as I've always seen it happen at much smaller places.

That is how it would have to work if the employer wants to restrict the risk pool to the company's employees. After all, money has to come from somewhere.

But employers are welcome to participate in healthcare.gov plans where the risk pool is much larger (across the whole state), and where individuals in the company cannot be solely blamed for increases in healthcare costs:

It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.

Employers are welcome to purchase healthcare.gov plans that are not allowed to price based on pre existing conditions:

https://www.healthcare.gov/how-plans-set-your-premiums/

If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it.

Which are stupid expensive for anyone much above the poverty level.

> If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it

A 250 person company wasn't self insuring or restricting their risk pool to only their employees. They wouldn't be negotiating premiums with an insurance company if they were self insuring.

When I was shopping around for health insurance for my businesses, the premiums were the same as what they would have been individually on healthcare.gov. Kaiser has a good report showing the costs are not that different based on firm size:

https://www.kff.org/report-section/ehbs-2020-section-1-cost-...

The cost of healthcare is pretty predictable, and spread over a sufficient population converges to the same numbers. Only option I can think of is people were thinking that the employer reduced their portion of healthcare they were subsidizing, and so people thought premiums were going up since the size of the portion they were expected to pay went up? Most people do not really know to look at box 12 code DD of their W-2 to know what is happening with their healthcare insurance premiums.

And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?

And Kaiser isn't run like most insurance companies.

>And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?

Yes, but that was my point about businesses being able to just buy the health insurance plans available on healthcare.gov. Earlier you mentioned the healthcare.gov plans were:

>Which are stupid expensive for anyone much above the poverty level.

But the data does not support that. Average annual employer sponsored insurance is $7,675 for single PPO coverage in 2019:

https://www.kff.org/report-section/ehbs-2019-summary-of-find...

And average lowest cost monthly gold premium on healthcare.gov is $516 ($6k annual) in 2019:

https://www.kff.org/health-reform/state-indicator/average-ma...

So employers can probably save money going to the healthcare.gov plans, albeit with higher out of pocket maximums probably. But at least a couple kids with cancer would not throw off the premiums.

Unlike property and life insurers, medical insurers generate very little income from investments. Premium revenue comes in at about the same rate as claims are paid out. They don't have large reserves to invest. And most large employers are self insured anyway, so the ”insurance" company just acts as a claims administrator.

The privatization of healthcare is a conflict of interest which is a product of our hyper-capitalistic society. You can't make a profit center out of human services without dehumanizing it in the process - the very nature of profit/capitalistic societies means someone has to lose and I see no place for these interests in healthcare or education.

Edit: yep - expected that. Maybe someone argue as to why privatization (which is a product of capitalism) isn't a conflict of interest in regards to healthcare?

It's not as if public health care doesn't have moral hazards of its own, including conflict of interest. The system may officially be non-profit but the interests of its workers and administrators (profit-oriented or otherwise) do not necessarily align with those of the patient.

If by 'profit/capitalistic societies' you mean those allowing for voluntary exchanges between its people, I would disagree. As an adherent to the subjective theory of value, I think it is common that both parties in an exchange would consider themselves 'winners.' [0]

[0] https://en.wikipedia.org/wiki/Subjective_theory_of_value

https://www.forbes.com/sites/jimcamp/2013/03/11/revisiting-w...

The reason I am firmly in this school of thought is that I've made the absolute mistake of a decision to try for "win-win" situations in a capitalistic society, specifically in regards to contract negotiations and ultimately pricing/billing.

When I'm making sure that the person on the other end of the table "wins" I'm putting myself at a capitalistic disadvantage; and - if both parties "won" then didn't both ultimately lose?

I get your ideal, but when money is involved I find that the "win-win" is very much that: just an ideal. And, anecdotally over the years I've found many business experts write on the topic of why "win-win" is a losing position which validates my position on this.

I'm not familiar with Jim Camp, but the term is vague. The linked article to me mainly seems to argue that:

- the side with a better BATNA has more negotiating power (yes, of course) and

- a negotiator should avoid agreeing to a bad deal out of desperation (yes, of course - but not always easy to do)

I'm not sure how the concept of "win-win" specifically plays into it, so I think this is where definitions are useful.

To me, win-win doesn't make sense for transactional negotiations where there is only one dimension (usually price), but CAN happen for more complex negotiations with multiple dimensions where each dimension has different value to each party (price, time, volume commitments, etc...)

No, because even in a capitalist society "winning" is defined by each party's relative improvement over the state they would be in if they didn't come to an agreement and make the trade—not by some absolute measure of whether they did better than the other party. A "win-win" is simply an agreement where both parties are better off for making the trade. This is the usual state of things when both parties are free to accept or decline and there is no deception (fraud) involved, since both parties need to accept the agreement and they will only do so if they believe that doing so benefits them. In rare cases one or both parties may be mistaken about the benefit, but they know their own business better than anyone else and are best positioned to judge the expected value of making the trade based on the information available at the time.

Many of the current US medical problems (bureaucratization of medicine) actually evolved out of massive government regulation with debatable value. EMRs, ICD/coding, the bureacracu that eats up 25% of your doctor's day? It is mainly for insurance companies and Medicare/Medicaid.

https://healthncare.info/history-healthcare-insurance-united...

> I'm a fairly capitalist person, but there is something awfully and fundamentally wrong about a society that monetizes well-being and health

All the medical providers (doctors/nurses/therapists/techs/PAs/etc) do not work for free, and there is a significant logistics and technology tail in providing medical services at huge scale.

If you really want to go after waste in medicine ask the following questions:

(1) How much are the nonclinical hospital mgmt & insurance executives paid?

(2) What is the ratio of clinical to non-clinical personnel?

(3) Why is the US subsidizing the vast majority of the medical research, and drug profits for the entire world?

These are serious questions because, as my nearby regional hospital group was firing hundreds of nurses during COVID, their CEO was collecting millions.

The last time you bought milk did you lose or did the grocery store? The last time you paid money for a hair cut, who lost there?

The extreme regulation of all aspects of health care that has developed over the last century has improved some problems and created other problems - the problems specific to healthcare have little to do with the "the very nature of profit/capitalistic societies"

There's way more people involved in that supply chain then me and the store. This is an over simplification.

Outside of the obvious answer of "the cows" - factory farming has been destroying my home state causing huge problems in rural America. Also - the environment. Big time the loser there is the environment for literally any bovine farming.

> The last time you paid money for a hair cut

When I was getting my hair cut professionally I tipped a $20 because I knew the gal cutting my hair working at the midwestern mall Regis Salon was making jack-all. I knew this because I worked at Geeksquad with her boyfriend, eventually husband. If I were not to tip well she would be at-risk for making minimum wage for that hour - and since you can't support yourself on minimum wage I see that as her losing.

I've always tipped my butt off because I know without that they lose.

---

So yeah - sorry... I anecdotally do see losers in the situations you described. I don't have to look hard to see them.

Factory farming probably does cause externalities that aren't addressed. People could choose to buy from grocers who only source from smaller farms but there isn't as much interest in that due to price sensitivity.

>...and since you can't support yourself on minimum wage I see that as her losing.

Even in the case where you didn't tip, she likely would have preferred having the work than there not being a job available at that location.

I asked why they said it would be covered. They said when they checked with insurance it says it’s covered, but for my age or whatever it’s not actually covered.

So then I said why is it my fault that you gave me something you said was free but actually wasn’t because your check wasn’t thorough enough?

They said they already spent it so someone has to pay…

In the end I didn’t pay for the fluoride after hours of argument.

Next year at a different dentist, same situation. I learned my lesson and just paid for the damn fluoride. Land of the free, home of the brave!

"No cavities again! Would you like a flouride rinse?" "Why would I do that? I have flouride in my mouth rinse and my tooth paste." "Well, ours is a higher concentration that I paint onto your teeth." "Didn't you say I had no cavities?" "Well, yeah." ".... so what I'm doing seems to be working without your rinse" "Well, it's only $16" "My flouride rinse has the exact same active ingredient as yours and costs $5 for an entire bottle." And it just goes on and on.

What we really need is for people to stop thinking of insurance as a big blanket you buy that reduces the price of things to zero. That’s not what insurance is for. Insurance is supposed to be a system where you still pay for the cost of the good, but that buffers it for you so when you get an outlier cost, it doesn’t break you. It doesn’t make the costs of things go away. On average, you should end up paying a little more than the cost of your healthcare by purchasing it through an insurance plan. A high deductible plan does this: you actually pay the cost of all your healthcare up until a certain point out of pocket, and if you reach a certain amount (which is pretty high, but significantly less than the premiums on a low-deductible plan), the insurance takes over. This makes you actually aware of the prices of things and is healthy. Not to mention the insurance is a hell of a lot cheaper.

Healthcare should simply be "free", ie budgeted into the operation of a modern society, like infrastructure costs and education.

I've never seen a dental insurance plan that actually makes financial sense. Most of them place significant limits on expensive and unlikely care, and cover routine care with little or no cost sharing. Insurance is a highly inefficient way to pay for expected expenses.

because our senators and congress critters are all on the buy for really cheap... it's not even hidden. something like medicare for all is the thing that makes sense but has a hard time finding traction because the people that it will negatively impact have the means to buy those politicians out.

You aren't exactly talking about "balance billing"[1] but you'll be pleased to know the No Surprises Act[2] tries to address this situation with required cost (estimate) disclosures in advance of a procedure and capping the out-of-network amount that can be charged in the event of an emergency where there can't advanced disclosure. The HHS recently promulgated regulations[3] under the Act but the compliance date is January 2022. For some reason I think there is at least one (maybe two?) other proposed rules in the works but I can't recall what they address and I can't seem to find them.

Edit: The other proposed rule is relating to air ambulance services[4]

[1]https://en.wikipedia.org/wiki/Balance_billing

[2]https://www.congress.gov/bill/116th-congress/house-bill/3630...

[3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule...

[4]https://www.healthaffairs.org/do/10.1377/hblog20210913.57633...

I believe this is called 'balanced billing'. Some states prohibit it under certain conditions but it seems either the government or insurance should be prohibiting this practice.

Was in a similar situation as you were, but unfortunately, what I'd have had to pay was still too much as it was clearly fraud on the part of an outpatient clinic - one side, the clinic, was approved by my insurer, the other side, the surgery center, was not, and they willfully lied about this distinction. I threatened a law suit and they demurred.

Recent New Yorker article looking at the "Costa Rica model"[0] raised this point as well. America, by contrast to Costa Rica, has a very weak public health sector and infrastructure, and this leads to a real weakness when focusing on preventable illnesses and issues.

[0]: https://www.newyorker.com/magazine/2021/08/30/costa-ricans-l...

> All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done.

It's common sense why they have better results and outcomes than we do here... Our system is optimized for capitalistic profit. I've got insanely good insurance and I still have no idea how screwed I am if I go to the doctor or especially a hospital. Although I've only had one major billing snafu years back I have real anxiety about going to the doctor here.

And hell, even if I go my PCP is going to be stuck in an "all or nothing" mentality where it's either OTC or getting in their own conflict with my insurer... ie: "If I can't justify this test with your insurer..."

---

Costa Rica's model is better than America's. The reason for this is because it's not optimized for profit, it's designed from the ground up to optimize for patient outcome.

Which is why hospitals charge higher prices to insurance companies.

Insurance companies often blanket deny every single claim made against them. This forces the hospital revenue cycle department to have an appeals nurse review just about every procedure done in the hospital, and justify its use. This almost always results in a "discount" for something by virtue of a care provider not justifying every action they take.

Revenue cycle management departments used to be small, about 1 per 1000 hospital employees. Today, they are so big - and make so much money* - that hospital systems are spinning off their revenue cycle management companies for billions of dollars. Private equity firms have been acquiring in this space like mad since about 2016.

* Really, they are actually getting the money that is already owed.

Just like how car insurance is not a mechanic.

> And this can really cause issues for people who are insured because if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for.

That doesn't sound like an "inflated" price? 25% of what insurance companies are billed for?

I'm confused. I'm not sure y'all are talking about the same things?

https://www.aha.org/factsheet/2019-01-02-uncompensated-hospi...

My understanding is that you would usually pay the price set by the agreement your insurance has, even if they deny coverage of it.

1. You have to back up claims like this.

2. I imagine for-profit Insurance companies would love to blame their prices on the uninsured.

3. Many poor people actually have insurance in the USA. Even if they don't apply for it, insurance can be applied for after the fact.

4. The wealthy, and the poor are usually covered by insurance. It's the middle class that needs attention. They have insurance, but it's not great.

I still don't belive our healthcare costs are due to the uninsured. Oh yea, every hospital has a fierce Billing and Collections department.

They are allowed to go after your assets if you can't pay your bill, and they do. Obamacare gave patients some rights, but hospitals blatantly abuse the regulations.

The right to collect in municipal court was never taken away from hospitals.

In my local newspaper, it's not uncommon for a hospital to sue a patient over a bill, and put a Judgment lien on the patients assets.

They claim they only do this as a last resort, but bankruptcy due to medical bills are still the number 1 reason people end up in federal court (Bankruptcy).

Your protections under a bankruptcy are not great either.

There are many hospitals that forced a former patient to sell their home (homestead exemption needs to be higher. In TX, they can't touch your primary residence.). under a bankruptcy.

In CA, for example, the primary home gets a $250,000 protection. (Look up that last figure. I know it's very low in CA, and needs to be raised to at least a million. You have a $600,000 home. You are only protected by $250,000 of it's worth.

So in America, if you do get sick, and can't pay all your medical bills, you have no protections. These for-profit medical companies will come after you with more zest than an unpaid credit card. I think CC companies are less aggressive.

2. I mean, I have no idea but for-profit insurance companies aren't out there really blaming anyone as they're just a faceless corporate entity. I've only heard hospital staff and normal people blame the uninsured.

3/4... no - poor people don't have insurance. I've grown up around people who were not economically privileged/who were struggling and this is just 100% untrue that poor people can get insurance as you posit. I've had private insurance and it's just not something someone can afford if poor. And, if you're referring to things like "Christian Healthcare Ministries" they're straight-up scams. Outside of that, there is no way American restaurant owners, retail franchises, etc will cover an unskilled laborer's health insurance - that just does not happen here.

---

> I still don't *believe our healthcare costs are due to the uninsured.

When it comes to hospital billing - yeah. It is a huge thing that's baked into their SOP. See item #1 above.

Also this isn't going down to your corner liquor store and flashing your drivers license... that thing is going to get scanned etc.

---

Actual protip: If you're uninsured and need care they legally can't turn you away at an ER. They have to provide the healthcare to get you stabilized regardless if they're going to be able to bill for it or not... which ironically this is a big part of why the insured end up subsidizing the uninsured at the hospital.

Also, if this ends up being you - don't sign anything until you're in the right mind to sign something. They're going to try to pin you to bill your ass off one way or another and if you're half way through a heart attack or something do not sign anything until you can 100% understand what you're legally agreeing to.

Giving a fake name is fraud, and people have been arrested for doing that at the ER. (Fuck America.) But I don't know that there's any legal obligation to give any name at all. If you don't give them a name, you're not lying to them, and oops, looks like they don't have a way to bill you. As you note, hospitals are legally required to provide emergency stabilization without regard to ability to pay.

I suppose the hospital could try to call the police, but AFAIK the police cannot compel you to identify yourself without reasonable suspicion that you have committed a crime.

https://www.npr.org/sections/health-shots/2019/05/07/7207022...

Hospitals that accept medicare do have a legal obligation to stabilize patients. But we're talking 'stabilize' as in 'you're not dying'. If you're alert and capable enough to be arguing with people and you're not a psych danger, you're likely stable enough to legally be thrown out on the street.

The discussion here is whether there is a legal obligation to identify yourself. If there is such a requirement, it would apply to someone who is fully capacitated but refusing to identify themselves. It would not apply to someone who is unable to identify themselves due to incapacity, because such a person obviously lacks any criminal intent.

If there's no risk of criminal exposure, even insured people should start doing this. Hitting hospitals with uncompensated care under EMTALA is one of the few points of leverage we have to fight back against these murderers. Hospitals are, by and large, not innocent parties in this -- several hospital groups are even members of the Partnership for America's Health Care Future terrorist group, which bribes politicians to fight Medicare for All.

It would bring me great pleasure to get to tell a hospital to go fuck themselves and to quit bribing politicians to fight M4A if they want to get paid next time.

Where do you think the money is going? Insurance companies are not as profitable as you might think, drugs are not a massive burden on healthcare expenditures, and many hospitals are non-profits. The truth is that most of the money is going to staff wages; if you want to reduce healthcare spending, the only way to do it sustainably is to increase the numbers of doctors and nurses, so as to drive down their salaries (but this is not a popular option).

Having said that, your belief that many hospitals are non-profit might not be as simple as it looks from the outside. I recently read an insider writing something about it on Reddit: https://old.reddit.com/r/SelfAwarewolves/comments/pruk4x/the...

Hope that gives you an additional viewpoint regarding the "non-profit" label of the hospitals.

>"The end result is a privately-owned hospital that operates as a non-profit on the books when it is anything but that... American doctors and hospital executives are printing money using the backs of their patients as the die. They take in millions per year in compensation that was given to them by people who worked hard and fell on bad times. It is one of the most shameful forms of exploitation in modern history."

I'm just unsurprised, as that is consistent with my view of many (most?) non-profits. I also think that the executive pay component is a smaller share than that Redditor seems to.

I'd love to know how much money is spent by hospital admin staff dealing with the insurance industry.

Many business which successfully reduce costs don't pass on those savings to consumers.

I will also point out medical students graduate (after 4 years college and 4 years medical school) on average with $210,000 of debt and make $60,000 dollars a year while working 60-80 hours a week for 3-8 years of residency. While yes doctors after residency are well compensated they have gone through 11-16 years of post secondary education by the time they achieve these salaries. Cutting salaries without reforming medical school tuition and residency salaries would be a mistake.

and tort reform to manage the lawsuits to enable lower malpractice insurance costs.

and a scheme to drive down med school pricing. Maybe more competition? Enabling more MD and DO schools? There are <200 medical schools (both MD and DO schools) in the US.

The current bottleneck in producing more physicians isn't medical schools but rather funded residency program slots. Every year some students graduate from medical school but are unable to actually practice medicine because they don't get matched to a residency program. We need Congress to increase funding.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

A great insurance company talking point! The purpose of 'tort reform' is to increase insurer profits.

We need more medical malpractice lawsuits, not less!

I won’t say always, but Medicare price is usually marginal but not profitable. I.e. if you’ve got an empty bed, Medicare is better than nothing, but you wouldn’t actively try to fill beds at sub-Medicare rates even without the hassle of dealing with insurance companies

That can't possibly be true of a hospital that charged $3000 for something on Tuesday, and $53000 for the same thing on Friday.

(Under reasonable assumptions like that Tuesday wasn't done at a $25K loss relative to breaking even; why would such be the case? And that they are busy with procedures, not simply doing a way overpriced procedure once every few weeks, and then just burning through cash in between that time.)

Non profits can be as greedy as any other organization.

Typically the money goes to wages for the leadership rather than profits to the owners.

The term ‘non-profit’ is one I find hilarious. With the smoke and mirrors of accounting and standard insurance company behaviour it can mean anything.

The directors can get bonuses, the cars can be upgraded and the conferences/holidays can get more impressive. It’s surprising that ‘non-profit’ doesn’t generate an eye-roll in more people.

From Wikipedia:

>"In 2003, of the roughly 3,900 nonfederal, short-term, acute care general hospitals in the United States, the majority—about 62 percent—were nonprofit. The rest included government hospitals (20 percent) and for-profit hospitals (18 percent)"

https://en.wikipedia.org/wiki/Non-profit_hospital

If you're doing accounting you have a ledger which balances down to the penny, and the expenses are spelled out in there with concrete amounts.

This is why that judge, as noted in the article, rejected the argument that the cost of an X-ray can be unknowable.

Healthcare companies would need to attribute things like depreciation of equipment (MRIs & CAT scanners for example), as well as doctor and nurse time (outside of operating rooms). These things are generally not tracked accurately, and many professionals are indignant at the idea that they could be.

Getting the hospitals to accept a price ceiling which forces the issue is another way to do it.

You can always lower prices by fiat proclamation, but then you have shortages and wait lines as hospitals go bankrupt and shut down, which will hit rural areas particularly hard.

If you want to lower prices and make sure that everyone gets served, you need to be a bit more sophisticated than just cutting hospital revenue in half and washing your hands of the consequences.

They were trying to solve the problem by increasing the supply of doctors into the system. The other proposed solution was taking the approach of reducing the supply of money into the system. Neither are contradictory to "maintaining an equilibrium of supply versus demand" but both are trying to move where that equilibrium is by adjusting the supply of two different things. So however you define "while maintaining an equilibrium of supply versus demand" either they were both doing it, or both weren't.

>then you have shortages and wait lines as hospitals go bankrupt and shut down, which will hit rural areas particularly hard

Sure, that is what happens if you only fix the prices in certain states and not others, which incentivizes the doctors to move from states that have such price ceilings into states that don't. That is why the only possible way to implement that solution is nation-wide.

>If you want to lower prices and make sure that everyone gets served

I don't see why lowering the price nation-wide would reduce the supply of doctors. What are the doctors going to do? Migrate? But no other large economy has doctor compensation as high as the US. So as a country, you are only competing against yourselves.

To the millions of people making a living in the health care system that have no actual role (direct or indirect) in improving the health of patients.

The key problem is that 20% of our GDP goes to healthcare, and similarly 20% of our population is employed in healthcare provision. This isn't just people sitting around doing nothing. It's nurses, doctors, administrators, etc. If you want to reduce healthcare costs in half, so that it is only 10% of GDP, then expect to throw 10% of the population out of work. That will include nurses, doctors, EMT personnel as well as administrators. Sure, you can try to shift that and fire a bit more administrators than nurses, but you will soon discover that's about as easy as eliminating government waste.

This inability to address the core issue arisies from people approaching these difficult problems in administration and systems science from a facile moral point of view. "it's wrong!" they say, to be given a big bill for a snake bite. Well, OK, it's wrong. But that same attitude will tell you "it's wrong" to fire a hard working nurse, or to reduce the pay of a doctor, etc. So now you are left with boogeymen like greedy insurance companies and fat cat CEOs. This is like the person who insists on a tax cut funded by reducing government waste. It's not a serious proposal. And what we have in the US healthcare debate is two sides, the first side is just lying and obfuscating (that is the side opposed to reform) and the second side is so bound in the chain of moralizing that they are unable to make any serious proposals. They can only go after the fat cats, and not the nurses. Thus their proposals will never work.

Same thing for education -- you need to fire most of the university staff and reduce the pay or fire many of the teachers. Same thing for all the difficult problems in life where we complain that things cost too much. It is not shadowy fat cats that are causing these problems, it is too many people employed in the provision of services who are earning too much. Ordinary professionals. The biggest problems of modern life are that professionals have too much power and are extracting too much from the society as a whole. Whether it is hospital workers or government workers or teachers, the issues of skyrocketing costs and bureaucratic bloat are very similar across these areas, and they cannot be solved by getting rid of shadowy fat cats or employees that "do nothing".

But that's the problem with your argument. Of course people have done it, nearly every developed country has.

> If you want to reduce healthcare costs in half, so that it is only 10% of GDP, then expect to throw 10% of the population out of work. That will include nurses, doctors, EMT personnel as well as administrators.

No, it won't. I'm talking about eliminating the positions that would only exist because of the private insurance system. Which is a massive amount of dead weight loss.

It's not remotely hard to understand conceptually, I mean EVERY dollar that's devoted to arguing over insurance bills is completely wasted. As are all the dollars spent on insurance advertising and marketing, and so on. Every dollar paid back to health care companies as dividends, or used for stock buybacks.

That's a lot of dollars.

Every time this argument comes up people in the US start talking about it like "Oh yeah? Sure but what's YOUR solution then smart guy? Stumped you didn't I?"

Um, no. My solution is the NHS. Like you can go there and look at it I swear it's a real thing, they have buildings and everything, just book a flight to London and see for yourself. Or, in US terms, Medicare for all, which is also a real understandable thing that exists, except for the "for all" part.

The US Government estiamtes the total adminstration and health insurance expenditure cost $288B in 2019. Total health consumption was $3.69T. Thats about 7.5% of total health spending. Even if you assume a 2 or 3x multiplier to the effect of eliminating insurance companies you STILL don't get US healthcare spending on a GDP basis in line with international norms.

Insurance companies are awful, but they alone are not the cause of American's health care spening problems.

Total spend is employees * average salary per employee.

Let's take a look:

* For doctors, there are roughly the same number, ~2.8 per 1000, but US doctors earn three times as much as UK doctors[1]. 294K/year US versus 66K/year (UK).

* The US has twice as many nurses[2] per 1000 people (17.4 per 1000) as the UK does (9.8 per 1000), and the US pays its nurses much more. The US pays 77K/year for an RN and 112K/year for an PN and 181K/year average salary for a nurse anasthesologist[3]. Nurses in the UK earn about 1/3 less, a total average of 33K/year[4]

* The US has 315K pharmacists (not assistants) or roughly 1 per 1000, whereas the UK has 43K or .65 per 1000. US pharmacists make average of 140K/year[7]. UK pharmacists make an average salary of 58K per year[8].

* The US has 23,200 microbiologists (earning 69K/year). The UK has 490 (earning 52K/yr)

* The US has 40 MRI machines per million. The UK has 6.

* Now let's generally talk about staffing. The US employs 20 million healthcare workers with a payroll of 1 Trillion (2018)[5] an average wage of 70K (and median wage of 42K/year). This is occupational data from BLS (https://www.bls.gov/ooh/healthcare/home.htm), so you can't complain about insurance employees at hospitals being included.

The UK has 1.3 Million[5] in both hospitals and clinics counting both NHS and Independents, with an average salary of 24.7K/year.

That means, relative to population, that the US employs 60 per 100,000 healthcare employees while the UK employs 20 per 1000. We have triple the number of healthcare workers and our health care workers earn double what the do in the UK.

Now let's talk about this enormous waste in insurance that will make healthcare affordable if only we got rid of it. Total insurance overhead in the US is 7% of healthcare expenditures[8]. So if we reduced it to zero, we would pay 7% less. Whoppee.

Thinking that you can keep paying doctors and nurses triple and have so many more staff and keep their high wages but merely with insurance reforms reduce healthcare spending by half is so wrong I am amazed I even need to say it. It's a terrible, misleading, evasive non-answer.

What we need to cut are salaries and employment. If you don't acknowledge that, then you are not a serious participant in this discussion because you are refusing to acknowledge that this problem has tough trade offs. You are not going to solve it by "cutting waste".

And this is important, because our problem, as a nation, is the general problem of professional guilds extracting too much from the rest of society. We have this problem with higher education, with finance, with healthcare. A large chunk of our professional middle class is employed by these sectors, and their well-being would be threatened if we significantly cut their wages and employment. It is not evil insurance companies, it is not shadowy billionaires, but our neighbors down the street -- the nurses, the college professors, and the X-ray technicians -- who are the ones blocking meaningful reform. And until we are willing to face that and recognize what must be done, then we will not get affordable healthcare. The incurable diseases of the modern west are all due to the professional classes extracting too much. It is not due to excessive "waste".

---

[1] https://revisingrubies.com/us-vs-uk-doctors-salary/

[2] https://www.healthsystemtracker.org/chart-collection/u-s-hea...

[3] https://nursinglicensemap.com/resources/nurse-salary/

[4] https://www.bls.gov/opub/ted/2020/number-of-hospitals-and-ho...

[5] https://digital.nhs.uk/data-and-information/publications/sta...

[6] https://www.census.gov/library/stories/2020/10/health-care-s...

[7] https://www.salary.com/research/salary/benchmark/pharmacist-...

[8] https://uk.indeed.com/career/pharmacist/salaries

[9] https://time.com/5759972/health-care-administrative-costs/#:....

Funny story - these days most DI (diagnostic imaging) machines (CT, fMRI, PET) are owned by doctors or consortiums of doctors.

They are money printing machines.

Doctors, and manufacturers know this. Manufacturers will find you doctors you can partner up with to buy DI assets, and get set up. You can pay off a CT machine in a couple of months, even high end fMRI in under a year. The manufacturer will finance. They'll even help you write CON applications (Certificate of Need, a nice little thing that hospitals lobbied for to reduce competition - if a new hospital wants to open up in an area it has to demonstrate that the existing community healthcare needs are being underserved. And the existing hospital gets input into the process). A nice little imaging production line.

Interestingly, though perhaps unsurprisingly, doctors who own an interest in imaging equipment tend to refer their patients to it at a rate approaching 2 standard deviations higher (comparing specialties like-for-like).

Yes I agree. Take the windfall profit motive out of the system and you’ll see quite a bit of change. Paying doctors less sounds like a great plan.

But we can start with the truly staggering amount of deadweight loss. Do you actually interact with the US health care system? Is it really that hard to understand just how much energy is wasted fucking around with just the billing component alone?

So when addressing a problem, you start with the first order stuff, and then go to the second order stuff, and you do this in terms of impact, not in terms of conceptual clarity.

Cut nurses and doctors, medical staff wages in half, and you save 40%.

The real point here is that you can't have affordable healthcare if nurses are earning 6 figures.

That's why nurses in the UK earn 40K/year. It's the price of affordable healthcare.

That's the core trade off between affordable healthcare and US style healthcare.

But all of a sudden now we do not have the same moral clarity as we did when we were only talking about "waste".

So let's have that debate right now - the real healthcare debate, not the fake healthcare debate -- and stop pretending this is a problem that can be solved with waste while allowing nurses to keep their 6 figure salaries.

It is what we call cheap moralism to decry how unfair high healthcare costs are in the US and then avoid raising any of the tough issues of what would happen to people whose livelihoods depend on those costs being so high.

What people don’t understand is the appetite for healthcare spending is practically limitless - there is always something more you can do even if the benefit is marginal. As such you have to control spending somehow and the options are (not exhaustive):

- ration care by capping total healthcare spending - “we will do 1,000 hip replacements this year, everyone else waits”

- make the cost visible to patients so they ration their own care - Singapore does this even in their public system. There is no free care, you are expected to pay something according to your ability. This is what the US is trying to do with the move to HDHPs

- closely regulate coverage and prices. Many systems do this.

There are some clever insurance companies whose entire model is "tell the hospital you don't have insurance, get the cash price, pay it with this debit card we give you."

It's pretty perverse that you, an insured person, would have to lie about having insurance because the provider would charge you more for being insured.

[1] https://cost.sidecarhealth.com

It's not illegal here, but in any case nobody asks, I just tell them I'm paying cash.

https://www.brookings.edu/blog/usc-brookings-schaeffer-on-he... (Fixed indemnity health coverage is a problematic form of “junk insurance”)

Six grand to shove a camera up your butt? That's the real scam!

Also, healthcare sharing ministries are not scams. However they are simply not guaranteeing payment. It sounds like the truth of it is that the "guarantee" of payment is what makes traditional insurance expensive. Is that worth it? I think that's up to each individual.

citation or story?

They're not inherently scams, but a major reason that the "premiums" are lower is that they have hardly any legal mandate to actually provide anything, which comes as a surprise to some members who are denied reimbursement. Their authority to deny "coverage" (scare quotes because that's not, technically, what they provide) is huge. In particular, HCSMs frequently deny reimbursement on the basis of conservative religious morality. Got an STD while unmarried, or cheating on your spouse, or just in an open marriage? You can't ask your good Christian neighbors to pay for that. Drug addiction or mental illness? The cure is more Jesus. Abortion? Not even to save your life. You get the idea.

https://openargs.com/oa497-christian-health-sharing-is-a-sca...

https://healthsharingreviews.com/

Not really? Which of the highly regulated healthcare insurers do you feel are scams?

They release 'standard charges' which as far as I can tell means 'the range of charges for this particular diagnosis based on past data' as an excel file.

But the price list is a text file delimited by pipes (vertical bars... |) which just seems unnecessary. They also do nothing to define the variables or column names they use...so that's nice.

A surprising amount of stuff (at least medical billing side) can be flat file moves, especially if you are billing into lots of different systems.

And yes, the idiot new person with a phD says, just quote every field with a ". Great - you program all this up, along with the required escape sequence handling, and then escapes for escapes. \ and / get used a fair bit sometimes already and we are dealing with tons of systems.

I think it must be at this point. The hot garbage that is medical data formats (HL7, in particular) and the ways you can break it as a user, unknowingly and silently. It’s incredible that a format this bad has hung around this long.

It’s not ok that users can type certain characters into a field and break the system.

[1]: https://en.m.wikipedia.org/wiki/Health_Level_7

(Can’t find the original source, but it goes “Cant breathe? Put in a tube. Can't pee? Tube. Can't poop? Tube. Bleeding? Tube. Infection? Tube. Heart attack? Tube.”)

They likely just exported the prices as HL7 from their EHR system and used Excel's built-in delimiter support, then called it a day

And there is the problem.

It sucks, but, like, I don't really blame people for being in a hurry to fix a problem.

For example, SCO Unix's Informix SQL's `UNLOAD TO <file> SELECT ...` queries output in a format that's very much like what avs733 describes, only that the values aren't separated by pipes, they're terminated by them, so every record ends with a pipe character.

If that's the case, there's unfortunately no built-in option to get it to include column identifiers in the report. :(

The machine-readable part is mandated here: https://www.federalregister.gov/documents/2019/11/27/2019-24...

As a taste of how specific this is:

    (5) The file must use the following naming convention specified by CMS, specifically: <ein>_<hospital-name>_standardcharges.[json|xml|csv].

They aren’t always quite as stupid as people make them out to be, these lawyers.

> c) Format. A hospital has discretion to choose a format for making public the information described in paragraph (b) of this section online.

This is how you get Excel files with certain column widths set to zero. All it has to be is searchable, free, public, and updated regularly.

[1] https://www.cms.gov/hospital-price-transparency/contact-us

[2] https://web.archive.org/save

https://www.cms.gov/hospital-price-transparency

Does say "provide clear, accessible pricing information" which I would argue this is not.

edit: Filed a complaint.

EDIT: Thank you all for your efforts.

I'm also going to post a review online, since poor reviews seem to get attention from them.

Instead of giving a hospital your insurance info, say "you don't know if you have it, the last one expired" - even if you have insurance they couldn't prove you did "know you had it".

Then get the bill in the mail.

Submit the bill to your insurance company.

Bill gets paid.

Hospital doesn't get to inflate.

Turns out the translator didn’t know you could resize the rows, so they had only translated the first few words that happened to be visible in each cell.

This is not correct for all practices

My wife's practice (of plastic surgeons medical providers only in a reconstructive practice 75%, cosmetic 25%, attempting to be in-network with every insurer, with administrative front-office doubling as billing, and dedicated personnel for resubmits) vastly prefer cash paying because they get the money right then, and they don't have to haggle with insurers around things like pre-authorization, billing, etc. Insurers regularly make physicians go through the ringer to get an pre-authorization for a vital surgery. Even worse, insurers will ask for a "peer to peer" and then have some underqualified medical provider understand what a board certified surgeon is doing, based on a complex diagnosis, and not understanding the actual surgeries or procedures involved. Insurers will forget pre-auths, and then reject billing, and they have a whole bunch of shady practices around, even with in-network practices for cancer cases.

So much of this price transparency stuff is a giant racket because it helps insurers, and not the actual medical doctors, PAs, NPs and other medical providers. However, it is medical insurers & Payors which are driving all the paperwork (Horrible EMRs, ICD codes, pre-auth, auths, etc) along with growing the tsunami of administrative personnel)

Insurers try to use being out-of-network to reject medical bills, so they use it as a weapon vs practices/hospitals, very effectively unless it is an emergent case (medical emergency).

What is completely missing from this conversation is who this benefits, who this harms, and how insurers exploit the status quo.

Cash paying customers should always be the cheapest option, since there is little overhead for them.

https://www.nytimes.com/2020/01/02/health/christian-health-c...

https://www.nytimes.com/2016/12/10/opinion/sunday/should-i-l...

There is no reason Medicare should be restricted to those over 65, or why Medicaid is implemented differently (and reimburses providers more poorly than Medicare). Or even Tricare. We have at least 3 different taxpayer funded healthcare programs specifically so not everyone can get access to equal care, but so that various classes of people can get healthcare proportional to their political power (which usually scale with money, but also votes in the case of old people).

Medicare/Medicaid reimbursements are insufficient to support most medical practices. Tricare is for military & their families. Most active duty military are young & extremely healthy compared to the general population.

Medicare/Medicaid combined are the largest single item on the federal budget. More importantly, they are still growing in costs because of an aging population, and are heading towards 30% overall of the federal budget [1]

Tricare operates as an employment perk. Medicare has a cap on benefits, but is effectively mandatory for 65+, and medicaid operates as a payor of last resort, after folks have run out their lifetime benefits on medicare.

However, an argument in favor of your suggestion is that the vast majority of medical resources are spent on the last 2 years of life, often for terminally ill patients with a ton of co-morbidities that are at death's door anyways. Most medical spending happens in the latter part of life [2]

> 25% of Medicare’s annual spending is used by the 5% of patients during the last 12 months of their lives [3]

[1] https://www.americanprogress.org/issues/economy/reports/2010...

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/

[3] https://www.acsh.org/news/2018/09/28/true-cost-end-life-medi...

Is there a reason that US doctors should get paid significantly more than their peers in other developed countries?

https://www.medscape.com/slideshow/2019-international-compen...

Big Nope.

Most practices have fairly fixed costs:

Medical malpractice

Facilities rent, or mortgage

Front office

IT & EMR

Privileging/Credentialing

Practice

CME/required education

The only highly variable cost is physician compensation, and considering the limited availability, this will merely cause the retirements and limited access to specialists.

Perhaps you have some evidence to support your extraordinary claim?

I'll provide evidence to the contrary, based on Hospitals and practices refusing to accepting Medicaid [1] patients, or, not accepting/limiting medicare patients[2], [3], [4]

The simple fact is, there is a limited supply of physicians, and many of them don't want to practice the higher volume, 5 minutes per patient, 5 minutes for notes x 12 hours a day type of practice. Not only is the higher volume more dangerous for the patient, it is also more risky for the medical provider, both in terms of quality of life, and also, the risk of an error, or inadequate information exchange.

[1] https://www.reliasmedia.com/articles/147019-when-hospitals-r...

[2] https://www.investopedia.com/articles/personal-finance/10021...

[3] https://www.verywellhealth.com/doctors-accept-medicare-insur...

[4] https://www.hlc.org/news/more-physicians-no-longer-seeing-me...

If the AMA isn't going to fix the physician and residency pipeline, could we not offer visas to physician immigrants who meet first world medical credentialing standards to deepen the supply and therefore support demand? If supply is the issue, we should fix the supple, not destroy necessary demand.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

Basically, you are saying American trained doctors only then, as American doctors are much better trained.

Because my experience is that a physician immigrant has to do the following:

Receive ECFMG verification

Complete missing medical education requirements

Study a boatload!

Pass US medical licensing exams 1 & 2

Find a residency (matching)

Go through Residency again

Obtain certification from ECFMG

start practicing, or

Complete Fellowship, then start practicing

Considering how much healthcare costs in the US and the quality of care received [1], I assert American doctors are not better trained, simply that they are more expensive and there are less of them per capita than other OECD countries [2] [3] [4]. I'm suggesting bypassing the undersized US doctor development pipeline until it is fully funded to produce enough doctors to meet demand and drive down costs.

https://www.ajmc.com/view/the-quality-of-us-healthcare-compa... ("A 2014 report from the Commonwealth Fund revealed continued trends that were along the same lines—despite the implementation of the Affordable Care Act (ACA) in the interim. In the report, the US “ranked last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity and healthy lives.” Significantly, the US was noted to have the highest costs while also displaying the lowest performance.")

[2] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?most_rec...

[3] https://www.fiercehealthcare.com/practices/how-u-s-stacks-up... ("When it comes to practicing physicians, there are only two physicians for every 1,000 Americans, nearly half the ratio of countries with nationalized public healthcare. Countries with nationalized systems saw the greatest increase in the number of physicians relative to their population.")

[4] https://www.medicaresupplement.com/content/global-healthcare...

M4A is overwhelmingly popular, at points taking majorities of Republicans. Also, the US government already spends as much on healthcare as Britain and the NHS; US healthcare is just allowed to cost twice as much.

Add in CHIP and the VA (Tricare). We've taken every vulnerable part of society (older, poor people, poor children, injured veterans) and given them government-paid, universal healthcare. This is around 100 million people.

Everyone left over is thrown into the private insurance pool. These people are typically working age population (18-60), making them both the richest and the healthiest. This is around 200 million people.

This is meaningless if the quality of healthcare is not the same. There are numerous hurdles placed for various different people to get the healthcare, effectively restricting access to healthcare itself.

Taxpayers cover the neediest, leaving the healthiest to for-profit insurers. The healthiest have no incentive to make sure the programs for the neediest actually work or are accessible.

Accepting the cash price after billing the person for the full price and writing off the difference.