Insurance is the only industry where they agree to pay for something (in this case, "medical care"), but then after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc. This combined with hospitals being run by non-physicians*, and people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans**, healthcare in the US is going to absolute shit***.

* I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies. Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).

** In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy.

*** I don't think the above points are unique to US healthcare other than cost considerations, but that's all I have experience with.*

As a quick counter-point to *, there is another sub-problem with healthcare/doctors in the US, where often patients with chronic illnesses or not-easily-testable conditions have to fight hard for doctors to take them seriously. The why of this varies a lot from what I've seen, but includes:

- an attitude of "most patients are just trying to wring medications out of you" - an ego-hit of "if I didn't make the diagnosis, I don't want to help" (this applies to both patients coming in with a suspicion of what they have, or getting a diagnosis from another doctor) - burn-out/overworking, where doctors have a hard time managing all the different cases coming at them without dropping the ball here and there

It's not a simple, single-cause problem at all, but just want to provide an alternative point of view about patients who look things up or come in asking about a specific condition or diagnosis.

When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed.

Even in cases like POTS, which has no medication involved in treatment, just lifestyle changes, and yet people close to me who have POTS all had an uphill battle getting it recognized by anyone, especially doctors who could diagnose (disclaimer: sample size = 3).

> When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed.

I told my doctor I had already been diagnosed with ADHD because I had a strong suspicion I had it and wanted to see for myself if the medication helped (it helped massively). I think medicine should be accessible for patients who need it but I don't know how to avoid large amounts of patients then taking medications for the wrong thing, which would probably happen if it was a free-for-all. It kinda comes down to the question of having the personal freedom to hurt yourself doing something stupid, which is a balance (a little of that freedom is good, too much probably bad). All-in-all I lean toward the current system of using on experts to make the final decision. Still, I would be really pissed if a doctor prevented me from getting stimulants for something I believe I need, so I am not 100% satisfied with the current system either.

Another wrinkle to the problem with that gatekeeping structure is that it is so prone to bias against women and people of color, who are much more likely to be undiagnosed and ignored or dismissed.

I'm not sure why this is being downvoted. This is a legitimate issue, divorced from politics completely (politics usually result in downvotes).

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275/

[1] https://www.medicalnewstoday.com/articles/gender-bias-in-hea...

Could someone explain what’s inaccurate here?

Edit: It originally appears to be getting heavily downvoted.

Nothing is inaccurate. Here's a few primary and secondary sources.

https://www.health.harvard.edu/blog/women-and-pain-dispariti...

> a 2000 study[0] published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack.

0: http://www.nejm.org/doi/full/10.1056/NEJM200008243430809

https://www.independent.co.uk/life-style/health-and-families...

> women with chronic pain conditions are more likely to be wrongly diagnosed with mental health conditions than men and prescribed psychotropic drugs, as doctors dismiss their symptoms as hysterics [1].

1: https://psycnet.apa.org/record/1990-98104-000

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

> racial bias in pain perception is associated with racial bias in pain treatment recommendations... Black Americans are systematically undertreated for pain relative to white Americans.

(To contextualize the votes: I think you were getting down voted for assuming that sexual and racial bias don’t exist. You assumed the statement mentioning that such biases existed was inaccurate and wanted explanation as to how. However, per my other comment, the biases exist and contribute to significant negative health outcomes for the disadvantaged groups.)

> I think you were getting down voted for assuming that sexual and racial bias don’t exist

I agree that they do exists and am aware of the research showing it. I work in healthcare.

I didn’t make the grandparent comment that got downvoted but was interested to know why it was happening.

I view drug enforcement policy meant to prevent individuals from making decisions for themselves as always doing more harm than good. The place for regulation in this space is controlling what claims profit-motivated entities can make about drugs, enforcing quality and safety standards in manufacturing, and honestly tying the hands of insurance companies as much as possible, if not just gutting them altogether

Yeah, I've witnessed this first hand with my spouse. She's been told she just needs to exercise more (she was a professional dancer when it hit her), that it's all in her head (actual psychiatrist said otherwise), that it will resolve in 6-18 months (it didn't), etc., etc. It's pretty appalling.

Thanks for mentioning POTS, btw. Despite how many people have it, it's still fairly poorly known about even within the medical community.

I'm more and more convinced that POTS/EDS/MCAS aren't rare diseases, they're just criminally under-diagnosed because they tend to affect women. FWIW, POTS is much more manageable with medication (e.g. Midodrine and Florinef).

> criminally under-diagnosed because they tend to effect women

I just can't understand this argument. Women already live 5 years longer than men on average. You mean to tell me if the system didn't discriminate so strongly against their best interest they'd live even longer than men?

Responding to both you and the comment above/below you:

Women have a hard time getting symptoms, esp around pain, taken seriously. Oftentimes these symptoms are downplayed or ignored, regardless of the sex/gender of the medical professional.

Again. If they are discriminated so strongly against, why do they live 5 years longer on average?

It's like you completely disregarded my comment and decided instead to just proselytize.

Because of biology? Other female primates (chimpanzees, gorillas, orangutans, etc) also live longer than males.

I don't understand your argument. Just because women live longer on average, they're supposed to live in pain without treatment?

My argument is that if there was a significant bias against them then that gap would not exist or be much smaller.

In reality they get about 7 times the allocated health expenditure that males get.

nurses are 91% female and doctors are about 37% female - are they also 'criminally under-diagnosing'? Seems there are quite a few more women in healthcare than men these days.

The counterpoint to your last thing is that there are also many ailments that we literally just do not have enough info about yet to have proper treatments. And if we are studying such things many doctors are not going to always be up on the latest research for that specific condition.

I have found it helpful to approach it in more of a teamwork-like mentality. Don't just read WebMD and try to diagnose yourself - journal your symptoms, observe the trends, record data. If it seems like it points to a specific condition hop on Google Scholar and look for some legitimate new research the average doctor may not have heard about. Print that out and then when you go in show them and ask questions without attempting to specifically diagnose yourself.

You could be totally wrong but with some background info your doctor is much more likely to accurately diagnose and take you seriously.

> people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans

In my experience, I have had:

1. Doctors that know nothing about a really basic ailment and not have any meaningful guidance or treatment to suggest

2. Doctors that Google something literally in front of me, things that I have already Googled myself, and draw the wrong conclusion because they're looking at results at a glance - when I had searched myself earlier and dug deeper though, it was clear to me the result he was looking at was just plain wrong

3. Doctors that provide very little to no guidance about a wide selection of medications available to treat a problem, leaving me to essentially guess which option of a dozen or more I should go with

4. Doctors that force me to advocate for myself and my condition before they agree to help treat it - so much so that I had to visit 4 different doctors to find one that would, wasting nearly a thousand dollars of office visits with nothing to show for it.

It's no wonder people do their own research and dare to advocate for themselves. Most doctors are fucking worthless.

I felt the same way until I started being more active in choosing quality doctors. Doctors are no different than any other profession - there are the ones at the bottom of their league that are just going through the motions and there are the superstars working for some of the best institutions in the world. The key I have found is to specifically look for doctors that are either actively involved in academic research pertaining to your ailment or are working at quality institutions that are engaging in research that is at least tangentially related to your issue.

Keep in mind they also have to do a stupid amount of paperwork these days for every patient and the place they work for may be overscheduling the crap out of them - generally (unfortunately) I always consider my first appointment to be sort of a wash due to this and assume I am not going to really get anywhere until the second time I see them.

I cannot agree enough. I think anyone who has dealt with a puzzling condition quickly learns how limited the "expertise" of these supposed authorities is. Sure, insurance companies are terrible, but so are most doctors. Great, quit, you probably sucked anyway.

It also probably doesn't help that doctors are jacks-of-all-trades medically - there are simply too much complexity to thoroughly understand the nuances of every obscure condition and interaction.

However, I think acknowledging when one doesn't know something is a skill many could benefit from improving...

Indeed, there have been mutiple instances where, if I had not put my foot down,i would be left untreated and undiagnosed.

Doctors are not like other proffeshions, they cannot put things right if the opportunity for treatment is missed

You forgot one.

Doctors that blatantly lie to your face because they want to push some procedure.

just adding a case when a doctor prescribed double the quantity for an infant. i spotted it right away, he panicked, asked to have the prescription back and promptly destroyed it.

> * In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy.

I still think it’s better than the other extreme of just showing up and trusting the professionals. That should work in theory, but my experience for myself and those around me is it’s incredibly ineffective. If what you’re dealing with requires the least bit of thought, odds are you’re getting brushed off to the extent you allow.

The real model of US healthcare is essentially apprentice/master, with the patient as apprentice. Apprentice does a lot of the work, not all, some needs to be approved by the master and the apprentice better know how to learn from the master, when to push back, and how to make it seem like it was their idea all along. You can imagine how this falls apart for mental health.

I also think the complete implosion of family medicine has made this worse. In the past, you would keep the same family medicine doctor for decades and trust them. They in turn would know what your values and priorities are. Moreover, they would be able to guide you through difficult healthcare decisions that inevitably come up (cancer diagnosis, mental health etc.). We have lost the human connection aspect of medicine and those few physicians that are able to hang on to it are burning out due to the massive amounts of paperwork they need to accomplish. From the hospital perspective, (which many physicians now work for) good paperwork=good patient care. Paperwork is measurable. Relationships (other than in the abstract) are not.

> * I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies.

The skills need to run a hospital are quite different than those required to be a doctor. I'm not saying hospitals aren't unique - I believe they are and their adminstration is highly specialized. Doctors should inform the administration at every level but it would be a waste of their training and a bad idea for doctors to run everything.

> Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).

Would you be as quick to say "Doctors should work without pay." ?

Why would not paying doctors be the natural consequence? It’s a fairly significant jump to go from don’t let cost be a primary decision driver to let’s force doctors to work without pay.

Because in reality, there are always tradeoffs and constraints. In the US, a disproportionate amount of healthcare costs come at the very, very end of life.

It's possible to meet the sole criteria of science, quality, and patient wishes with exploding costs. I think the OP's point was that money has to come from somewhere.

"a disproportionate amount of healthcare costs come at the very, very end of life."

One might ask why that is; while some is surely due to natural decline in later years, one could likely also posit that the cost-fears leading up through that period (decades), and the general inability to get people to do preventative care throughout adulthood contribute to that significantly.

> One might ask why that is

Indeed.

It is one consequence of a highly atomized culture. I suspect it happens because individuals are expected to take responsibility for their care (basically, this is the human side of cost-shifting and corporate planning around the care gradient available to someone at a given wealth level).

To someone at the end of their life, money is usually less interesting to them than a few more days of breathing. So the market provides.

The explanation I've heard is that it's rooted in the cultural sanctity of life and how that translates to trying to preserve life at any costs (even when quality of life is no longer present).

To be clear, I'm talking about the absolute twilight of one's life that's reached regardless of levels of preventative care. I think there's potentially an opposite point that could be made: taking care of one's self can prolong this period and make it cost more. Someone who drops dead of a heart attack one afternoon won't have the same end-of-life costs as someone who gradually becomes enfeebled with age.

Doctor pay is high because supply is constrained.

We’re “fixing” this by flooding the market with less trained nurse practitioners and PE. Doctors are being gobbled up by regional medical cartels and put where they can maximize billing.

>>We’re “fixing” this by flooding the market with less trained nurse practitioners and PE.

In reality though, the overwhelming majority of cases that walk into a doctors office on any given day do not require an actual MD - NP and PA's are more than capable of handling many, many things that a typical patient needs.

Everybody tends to think they need a 'real doctor', they usually don't. Its good they are there when they are really needed, but do you really need an MD to diagnose a sore throat, adjust your BP meds or many other routine things that are people are seen for everyday?

True, but which ones?

> The skills need to run a hospital are quite different than those required to be a doctor.

And still, in many countries, including highly industrialized ones, hospitals are run by doctors. So either US administrators are making their hospitals run a lot better (which does not seem to be the case), or the core incentives each group optimizes for are different.

It should still be doctors. Just makes administration a career path that a doctor can choose to move into. There would be plenty of takers from the ranks of those burnt out on patient care. They could even find new meaning in being able to help people without going through the bedside wringer. If professional administrators have a place in the system it’s in positions under experienced physicians where they can help with implementation of policy, not shape it.

> The skills need to run a hospital are quite different than those required to be a doctor.

Why do you think law firms and accountancies are partnerships? Because the best proffesional for managing lawyers/accountants/develipers is such a proffeshional with loads of experience. Thats why we have progression, you gain management skill as you bevome more senior but you still know how the industry works and the people you manage

That’s the definition of the “Peter Principle”. Just because you are good at your profession doesn’t mean that you are good at management.

Is it impissible to select those who are good at management from the pool of thousands of people who are good at that proffeshion?

No, you first find people who want to go into management, then you give them management responsibilities without promoting them until they prove they can handle it.

> I strongly believe that only physicians should be running hospitals.

This is how it is for other professional industries. As an attorney, you can lose your license for sharing any profits with someone who isn't a lawyer. I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.

From what I can tell, this is just to keep money in the hands of lawyers and keep prices high.

There are plenty of things that could be done better now by non-lawyers with the help of lawyers (look at Rocket law).

Why shouldn‘t money from law be kept in the hands of lawyers? It‘s a grueling education with an even more grueling exam and even now a lot of law graduates can barely afford to keep a roof over their head

Because the profession is meant to serve the public interests and not just be a money grab. According to government data, the median lawyer is in the top 10% of income earners.

To put numbers on it. To get to the top 10% of income you only have to make around $120K.

Correct. ONet data puts the median lawyer at about $127k. From what I could find, 90th percentile of income is around $126k.

While I know HN is probably SV and software biased, saying "only" $120k comes across as out-of-touch for the way most people live. For comparison, the median SF lawyer makes $191k according to BLS data. I could not quickly find 90 percentile data for the area.

Your average Enterprise CRUD developer in any major city in the US can hit that number within 3-5 years and a job hop. It’s not exclusively a SV thing.

And your number is correct according to Census data.

https://dqydj.com/average-median-top-individual-income-perce...

I agree, but it's still out of touch. (not a knock on you, we are all subjectively influenced by what we come into contact with the most and interpreting it as 'normal'. It's also why something like 90% of people consider themselves middle class.) The fact that you have to narrow it down to software development and major cities should tell you that much. That's also why my original comment included both SV and software as biasing factors.

The average person does not develop software and does not live in a major city. If somebody is making double the median wage and 2.5x the average wage and complaining about keeping a roof over their head, they can probably expect some sideways glances. It's like when people complain about the difficulty of making ends meet once they make their Lexus payment and pay their kids private tuition bill. The subjective struggle may be legitimate but it's still out of touch with the experience of most people.

Many states of laws regulating the "corporate practice of medicine." But it seems like that leads to a hospital just being bunch of loosely held together independent businesses/contractors.

What does that even mean? All lawyers have support staff where the lawyers “share” their billable votes with non lawyers

I'm pretty sure no jurisdiction allows lawyers to share their billable hours with their support staff. You have to pay them either hourly or salary, not linked to how many hours you're billing. You can't give them a law firm stock package or say they get a 10% commission on all billed revenue or something. At best, some jurisdictions allow law firms to give an annual bonus if the firm does well.

> I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.

What states are these, Canadian states?

In the US, many many many SaaS shops are wholly owned by businessmen / bean counters. It's like, weird, to be an engineer who runs a software company.

I feel like the person you are responding to was not meaning software engineering. Electrical engineering, Chemical engineering, Civil engineering, Mechanical engineering, etc are all more likely: especially as what you say about software engineering is definitely well known.

> engineering firm

> SaaS shop

Now, I get we like to refer to ourselves as Software Engineers, but surely you understand he means actual certified engineering firms, not groups of code monkeys, right? Software is virtually never engineering, you'd have to get to a situation like flight control software before you're doing anything legit

I am a software engineer and do not consider myself a code monkey. Do not speak for all of us.

If you have never stepped into a domain where you have to formally verify your software, I think you should probably not take too much offense to such a comment. While I admit it may be slightly negatively connoted, I primarily used it to illustrate that the kind of engineering going into making a bridge differs greatly from making your UI widget pixel-perfect or your SQL query from being too polynomial

I’m sure “sales engineers” feel the same way…

I believe this is in reference to Professional Engineering firms, which often requires PEs either as owners or in certain roles. As far as I'm aware software engineers are not required to be Professional Engineers in the US for most tasks, nor are SaaS shops required to be licensed as Engineering firms.

[1] https://www.harborcompliance.com/information/engineering-fir...

NCEES did toy with the idea of a software engineer Professional Engineer license, but it went away due to too little interest. I think it was in part that industry didn't want it because it would give more leverage to SEs. IMO the only way that will become commonplace is if it is forced by regulation.

They are talking about the "applied physics" engineering fields.

> insurance is the only industry where they agree to pay for something (in this case, "medical care"), but then after service has been rendered can decide to pay less

That's not always the case. The reason I stopped writing mobile applications long ago was because the mobile carriers were doing exactly this, and not even providing enough paperwork for you to argue with them about it.

People like to lambast the Apple App Store for being greedy, but the fact of the matter is that people netted 3x as much off Apple that they did from the carriers. They are asking too much money now but their rates were absolutely defensible at the time. It's not a coincidence that we had a gold rush that started almost exactly when the App Store became a viable target.

One might ask what would happen if we joined the rest of the 1st World in providing medical care and marginalized private health insurance. Would it be a similar watershed moment?

The only gold rush in medicine where I’m from involves moving to the US to get away from a nationalized health care system.

curious - where is that?

The "only physicians should run hospitals" doesn't make that much sense to me. Reminds of the technocratic argument you used to see a lot on the internet that instead of politicians we should have scientists and engineers in legislature.

The issue is if you have someone with a scientific background doing politics, what you have at the end is still a politician. Same thing here. An MD doing hospital administration is an administrator.

Which is not to devalue specialist expertise in these roles. I definitely think you want people with these backgrounds in those roles as well. Just not necessarily exclusively. A career administrator has different skills than a physician, you want people with both, and other, roles working to run a hospital.

The real problem as I see it is probably the incentives, constraints, and pressures they work under, or towards. A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. The thing is to change the situation, not put different people into that role and expect them to do it dramatically better.

Works pretty well for lawyers. It's not perfect, but lawyers have to adhere to a code of legal ethics, and only lawyers can have equity in law firms. Seems like this model could be transferred directly to the medical industry. It would not solve every problem ever, but it is an interesting thing to look into.

Yeah that sounds fine too if you can do it. Anything that prevents hospitals from being operated by large profit-seeking entities with no other stake in them would probably be a strict improvement over the current system.

I think the practical issue is those fields that have similar restrictions basically predate a major societal shift. We now consider the only valid limits on profit and ambition to be market forces. I'm not sure restricting hospitals in this way is less radical than just nationalizing them, in terms of practical politics.

Anyway, again, sure. I'm not informed enough on this subject to know what model would actually work best. I think the problem is the raw exclusive profit motive rather than who specifically is running them, but there are a lot of ways to eliminate that.

There might be a parallel to a medical group or a professional corporation, but a law firm is a vastly simpler operation than a hospital. Orders of magnitude simpler.

The problem with this is that the MBA programs that churn out hospital administrators tend not to be very good...focus on mergers, cost cutting, not so much on optimizing care. The pendulum has swung too much onto the MBA for MBA's sake hospital administrators and less so on actual medicine.

> A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation.

Indeed! Whereas a doctor might say yes, give that patient with cancer the treatment they need, the MBA is going to say no, it costs to much, let them die. If the goal is to maximize profit, the MBA is doing a better job. If the goal is to maximize the health of your patients, the doctor is. We must realize that these two goals are fundamentally in conflict with one another.

The question isn't whether a doctor or an MBA should be running a for profit hospital, it's whether we should even have for profit hospitals. If we care about people more than profits, then clearly we should not.

At some point, you have to put a value on a human life.

It sucks and no one likes it, but what is the alternative?

Each human life is worth infinity? So we should bankrupt the entire country, spending 10 trillion dollars on a surgery that has a 1% chance to save a 98 year olds life?

Obviously that is an extreme example.. but the point is sound. We only have so many resources, how do they get divided up? Should be spend millions to give 80 year olds 1 more year of life? Do we value life on the reverse of age, so a baby we value at 10 million dollars, but a 90 year old we value at $20,000? What if that 90 year old is your Grandpa?

> So we should bankrupt the entire country, spending 10 trillion dollars on a surgery that has a 1% chance to save a 98 year olds life?

This is a pretty wild straw man fallacy, but I'd like to give a good faith response nonetheless.

You may not know, but the US spends more per capita on healthcare than any other country in the world, by a longshot. Many other countries provide unimpeded treatment for all of their patients. If a doctor in Japan wants chemo, the patient gets chemo, and treatment starts immediately. So how does it make sense that we spend more on our patients but doctors are still told no, the patient can't have that treatment? It's because a larger share of our biggest-in-the-world healthcare spending goes to for profit companies, like insurance companies, than anywhere in the world.

So when an insurance company says no to a treatment, it's not because we don't collectively spend enough for that treatment, we do! It's just that the insurance company wants that spending for themselves.

I would recommend the following EconTalk podcast on the history of the American healthcare system.

https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...

Spoiler alert -- the author being interviewed doesn't have a solution, quick, easy or otherwise. But the history is fascinating -- in the end there are a lot fewer villians than you might imagine. A lot of good faith decisions seemingly made in the public interest over the past 150 years have led us into a weird local minimum that seems inescapable. Where we are was not inevitable, and as they say if something is unsustainable it has to end eventually, but before suggesting sweeping solutions I'd recommend hearing a detailed history.

Let's not be obtuse though. The majority of healthcare costs are incurred at end of life. Perhaps insurers and the government should not subsidize any life saving care for those over the average mortality.

I know for example, my grandmother who lived in europe many years ago, had failing kidneys. While today it's likely she could have subsisted for more years on dialysis, perhaps that money didn't need to be spent.

Life is finite, and racking up bills at EOL is a waste. People need to learn how let others die with grace, instead of giving chest compressions to a 85 year old 80lb grandmother.

If you want to do that, then you have to legalise euthenasia and dace all the thorny questions that comes with

Euthenasia is already readily available in the united states. It costs somewhere around 10-15 cents per round.

>"This is a pretty wild straw man fallacy, but I'd like to give a good faith response nonetheless."

Your interlocutor was actually using "reductio ad absurdum", which is a valid style of argumentation. https://en.wikipedia.org/wiki/Reductio_ad_absurdum

You didn't address the scenario as presented, or demonstrate how it violated a principle you had described. Instead, you shifted to excoriating the insurers for greed and waste.

Should the insurance company bankrupt itself on the first client? If not, how should they decide how much to spend on each? I should note that non-profit hospitals have similar results as for-profit hospitals (in the USA), so there's little evidence of shareholder greed playing a significant role (though there are many other stakeholders including employees).

We already have decent (not always great but decent enough) government provided healthcare for the elderly through Medicare. So in fact, we've completely avoided your example already and said "yep, all life has value if you're eligible for medicare".

Of course resources are finite, nobody ever argues that they're infinite. But we treat healthcare as if there's a constant scarcity of medicine with how much is charged because there's a constant urge to squeeze even more profits out of patients who probably have only 2 choices- pay for the medicine or die.

The counterpoint is that you have the exact same decisions being made in systems like the UK. People get refused cancer treatment because they were too old and their were younger patients that had a better prognosis. The fact is both types of systems don't have unlimited resources.

Yes, care rationing is a thing. But in the UK care is rationed due to capacity constraints whereas in the US it's rationed in order to make a profit. These are very, very different things. It means that people's welfare, and death, is being traded for profit.

re: "Medical decisions need to be made outside of cost considerations."

In the end, labor hours of professionals are finite. Even if you don't need to pay doctors, you only have so many, they can only work so many hours, you will need to prioritize who to help in what way, which procedures to do. Same with all the other personnel, the consumable stuff, the devices/scanners/equipment, etc. So someone is going to have to prioritize. It can be just "how much quality of life can we save using the resources we have", regardless of the patient's ability to pay/insurance/citizenship, but some prioritization will need to happen. The policy of the death panels can be changed, but their existence is inevitable.

> labor hours of professionals are finite.

This is why it makes no sense to have doctors and nurses waste time battling insurance companies over treatments, and hospitals over staffing. Their time is indeed too valuable.

This is exactly why we should simply just expand medicare to be an option for everyone. If it's good enough for everyone over 65, it's good enough for everyone under it too. I'm ok with paying a reasonable premium to have access to the largest insurance network in the nation.

Simply? It is not so simple. Medicare reimbursement rates are way below commercial rates and hospitals wouldn't survive just from medicare reimbursement alone.

Let's stop trying to come up with "simple" solutions to the healthcare catastrophe in the US because the reality is more complex.

So raise the reimbursement rates to the point where hospitals can survive, or cut the fat. See? Simple.

Every time someone makes an argument like this, it's always to say that somehow, medical treatment in the USA is special compared to other countries. We couldn't possibly have universal healthcare work here. Please.

Possibly misattributed, but usually given to HL Mencken:

"For every problem, there is a solution that is simple, neat, and wrong."

Don't kid yourself into thinking a complex system that makes up 20% of GDP is going to have a simple solution. Just a couple examples you'd have to contend with:

1) Insurance companies get a say too, according to the Constitution. That means they get to lobby in their own interests. That political problem itself is a boondoggle.

2) The US funds a disproportionate amount of medical R&D. Some of that fat is going to be cut from research. You need to have a plan on how that will effect long term quality of care and innovation.

3) Physician licensures are limited by the AMA. If you expand coverage, you will need to expand supply because any time something becomes "free", people will consume more of it. That's not a necessarily bad thing in healthcare, but needs to be addressed. The AMA also gets to defend their political interests.

There's lots and lots of other issues. I'm not claiming the US healthcare system is great. But pretending it has a simple fix is naïve.

Again, I point to the fact that nearly every other industrialized nation does it better than us, with a fraction of the resources. I find it highly suspect when people say the problem is so complex we can't possibly fix it. Every other major western (and some asian) economy has addressed this. We are not exceptional. We can fix this too.

Yes, but that is, in part, because the US effectively subsidizes other countries medical R&D. Similar when other countries cap their drug costs while the profits are made up within the US. That means we subsidize other countries healthcare costs at the expense of our own. A country-to-country comparison is incomplete without understanding those systemic issues.

It's like when people point out how much the US spends on the military compared to other Western industrialized nations. Part of that discrepancy is due to the fact that the US disproportionately funds organizations like NATO. Other countries reap the benefit without footing the bill. There was a lot of outrage in Europe when the US tried to enforce the NATO GDP spend that other countries already agreed to.

The US can do better, but I would argue we can't unless we fully understand the complexities of the system. That means not getting enamored by the idea that there are simple fixes. The first step IMO is getting the political will to do so (and to understand the tradeoffs within a complex system), because many of the potentially solutions are stymied at Congress.

But this is exactly why administrative roles are created to help alleviate that dilemma, so primary care providers can focus more time on patients.

> Medical decisions need to be made outside of cost considerations.

A common attitude which may cause:

Health care is extremely costly in the United States. Although the rate of growth in spending has attenuated in recent years, per capita spending on health care is estimated to be 50 to 200 percent greater in the United States than in other economically developed countries. Despite leading the world in costs, however, the United States ranks twenty-sixth in the world for life expectancy and ranks poorly on other indicators of quality.

https://journalofethics.ama-assn.org/article/complex-relatio...

Looking at the levels of obesity in the U.S., I consider the 26th place a true miracle of American medicine. If it can prevent people who devastate their bodies with junk food for decades from dying at 50 ...

On the other hand, imagine the world where Coca-Cola makes billions on healthy drinks, people are slim and fit until they die, and half of the money spent on treatment of chronic diseases of excess can be used for something else.

> Looking at the levels of obesity in the U.S.,

This is not unique to the US. Can't really say "but we only have 25% obesity here" and call that any kind of win. Maybe the US leads in this regards (though it varies by region, some areas have European-level obesity rates), but obesity is a worldwide problem.

>Medical decisions need to be made outside of cost considerations.

It's really jarring to read an otherwise reasonable comment that drops a whopper like this. Nothing exists outside of cost considerations. The NSA has cost considerations. The Space Shuttle had cost considerations (obviously, not great ones!). The design of nuclear submarines involves cost considerations, however unsettling that may seem. You're telling me that my broken hand needs to be judged outside of cost considerations? Give me a break.

The problem is that there is a lack of "trustworthy" parties to evaluate cost expectations in medicine. The patient often doesn't understand their condition or its treatments, the doctor has a clear perverse incentive to inflate costs, and the insurance company may actually be better off if the patient dies. At least that's the conventional picture. Leftist pundits often complain that the American economy is based on "greed", but a more precise criticism is that there has recently been a trend away from expecting benevolence and for-its-own-sake honesty from anyone under any circumstances, or equivalently an increasing cynicism about human motivations. It remains to be seen whether a medical system can function when nobody expects to trust anyone.

"The Space Shuttle had cost considerations (obviously, not great ones!)."

It absolutely did, and great ones too. The program was too costly and never lived up to the original expectations of fast and easy access to orbit.

Falcon 9 + Dragon is the first American human-rated launcher and ship that can be labeled as somewhat cost effective.

> * In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy.

I think this is exacerbated by doctors a lot of the time. I'm in Canada so it's obviously a very different system, but visits to a GP often have strict time limits and "one issue only" rules. When you can only talk about one symptom, and you only have 5 minutes to explain it, it's natural to try and do homework first to see what you're going to use your limited time on.

> * I strongly believe that only physicians should be running hospitals.

Strong disagree. This same attitude pervades the military ("only pilots should run the air force") and really all it does is that lower representation of the interests of the other non-pilot 90% of your organization and put a pilot bias on every decision being made.

Those are extremely different situations and you’ve not really justified why they’re being compared. A “doctor bias” in every decision being made would ideally prioritize health outcomes over decisions made for profit or convenience. It’s possible that doctors will make poor decisions too, but on balance our expectation based on their training is that decisions made because of healthcare outcomes would be more likely in this scenario than the current state of affairs, which prioritizes economic considerations as administrators in every context currently tend to

I think the point is that "doctor bias" will not take a balanced approach to the other systemic factors. I'd argue it's the same with the pilots. If you asked pilots, they'd likely say the same thing: their priorities are going to align with the mission better than anyone else's.

Anecdotally, this has been true in my experience on complex engineering projects. When the project manager is a mechanical engineer, guess which systems get the most time, money, and priority? Mechanical. And when it's an electrical engineer, the electrical system gets the priority. When it's a software engineer, the software etc. They all recognize the other systems, but availability bias skews their worldview and priorities to the neglect of others.

> I strongly believe that only physicians should be running hospitals.

More than that - hands on healthcare should not be a for profit industry. The need to make profit is fundamentally opposed to providing the best care. As the push for profit increases, more people get sick and die. This goes for long term care as well, which is facing a similar staffing crisis for similar reasons.

Your local hospital is likely a non-profit. Your health insurance company might even be a non-profit. But they don't do any better. Corporate profit motive doesn't seem to be at play here.

It's executive/board/administrative compensation that's more of a problem than profits for most hospitals/insurance companies.

>I strongly believe that only physicians should be running hospitals.

Can you elaborate on your rationale? I ask because I've worked in hospitals run by a cadre of physicians and it was not run well. Anecdotal, obviously, so I'm curious on your thoughts on what they provide.

My worry is that it can lead to an unbalanced technocracy. It's like saying a politician needs to come from [industry x] to govern [industry x]. Technical competence is a necessary, but insufficient criteria when managing a multifaceted problem. The risk is that the front-line physician priorities would always become the organization's top priority. In reality, a hospital administrator has to manage competing priorities across many different domains.

> after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc

This actually isn't necessarily true when you learn how billing codes work. Most insurance companies pay out at a fixed rate per billing code based on your plan. That doesn't change. What does change is that hospitals can retroactively apply new additional billing codes.

This happened to us once for an ER visit where we got 3 additional surprise bills over 6 months because the hospital retroactively applied new billing codes to our visit.

Opposite anecdote: For done reason about 10 years ago my asthma that had just been a minor nuisance and didn’t stop me from running, teaching fitness classes part time, etc. for a decade, sent me to the hospital and kept me coughing for nearly a year.

The doctors and specialists gave me every treatment under the son to no avail.

Then I did my own research and read I should try OTC psuedophredrine. It worked like a charm. Now every time I catch a cold (and when I got Covid), I pop psuedophredrine for a few days and I am good.

Yes, psuedophredrine is suggested to treat Covid if you have virus induced asthma.

Second anecdote: I have relatively mild cerebral palsy. As I’ve gotten older, my affected foot tightens up especially in the winter. My neurologist said it was physical and not neurological. I went on vacation and was drinking more alcohol than I usual do. I noticed I was walking without pain. I did my research when I got home and found a prescription muscle relaxant with the fewest side effects and ask my doctor about it. He prescribed it to me.

He didn’t bother telling me that I should get blood work done to check for liver problems. I had to bring it up to him.

I can now walk without pain and run when properly conditioned.

* In this day and age not being your own doctor/advocate will produce unwanted unnecessary results.

If you look up possible treatments /side effects and your personal history you will be in a better position to engage and weight options. If you blindly accept everything you will end up on the most profitable treatment plan plan insurance allowed.

>I strongly believe that only physicians should be running hospitals.

(Disclaimer: I have been on the design team for several hospitals, including El Camino and San Francisco General, in the bay area - and I have a family of doctors and nurses in my family - my brother was head of the Veteran Administration for the state of Alaska, and is currently CMO for a large health provider (he is a doctor)

---

That said, the "running" of a hospital isa hell of a lot more than medicine (when we are specifically talking to the running of -- but this comment was made in relation to costs/efficiencies as far as outcomes, patient treatment, insurance etc...)

Hospitals are really complex ecosystems and should be thought of more like an aircraft carrier than an other form of business.

The costs within the realm of a hospital are ridiculous - as are the methods and manner in which hospitals raise money.

Insurance is cancer to be sure, but there are so many other factors that go into the operational costs of a hospital - and I don't just mean ngoing care and operations - systems and technology and medicine evolve. People are people and regardless have the same hierachy of needs in any environment.

You have every single actor as an enemy of the hospital bottom line:

New tech, $$

Older nursing pop $$

Current nursing/doctor market salaries $$

Maintenance for existing systems $$

Insurance billing code lock-in $$

Competing hospitals for doctors and nursing staff $$

California $$

Corruption $$

Utilities and related redundant infra to ensure life systems

The ridiculous cost to upgrade

The list goes on and on...

(The cheapest hospital project I worked on was hundreds of millions of dollars)

etc...

Hospitals are really expensive to run, and it requires a hell of a lot more skills than simply being a "doctor" to run one.

Let me add two more payment scenarios: 1) Pay in the form of a credit card number, where the provider ends up paying CC processing fees to process the payment. 2) Ask for the money back, months later.

> Insurance is the only industry where they agree to pay for something (in this case, "medical care"), but then after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether

This is precisely why I think we will never be able to effectively treat healthcare as a "free market" with tools like HSAs, posted price sheet, etc. The end user can never know the true cost of their procedure until it's long over (sometimes years later) and often don't get to choose at all.

The hospitals themselves are also to blame. There are a couple court cases where the hospital threw the nurse under the bus to cover up for their own issues (short staffing, bad safety procedures, covering up for a doctor, etc), and nurses are justifiably pissed off right now.

There was a time when hospitals could have helped the nurses with the stress and workload, but the admins bungled it at every possible turn, and now it seems they missed their window.

I doubt that it's as simple as that. Nurses are also leaving in Canada and we don't have insurance breathing down their neck.

Insurance / government repayment is mostly the same thing. A layer of bureaucracy.

But they have zero autonomy there too I assume?

Sample size of 1, but my gf blames forced overtime. Being legally obliged to stay for an 8 hours shift after finishing one has a way to drive you to depression.

I would pay more to go to a hospital where I know people are actually well rested. My last few hospital stays have been saturated with clearly agitated staff (doctors, nurses, reception) who were putting in minimal effort, and clearly didn't want to be there, and I can't blame them given the conditions that they're being forced to work under.

This is in the US, and I can't figure out why the Department of Labor hasn't cracked down on the medical industry yet. It's really horrific, especially because these are the people we're supposed to be relying on to keep us healthy and safe.

How hard is it to enforce 8 hour days 5 days a week? Every other industry has figured it out.

To be fair, most industries don't have evening and night shifts and a supply mismatch, most nurses want to work the day shift, it's harder to find candidates for evening and night.

At least at my local hospital, it's not just overtime -- regular shifts are 12 hours even when everything is normal. That's nuts.

That's a little bit different and not as detrimental though. It's actually an incentive for nurses because they get to work fewer days. Instead of doing 10 8 hours shift every two weeks they'll do 6 12 hours and basically get 8 days off every 2 weeks, which is pretty interesting from a free time perspective.

My gf did both and while she was tired after 12 hours, overall I think she preferred it.

Canada's solution will be to mass-import nurses from the third world who will do twice as much work for half as much money. Mark my words.

It's already happened with low-wage fast food jobs. Health care is next. Nurses and doctors will be replaced by poorly-trained third-world counterparts.

> Canada's solution will be to mass-import nurses from the third world

Yes that's basically what Quebec (and probably other provinces) is doing.

> Do twice as much work for half as much money

I might get tomatoes thrown at me for this, but anecdotally "third-world" nurses are usually not as good due to having experience on different equipment, drugs and often languages. It's better than having no one to cover the shift, but it can be seriously dangerous due to lack of training on specific protocols.

They get paid the exact same amount of money and are in the same union, so they absolutely don't do "twice as much work for half as much money".

I agree with your assessment regarding foreign trained nurses. I think it also applies to doctors as well.

Regarding the pay structure for nurses, over time the unions will be filled with mostly third-world ones, so I predict their bargaining position will be weakened and they will accept worse conditions.

Are they? Leaving to do what, exactly?

For every story of 'X leaves to do Y', there are a thousand people claiming they'll leave, that never do.

Instead, you're left with the diminished quality of care from people who desperately want to leave but they're only there because they can't afford to.

Some just leave to stay-at-home, some go back to school and a lot will take early retirement.

In the book The innovator's prescription: a disruptive solution for health care by Clayton Christenson, there are some good analysis of where the complexity and problems come from in the current US medical system.

A lot of it has to do with size and the complexity that goes along with it. So, as hospitals get bigger, do more, and increase in size and complexity these issues become worse.

The economics math even mirrors factories... a factory that can build 100 things compared to one that just produces one thing.

The book was enlightening, even though many of the time frames called out in the book were wrong. Disrupting medicine is a lot harder than something like technology.

I think this alludes to it, but it's one thing mentioned in one of Atul Gawande's book is that in India they have hospitals that focus on one thing:

https://www.businessinsider.com/inside-indias-no-frills-hosp...

So like a 2000 bed hospital just for heart surgeries. Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.

Yes there are hospitals in India that cater to a specific aliment. For instance, eye hospitals, cancer centres, hospitals that cater to pregnancy, childbirth and neonatology etc.

> Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.

Not necessarily.

1. A heart surgeon is going to be doing heart surgery at more or less the same frequency regardless of whether the hospital they're at handles only heart patients or not. Wouldn't they?

2. I doubt if anybody here considers them cheap. Yes it's probably cheaper than in the US, but still it's rather expensive. But then again, since life is priceless, ...

At a 2000 bed facility though, you could specialize in specific types of heart surgeries. At a general hospital you're probably more likely to take on a wider variety of heart procedures. It's not just experience, but experience in specific procedures that can dictate outcomes:

https://www.reuters.com/article/us-healthcare-quality-surger...

Maybe cheap is the wrong term, but less expensive? I mean $800 may be expensive but certainly it's better than more?

I see your point about experience with a specific procedure. Makes sense.

About the cheapness aspect, what I've seen in India is that if a hospital specializes in a specific type of treatment, there's a good chance it is going to be expensive. Unless it's run by the government or something. But a lot of super-speciality hospitals near me are private hospitals.

It’s like that in many countries, also in EU. Average age of a nurse is rising, richer countries rescue themselves by importing workforce, because they can’t find workers for the rates they have budgeted at home.

It’s is like that in other professions too if it’s only the tech that gets compensated well. There is a shortage of skilled labour.

Errata: there's a shortage of skilled labour for these working conditions. Said budgeting is not set in stone, and as long nurses and whatever else professions can vote with their feet (by leaving the profession) no amount of politics-led finger-pointing can replace a real-world change in the healthcare policies.

No one wants to hear the truth.

There’s near-infinite demand for healthcare and a constrained (mostly artificially) supply.

Insurance, people and government can’t solve the problem of the supply and demand by throwing money on it.

You either expand supply or remove demand. Given removing demand is... not desirable. The only alternative to fix the issue is remove regulation and expand supply. That’s it.

Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures.

Government limits supply through regulation AND expands demand by paying for procedures.

An approach is to deregulate, such as removing government licensing, remove Medicare, etc.

Imo Prices would drop >95% within a 2-5 years (to India or Mexico levels).

I worked in medical billing for a few years and the issues are beyond obvious.

I think there needs to be some new approach to how medical services are being paid for. My 70yo father fell off a ladder and drove himself to the hospital in Calhoun Georgia (2 hours north of Atlanta, a small town) with a bruised eye and a broken wrist. He got in late afternoon, left the next day, and the bill to insurance (which of course they won't pay) was $69,000... more than per capita income in the US. The system is ridiculous.

In my opinion, healthcare has reached the state where the people who receive the benefit are too far removed from the people who pay for it and given there is no "victim" of price gauging, the prices will just keep going up up and way.

I defer to those wiser than me for the solution. I don't like complaining without being constructive so here is my ignorant pass at it. This will require a few key steps: 1) Yes, we need more supply (by deregulating the profession) 2) I personally think a more effective solution would be to gradually eliminate insurance except for catastrophic risk (like emergency medical care from a car accident). #2 will shift responsibility to the individual and the system will be capped at what they can charge based on the average person's ability to pay for it (which is how it works in many parts of the world).

> left the next day, and the bill to insurance (which of course they won't pay) was $69,000

I agree with you and the quote above is because of insurance. Medicare will pay 10% of that total and your father would be charged 2-5%. If he has private insurance you’ll see something different, maybe 15% and your father would be charged 3-6%. If he’s going out of network could be 100%. Hospitals / practices charge insane bills because people pay just a small fraction typically. It really impacts those without insurance or private insurance the worst. It is insane.

This is why I have suggested deregulation, particularly around licensing. It drives down the cost. Insurance may cover doctor X, but if nurse Y can do it for 5% the price... well use the nurse. All doctors would have to reduce prices and insurance would have to raise the coverage amount to compete. It’s what is done elsewhere in the world.

> Yes, we need more supply (by deregulating the profession)

So it looks like software development? Are you comfortable for your life to be in the hands of a rando who just finished a 6-months bootcamp?

I don't think it has to be binary. For situations that are life threatening, I'll opt for a premium service and for situations that are not, I may opt for an alternative. I think almost anyone at our company can be trained to reliably operate and interpret an x-ray machine for the vast majority of use cases.

'For situations that are life threatening, I'll opt for a premium service'

1 - what does the 'non-premium', i.e. bottomn of the barrel service look like, is that incompetent people offering rock bottom prices (resulting in death?).

2 - are you sure you can identify a life threatening situation correctly? Because my father did not.

3 - how do you know the 'premium' provider in question results in better outcomes, rather than being the same rubbish well presented in fancy packaging?

Re #1 and 3: you have this problem with or without my system (take a look at plastic surgery clinics in Miami for example). Doctors can be incompetent too and the system is so opaque you can’t readily identify or measure the outcome.

I think markets are efficient here and there are plenty of services we operate in now with similar spectrums of quality (food, airlines, general contracting, dental work, etc).

The gap between my position and yours i believe fundamentally is that I believe people can and ultimately should be accountable for their decisions. I suspect you believe they need to be protected by a system of accreditation. I guess I don’t put too much weight into that.

When you own the outcome, you are far more likely to do research, ask questions, compare etc.

2- I’m very sorry to hear that. I believe most people can most of the time. The more people are tasked with doing this, the more likely they will be to invest the time and effort to understand their health choices, seek counsel of others and potentially lead healthier lives.

I too am a bit scarred by the medical system. My sister was diagnosed with colon cancer at 33 and it was discovered “just in time” because she kept rejecting the quick diagnoses multiple doctors in Boston gave her. Had she not self advocated she’d likely be dead. I made a similar mistake when my son was born during Covid. We went into an nyc hospital foolishly thinking that if you are nice, quiet and well mannered you will be treated with respect. My wife went into labor alone in a waiting room where she was abandoned for hours despite us telling them how long she was already in labor and her ringing the help button numerous times. I wasn’t allowed until she went into the delivery room but she never made it there.

The lesson for me was clear 1- do your research 2- be prepared to self advocate 3- doctors are humans. Humans make mistake, they have limited and often flawed memories but unlike software development professionals, they do not have the benefit of being able to deploy state of the art systems, technologies and libraries

Happy to take this offline if you care to. My email is in the profile.

You should educate yourself about how most of the western world manages to have a functioning semi social health care system. US is broken because of this blind fantaic faith in free markets deregulation simplifications.

The problem is a large swath of the population that believe in all earnestly that squeezing profit is some magical tool for a functioning economy.

Too bad US is so good at PR, this mind virus is wreaking havoc all over the world.

I would say that most western countries do have both public and private healthcare. I did have private insurance here in Spain and it's nothing like in the US, as far as I can tell. Service was excelent and I didn't felt everyone was stressed.

In france your public insurance allows you to walk in a private clinic or hospital too, as a relative did and they cover her post-cancer treatment better than in the public hospital (by her account at least).

So yeah, "free market deregulation" may be an oversimplification but you have a problem in the US that's also far more than just being for-profit. We have for-profit over here and it works.

And that includes private & public institution doing medical R&D and selling their products to the national health services and private clinics, like quite a bunch of spanish companies do, for example. I say this becase it weirdly pops as an argument when it's totally unrelated, and it may be only a tiny fraction of the total cost.

> You should educate yourself about how most of the western world manages to have a functioning semi social health care system. US is broken because of this blind fantaic faith in free markets deregulation simplifications

Most healthcare in the west is subsidized by the US. The US market is far more lucrative, so companies do R&D and make capital from the US. The US also subsidizes in terms of both military and energy almost every western country. Even then, Europe has a higher tax rate and on average is far poorer.

I’m well educated on this subject and worked in this area in the US and spent time in other countries. You have no idea what you’re taking about.

"The US also subsidizes in terms of .. energy almost every western country"

These claims are outrageous and totally unsubstantiated. How does US subsidise energy of France or Japan?

"Most healthcare in the west is subsidized by the US." "The US market is far more lucrative, so companies do R&D and make capital from the US. "

You are subsidising the companies, not my healthcare. And they pay out this money in dividends to shareholders. I am sure they are very gratefull, maybe you should ask them for a rebate.

Stop subsidising them and overpaying - do you think healthcare costs in Europe will rise? If you do, I've got a wager.

> US is broken because of this blind fantaic faith in free markets deregulation simplifications.

The US is broken because we somehow believe that a highly regulated market is "free" as long as the government isn't paying for it. We literally have the worst of both worlds.

> "An approach is to deregulate, such as removing government licensing, remove Medicare, etc."

This worked so well for Rosemary Kennedy when she could be prescribed an ice pick lobotomy. And so well for Eben Byers when his doctor prescribed him radioactive water, and he drank so much his jaw rotted off. It works brilliantly for this woman[1] and her cheap Turkish dentist work leaving her in pain. And for, well all of this junk: https://en.wikipedia.org/wiki/List_of_unproven_and_disproven...

Deregulation is what we had when things were terrible. Regulation and licensing is what we use to block the most obvious junk 'treatments' and the worst con artists.

> "Given removing demand is... not desirable."

Removing demand is enormously desirable. Regulate the shit out of CocaCola, Marlboro, and all the other health destroying parasites and their advertising, tax them, rework town and city planning to remove driving as the primary transport in life and all the associated exhaust fumes, rework public schooling and rebuild trust in the government and medics so people aren't anti-health-advice on principle, rework employment so that employees have some rights and aren't stressed out all the time with no sick breaks. Rework medical access so people can see medical professionals, and sickness can be caught and treated early, which reduces demand on seeing much sicker people later.

> "Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures."

Insurance makes the issue worse by driving up costs to patients and at the same time driving down pay to medical staff, by insurance taking as much as possible. Without insurance, supply and demand could remain the same, medical staff earn more, patients pay less, and services be more efficient with less time wasted fighting insurance companies and filling in insurance paperwork.

[1] https://old.reddit.com/r/northernireland/comments/ua9me9/eas...

Insurance companies is a symptom of the REAL issue.

Unfortunately the American public hasn't figured out what the real issue is yet. They reason why they haven't is mostly because the Democrat party , Republican party, entertainment industry , the Main Stream Media, tech industry, and the the Commission on Presidential Debates (CPD) has them occupied with the symptoms of the REAL issue in order to keep them chasing their tails.

The REAL ISSUE why healthcare isn't getting fixed is because of Conflict of interest.The American public hasn't figured out that going to congress who is riddled with conflict of interest and who designed the existing system that we have in place and is benefiting from it, might not be the best idea to fix healthcare.

In fact the best thing to fix healthcare (and the other 99 problems)is to STFU about it and focus ONLY On reducing conflict of interest in congress. Until we reduce conflict of interest in congress nothing will be fixed.

The Democrat party ,republican party, CPD and MSM want you focused on everything but reducing conflict of interest in congress. In order to fix healthcare and any of the other issues we must FIRST try to minimize conflict of interest by implementing the following as a start:

1. Term limits

2. Closing or reducing revolving doors between private and public sector.

3. No private campaigning contributions. Use tech to overcome the need of money.

4. Reform lobbying by doing away with the money aspect of it and utilizing technology to get your voice heard.

5. Pay congress members more and better benefits, but in return demand complete transparency from financial information to limitations in investments , NCA , and make pay and benefits tied to the general overall approval of congress by the American tax payers.

6.etc

Both party and the MSM solution to fix healthcare is the equivalent of going to the MOB and asking them to fix crime in your neighborhood which the MOB is benefiting from and is promoting. It just makes no sense to talk solutions with people riddled with conflict of interest.

You want to fix healthcare stop talking about healthcare and get the individual republicans and individual democrats to put their political ideology on hold and join forces to demand that their party ONLY focuses on reducing conflict of interest in congress.

I've worked with both, and by far hospitals are much, much worse actors.

Hospitals are legally enforced local monopolies (look up Certificates of Need). Meanwhile, you might have a dozen choices of insurance companies, but they all suck because they have to take what the hospital billing departments give them and take the blame or risk being dumped by the hospital.

> You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay.

This is the part that makes the whole experience so sadly ridiculous. Nobody could ever tell patients what something might cost and let them make choices, it was (and is) "Sign here to acknowledge you'll ultimately be responsible for all charges, no matter what they turn out to be." But the insurance company doesn't operate like that, they say "Want to be part of our network? Guess what, you have to ask us for permission or we just won't pay you."

We need to rip off the bandaid, as it were, and reboot the damn system. Pick one of any number of good examples from other modern industrialized nations that have functioning healthcare, and copy it. Yes, everything will be a zoo for a while. We'll survive, and maybe even come out the other side with a better system. And maybe some bankrupt insurance companies, let me find my handkerchief.

Prioritizing profit corrupts the commitment to providing care.

Healthcare can be either care or industry.

Applying corporate values to a healthcare system leads to maximum wealth extraction from both providers and patients.

In this context innovation focuses not on the care part but on the extraction. The care is secondary.

How can anyone who cares be a proponent or coexist with a healthcare industry?

It is definetely a (big) part of the reason, but if it was the only one, things wouldn't be in a similarly terrible situation in other countries. Take the UK as an example which has a single-payer system, and morale is overall really low, too, and nursing isn't an enticing career. (On a side-note, the BBC show "This is going to hurt" is quite good and on topic)

Apart from administrators and insurers, I think a large problem is that the job has become substantially more difficult and technology intense, while support and pay hasn't kept pace. At the same time, liability is more serious these days, which I don't think is a bad thing, but certainly sucks for the workers who have to constantly justify themselves and can get crucified for mistakes.

+1 very similar story in Canada.

It blows my mind that super long shifts are the norm for a job that's generally more exerting/stressful than your average 9-5. But it's a viscious cycle now because of the shortages of qualified staff.

Here in BC we have a full on crisis where family doctors are retiring at an alarming rate and not being replaced.

> Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay.

Framed that way, this sounds terrible. But... the truth is actual health care outcomes for insured patients in the USA are extremely good. This holds in comparison to other nations, when corrected for GDP and patient income, etc...

"Insurance companies" are, at least in the narrow sense, doing what we pay them to do really well.

They may or may not be making things easier for nurses, which is a different metric. But nurses aren't their customers, we are. And we're getting a fairly good[1] product.

[1] Albeit extremely expensive relative to other nations.

Offer to pay in cash and it is amazing how much better the customer service and general demeanour is from a medical office - it always blows me away. They must REALLY hate dealing all of the insurance BS.

I had not done an eye appointment in years and years because my vision is generally very good - I went in expecting to offer cash, negotiate, and generally play a bit of hardball. I was amazed when the front desk person IMMEDIATELY perked up, looked super happy, and started offering massive discounts before I even threw numbers out. The eye doctors as well were very enthusiastic.

This. I had a great doc until a few years back. Best doc I've ever had by a long ways. He'd spend a good amount of time with you, actually listen to your concerns and even bring up recent papers he'd seen on topics related to my health issues. A few years ago he decided to mostly get out of doctoring because he was tired of dealing with insurance companies. For a while he went to a retainer model ($2K/year up front, $250/visit) and cut the number of patients he was seeing down significantly. I can't say as I blame him.

MDVIP does that model in the US too.

I've heard the same thing from mental health counselors and therapists. In wealthier areas many will just stop accepting insurance entirely and make people pay out of pocket to avoid all the insurance paperwork and requirements (some insurers require specific diagnosis to continue paying for services). If an insurer decides to not pay you? good luck. Now you need to throw hours of unpaid labor at them to get money you're owed.

Unsurprisingly, this means many normal people can't afford a therapist and they're getting harder to find.

Granted, there's a niche for cash pay docs. Example being psychiatry - it's extremely hard to find a psychiatrist who takes insurance, even Medicare. The good ones are all cash pay...

I don't hear it talked about enough, but I think the biggest problem with insurance is that their profits are pinned to how much they spend on medical costs.

https://www.verywellhealth.com/health-insurance-companies-un....

In theory, this sounds like a great way to make sure insurance companies aren't just taking unreasonable profits, and that they are spending money on medical care, not administration, keeping the business lean.

In _practice_, what it means is that profits are constrained by medical costs, so the insurance companies are literally incentivized to pay _more_ for medical services. Originally, insurance companies were supposed to be an intelligent negotiator on behalf of their customers. After all, their experts should know much more than a layperson every will.

But with the poisoned incentive to raise costs, customers are basically held hostage by a bag faith negotiator. Not bad faith as in malicious, but in terms of having an enormous conflict of interest.

Previously, that wasn't entirely true.

In the very early nineties, insurance companies lured doctors in with promises of referral if they would just accept certain terms. Originally, this was to the benefit of the doctor -- more referrals. But only originally: once lock-in occurred, the insurance companies began to set their own terms. They couldn't have accomplished this without some greed on the part of many doctors early on.

Consolidation's a big part of it. The last decade has seen nearly all the small practices and offices in my city gobbled up by a couple of huge companies. With that comes the MBAs and the bureaucracy.

The healthcare in my area is like watching feudal lords rapidly claiming their territory. With central fortresses (hospitals) and outposts (smaller treatment centers).

Have US hospitals ever had transparent pricing?

This seems like the root of the problem, and insurance seems like what "fixes" that but causes tons of downstream unwanted side-effects.

Yes. Prior to insurance. Insurance is the reason prices aren't transparent; insurance companies demanded discounts, so providers raised their prices to then say "you're saving X from list". But not every company had the same bargaining power, and individuals had none, so the actual desirable price to offer couldn't be made broadly available. With a hidden price (so no shopping around), that is discounted at wildly different rates (so no meaningful way for third parties to track it), and a necessary service (so no just avoiding it), in a private for profit industry, of course it skyrockets.

Our options are either to mandate publicly available price lists that are adhered to and hope the market pushes things downwards, mandate prices, or socialize insurance (so that the sole representative of everyone can negotiate the price downwards using the leverage of the provider risking losing most if not all their clients). Or, you know, keep doing what we're doing which is working so well (/sarcasm).

It’s always astonishing how I can get a fully itemized vet bill right after a visit and pay for it. Meanwhile going to the hospital is like “well gee, let’s submit to insurance, see what they’ll pay, we’ll readjust prices and then come back to you in a few months.”

Months after my last real procedure in a hospital, even after the insurance was settled, I could not get them to tell me how much money I owed them. Even when I went in person and told them "I want to pay you all of the money right now" they just shrugged their shoulders and told me they didn't know how much I owed them.

They just sent me a bunch of small bills in the mail one at a time and had a text field online where I could blindly pay them without indicating whether or not I had completed my payments.

Makes you wonder how this works for them. How do they know if they are in the black or the red if they can’t tell who owes what?

Fucking beats me (although this particular hospital seems to be very disorganized). I will never understand why anyone would make it difficult for me to give them money.

Yep. Seems ripe for fraud too.

I ended up getting sent to collections for $40-50 for missing one of the bills. Never in my life have I not wanted to pay a bill, but god forbid any large organization just take my money and leave me alone.

More than that, I can get an estimate upfront, that in 100% of cases matches the bill unless they find something additional they need to do, which they'll inform me of and create a new total estimate for.

Of note, my vet insurance doesn't negotiate on my behalf; they just pay X% afterwards. The price the provider quotes for a given service is the price everyone gets (probably; some of the smaller vets might modify it if someone is low income and in need).

Insurance companies are awful and should not exist, sucking up a lot of doctor time, but when it comes to nursing, hospitals are particularly awful, cutting staffing levels to the bone in order to maximize profit. People die as a result, and nurses are burnt out.

This inefficiency and it's resulting poor working conditions aren't unique to countries with health insurance and private healthcare tho, see Canada.

Why doesn’t the American Medical Association start its own insurance company?