This is why we should not accept any health care reform proposal that any of the American Medical Association, the Pharmaceutical Research and Manufacturers of America, or the American Hospital Association are generally supportive of. Whatever we try, they should be vehemently against, just like they were with Medicare.

That seems like a lot of people to piss off to get any reform done.

Wouldn't an actual smart negotiator play off one against the other, and make the doctors support the initiative at the expense of the pharma industry, or vice versa?

Speaking of negotiators. These groups have very skilled so they wouldn’t just let themselves be played off against each other to their own detriment.

A lot of negotiators talk about win-win agreements which may be true with just two parties. I think once you get beyond that, no true win-win agreement is possible and some people are going to lose out. Trying to appease every single interest group is what leads to a lack of progress.

Middle men jobs, no matter how good, need to be on the chopping block if all they do is be extractive pests. They can't both be protected from the pressures of the free market, and not have any accountability from an improved service standpoint.

As for the actual workers, Doctors can charge what they like, but they shouldn't be able to limit the supply of doctors within the nation. That is NIMBY mentality.

The government acts at the behest of the governed so they need to get support from at least some of those groups because a lot of families rely on someone working in one of them.

Can defend why Obamacare marked government interference and , for example, not medicare?

It also changed small medical practices because suddenly everyone wanted to use this insurance they were paying for. No longer could it just be a doctor and maybe a couple of medical staff; they needed medical coders, specialized software, and so forth. Some decided to join large hospital networks (for worse, from what I have generally heard).

And this cascaded into multiple sub-industries developing around this revenue stream and the medical system. Everyone trying to sell something and grab their piece of the pie.

It was not great before, but you could go see a doctor and literally pay a small amount of cash for an appointment. Many won’t even accept anyone without insurance now.

Edit: as mburns@ pointed out, the IRS no longer asks individuals about their health insurance status since 2019.

US here. I remember a Princeton Study from 2014 that found no correlation between public opinion and public policy.

https://www.cambridge.org/core/journals/perspectives-on-poli...

I suspect that the disruption will come outside of the regulatory realm: As prices go high enough it's cheaper to get the same treatment in Mexico, or have an AI be your primary care provider, the US system will fall. It will not be this year, and probably not this decade, but eventually such level of waste crashes big.

(Full disclosure: family member works for Big Pharma)

You might not get them to admit it out loud, but Big Pharma sees the USA as the cash cow that funds R&D for everyone on the planet. If a potential product can't or won't ever make it to market in the USA, or if there aren't enough potential patients in the USA to be prescribed said product, then it might never get off the drawing board.

It's (unfortunately) that simple.

We need India to get rich ASAP, so Indians can start paying for it. :-)

Trials are punishingly expensive.

Edit: protocol development. Drug interactions. Poisonings, Doctor education -- er, marketing. Incorporation into manuals. There's a lot that happens after the research talent has strutted its stuff.

Edit edit: oh, yeah developing manufacturing and logistics as well. The 'D' part of "R & D" is usually over 95% of the total for a reason.

https://www.raps.org/news-and-articles/news-articles/2019/7/...

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

Frankly this system is already deep into market failure in the US and should be reformed anyway. We are not getting important drugs approved here because they can’t make it through approval despite track records of safe and efficacious use in hundreds of millions of people. That’s an intense life-wasting market failure.

Healthcare? Doctors, hospitals, insurance, etc all are taking a bigger cut than they should. You'll get a ton of pissed people if you want to solve it.

Housing? Nimbys are just regular homeowners that block housing to implicitly (or explicitly) protect their property value. Solving that gets a ton of homeowners pissed.

Universities? Tons of university admins and loan programs that benefit from restricting tertiary education supply. Fixing is pissing lots of people.

So much of our economy is captured by large cohorts of people that are not explicitly conspiring to do so, but their incentives moves them to behave like that.

Worst part of the privatization of the Swedish school system is that we know that the tax-money we pay to educate our kids is being diverted to Neo-Nazi funders and Saudi oil funds.

None of the entrenched interests really seemed to mind.. Wonder if Obama does that wink to his PE friends when they meet

You don't have to be a sole proprietor for those at the top to take a ridiculous level of compensation.

> Nonprofit hospitals are under increasing scrutiny for skimping on charity care, relentlessly pursuing payments from low-income patients, and paying executives massive multi-million-dollar salaries—all while earning tax breaks totaling billions.

https://arstechnica.com/health/2023/10/nonprofit-hospitals-s...

> ...insurers, chemists, drug distributors and pharmacy-benefit managers (PBMs)—sitting between patients and their treatments. In 2022 the combined revenue of the nine biggest middlemen—call them big health—equated to nearly 45% of America’s health-care bill, up from 25% in 2013. Big health accounts for eight of the top 25 companies by revenue in the S&P 500 index of America’s leading stocks, compared with four for big tech and none for big pharma.

It goes on to detail their profit relative to the S&P as well.

Why? We're currently undergoing a major shift in labor wrt to automation, AI which will absolutely destroy entire sectors. Not a lot of people give a shit, it's considered good for the bottom line and for profitability. But when it comes to healthcare, the narrative is that we suddenly care about labor? People applauded the tech layoffs but the parasitic private insurance overhead is just too important? Disgusting

There’s a parallel to that observation: these parasites are a major part of the S&P (not as much as the article claims, per another comment) which means if they decline it will look like a secular decline in the market (=> peoples’ retirement savings) which will cause vocal anguish.

That latter phenomenon is why bills like the IRA splash out so much money on the fossil fuel companies.

I don’t think AI diagnosis is going to change costs noticeably because tests and treatment is so much more expensive and you need people to provide that.

A lot of people __do__ give a shit and this is a very common conversation among blue collar workers. I've heard about it every Christmas for the past 5 years from people who don't know how to google. Mass shifting in jobs has always been a big conversation but there's just a big divide between the working class where people aren't talking together as much.

We have coal miners complaining about "big solar" taking their jobs. We have the whole "just teach to code" fiasco. We have a lot of discussions about Amazon. And I can keep going. If you think this is a "suddenly care" type of thing then you're likely in a bubble or not paying attention (a different bubble).

Basically a bunch of journalists told laid off coal miners that they should just learn to code, which some people saw as callous. Then in 2019 Buzzfeed and Huffpo and a few other places laid off a bunch of journalists. People started tweeting "learn to code" at them and they weren't happy about it.

Plus, we all know code bootcamps don't make great programmers. And if we're being extra honest, LLMs have a good chance of replacing low quality coders, so now in hindsight the advice comes off as even more pejorative and low quality. Hindsight is always 20/20.

I don’t know if the outcome you want is the outcome you’re gonna get with that strategy. Might want to consider the humans actually affected and how they might react instead of treating everyone as some faceless cabal of evildoers bent on pulling money out of your pocket.

As an example, in many countries where they have socialized healthcare, nurses and doctors do often go on strike, which has always resulted in worse care during those times...

Speaking of which, I am not sure why doctors are allowed to limit the number of doctors who can become licensed each year.

I agree with your concerns with the AMA et al. It’s clear that we are way overpaying SOME doctors and hospitals.

It’s also clear that our demand for medical treatment is almost insatiable and about as inelastic as it gets.

Ie we need to tell some drs and hospitals, fu the gravy train is over; but we also need to tell Joe Public, no you don’t have an existential right to wegovy.

And small and big fortunes. Don't forget that those that protect fortunes are way more effective than all other.

The same issue plagues the American higher education system, which is wildly overpriced.

> Since 2016-17, the average net tuition and fee price paid by first-time full-time in-state students enrolled at public four-year institutions has been declining after adjusting for inflation; it was an estimated $2,250 in 2022-23.

https://research.collegeboard.org/media/pdf/trends-in-colleg...

If you want to criticize colleges on their cost, the data to use is expenditure data, which is much cleaner.

These are probably emergent effects of capitalism. I have a systematic fix, but I can find no margin to write it.

Regulated, subsidized capitalism. If insurance was only for catastrophic losses, and all premiums (government, employee and employer paid) were instead paid into things like health savings accounts, network and oligopolistic effects would start to disappear. Maybe not disappear entirely, but instead of locking people into networks the effort would go into marketing their networks as 'the best'.

You could also fiddle with pharmaceutical costs by allowing the patent monopolies to exist until a certain amount of revenue is collected from the patent, and then negate the patent. Instead of the current system with time-limited patents. This would massively disincentivize a lot of pharma-to-physician marketing (at least until the patent expires). Though there would still be some incentive to profit before the next drug comes out that makes yours irrelevant.

> If you want to criticize colleges on their cost, the data to use is expenditure data, which is much cleaner.

As if the opaque pricing of colleges isn't just as baffling as the healthcare system's resulting cost situation.

Another function they have is to exclude the poor and naive. Richer and more worldly students probably have higher completion rates.

Median is more important than average. A 2 or 3 variable analysis would probably be even better. I'd like to see how costs actually distribute for all students.

College is mostly about the private institutions at a national level. That's where people would like to go.

Quality education can be public and free.

And not all private universities are "better" than all public universities. Think Berkeley, UT, umich, etc. All fantastic and in many areas clobber many / most private universities. There are some obvious outliers at the very top-ranked schools but, statistically, almost nobody goes to them.

It's messy and complex, but at the end of the day, the public universities educate drastically more people and generally do a good job of it; they have to be considered any time we talk about access to education.

I think the point is about access to higher education.

> College is mostly about the private institutions at a national level. That's where people would like to go.

Where people would "like to go" is highly subjective, and the statistics would wildly disagree with your statement on where people actually go.

Yeah, I think this is an uninformed take, and that many students never even consider a tier-1 private university. They attend their local university, or even a community college before transferring.

A good way to think about this, and why it should reason that this data at face value isn't useful, is with a rather extreme example. If you took the average income across the globe then you'd conclude that no one could afford college. But that'd be unreasonable because the distribution of incomes is not the same as the distribution of people going to college.

Similarly, in these types of numbers there's a large difference in groups. In fact, contrary to popular belief, those straddled with the most debt are not liberal arts degrees for people with low job prospects but rather high level education of and high prospect jobs. Graduates take out more loans[0]. Medical students take out by far the most[1] -- side note: maybe we should discuss this given the doctor shortage -- followed by PhDs and then masters. Obviously these are in lower numbers though But there are a lot of variables at play here that affect things and it should be rather obvious that you can't treat all these things equally. There are also other issues where private colleges have higher debt burdens and there's also a lot of dubious institutions taking advantage of people (which do we want that happening for people who are specifically trying to become more productive members of society? The most vulnerable are also the "least productive" and even small changes can result in large outcomes).

[0] https://www.brookings.edu/articles/who-owes-all-that-student...

[1] https://wordsrated.com/student-loan-debt-by-degree-statistic...

One big driver to health care costs is artificial price inflation through insurance negotiations. Where insurance brokers need to get a deal but hospitals can't give a better one, so they raise the price and give a bigger discount on that. You know, the same thing that happens on Prime day.

Schools do this too, in many different forms. Let's look at graduate student pay, for instance. A lot of graduate students don't actually pay because they're doing a lot of work for the school and bringing in a lot of money. But if you go look at the pricing of credits you'll find that it is common for graduate credits to be more expensive than undergraduate. Is this because graduate students cost more? No, they definitely cost a lot less. So why is this number high? Because it is used to validate any pay from outside the university for those graduate workers, where the school takes a large chunk of that not just for admin fees, but to cover "the student's academic costs." This too is an artificial "book keeping" number and why we should not be counting this as income (yes, some states want to do that). It also creates for weird situations when a student needs to pay for credits themselves.

Or how about business class on airplanes? Few people are paying that actual rate.

Also, I think you cherry picked form your source. They also say:

> Over the 30 years between 1992-93 and 2022-23, average published tuition and fees increased from $2,340 to $3,860 at public two-year, from $4,870 to $10,940 at public four-year, and from $21,860 to $39,400 at private nonprofit four-year institutions, after adjusting for inflation.

I should also mention that the $2,500/yr claim you're making (drawing from their numbers, but your interpretation) is a clear example of an Aggregation Paradox (see Simpson's and Berkson's). If we took this number at face value the $1.63 trillion debt level wouldn't make sense. Room and board isn't that much, even if many colleges require Freshmen to stay in dorms and buy a meal plan. Given that number, clearly there's a large variance to those numbers. There's always an advantage to reporting the mean, and if we have the mean and average we know these are within one standard deviation of one another. It is interesting to see that college board is reporting averages but when they talk about incomes they are using medians (which are reported from the fed).

Averages, alone, are often a terrible metric and you need significantly more information that that to make any reasonable conclusion from data. Relying on averages alone will make you come to poor conclusions. Reports like these are for bureaucrats, not people trying to understand or solve problems.

https://research.collegeboard.org/media/pdf/trends-in-colleg...

I would not say that I cherry-picked from my source; the argument expressly is that *published* tuition numbers are meaningless, because few students pay them. The correct number to use is tuition net of Grant Aid, which is also listed in figure CP-9, and hits my $2,500/yr. The $1.63 trillion debt level does make sense when most students do use loan money to pay their room and board, and do so for 4 or more years.

Obviously, some families do save money to cover college costs, so most students aren't taking out 20k+ worth of loans each here, but the driver is not the expenses of the colleges. Indeed, if you look at Figures SA-1 and CP-11A, you can see that when college affordability became newsworthy, as loan amounts went up by over 75% is exactly when states were slashing support for students, during the Great Recession, between 2006-2010. Since then, states have been restoring funding, and loans are down. Many state college tuition rates have been flat or flat in real dollars for the last decade. As an example, the UC system had completely flat tuition rates for 4 straight years, and now guarantees each student that they will not be subject to tuition increases during their undergraduate education, and will pay a flat rate.

https://fivethirtyeight.com/features/fancy-dorms-arent-the-m...

Federal student loans start at 5.5 and go to over 8% interest.[1]

Private student loans start at 5% and go to 17%.[2]

I'm not sure where you get "almost no interest" from.

[1] https://studentaid.gov/understand-aid/types/loans/interest-r...

[2] https://www.nerdwallet.com/m/loans/student-loans/private-stu...

Those rates should clearly be higher than the rates for Americam mortgages, which, after all, have down payments and are secured by the most privileged asset in the history of the world.

If the argument is "student loan interest rates should be higher" then 1) they should be dischargable, and 2) I'm not sure I'd agree. Though I'd hope that that (and falling applications to schools) would have a downward pressure on tuition rates, I'm skeptical that would happen. So now student loans just become more expensive, and less attainable.

And some of the ones we do have might have contractual arrangements with corporations that funnel students into jobs at those corporations (possibly by contractually binding the students into a job a those corporations for a defined period of time). There are both pros and cons to that sort of apprenticeship arrangement. It would be bad, though, if the apprentice also had to monetarily pay part of the cost of attending college.

The same thing drives government bureaucracy growth and the ridiculous amount of administrative overhead at universities. At the root I think a lot of this kind of thing is a kind of unplanned jobs program.

I also think a related sort of dynamic might drive complexity growth in software. Every layer and every feature has stakeholders and people employed to maintain it, and all those people become defenders of all these things.

One of the factors behind “worse is better” in software and systems engineering might be that worse employs more people. Clean well thought out systems are not inefficient enough to create large communities around them because they don’t need enough babysitting.

Or, as Oscar Wild stated:

The bureaucracy is expanding to meet the needs of the expanding bureaucracy.

The reality is that the current standard of living could be maintained or even increased with many fewer people working. Or an even better standard could be reached if those people could be doing jobs that are actually useful like construction, nursing, or basic scientific research.

Unfortunately the economic system doesn’t value those things so people only do them if they’re desperate, passionate, or independently wealthy.

Our system does put a price on "well you have to earn your keep and you have to sit here all day."

I'm not sure how or if it could be done, but there is definitely enough wiggle room and waste in our current system that we could have people start doing more useful things with their time.

> Fueled by international private equity funds, consolidating firms have been on a tear in health-professional fields, buying up practices in fields such as veterinary medicine, dental care, optometry and pharmacies and assembling them into chains

https://www.theglobeandmail.com/business/article-private-equ...

As of a few year ago, anyway. I haven't been paying attention recently and the situation may have developed.

This might be true for primary care and family practice. I don't think it's true for specialities. And part of why it is true for primary care is because nurse practitioners can do that job now.

[1] https://www.stlouisfed.org/on-the-economy/2023/feb/nominal-w...

According to one historical physician earnings survey [1]:

> During 1987-1990, median earnings for physicians were $143,963 (interquartile range, 96,718-175,850) compared with $157,751 (IQR, 101,279-203,281) during 2006-2010 ($13,788 increase or growth of 9.6%; P < .001).

If we take the most conservative time interval (1990 to 2006) and plug it into the Bureau of Labor Statistics CPI Inflation Calculator [2] we see that the median 1990 physician wage would be equal to 224,080 in 2006 dollars.

Median physician wages as of now are $229,300 (2022) according to the BLS [3] or $255,200 (2020) according to the US Center for Economic Studies [4]. Plug that into the CPI inflation calculator, and the 1990s median amounts to $291,509 in 2020 dollars. So yes, physicians have seen a sizable decline in real wages over the last 30 years. Americans overall saw a significant uptick in real wages in the same time period.

Also, when discussing physician compensation, it's important to remember that there is a very heavy rightward skew. Mean wages are not representative of the typical physician. According to the CES report [2], the mean physician wage is $343,600, while the median is $255,200. This is why you will see dramatically different "average" numbers on physician wages in different outlets -- you should always check if it is a mean or a median.

[1] https://jamanetwork.com/journals/jama/fullarticle/1456053

[2] https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=143%2C963.00&y...

[3] https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...

[4] https://www2.census.gov/ces/wp/2020/CES-WP-20-23.pdf

[5] https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=143%2C963.00&y...

Fun examples -

My dentist has a waiting list of like 3-4 months to schedule a cleaning, so if you don't schedule the next one as you leave, you'll be out of luck later. HOWEVER, if you opt for any of the elective procedures (ortho/veneers/etc) they have vast availability and can take you next week. Funny that. And this is the third or fourth dentist we've used in the city, after dealing with both negligence and worse overselling elsewhere.

In my condo there's a dermatologist specialist that makes enough money to own two homes before 40 and operate his own practice in Manhattan & in the rich suburb of his second home. He always seems to be home by 6, and the last time I saw him, he was wheeling one of those coolspa coolsculpting machines around in his newest truck..

My previous GP was great but she only worked 2-3 days/week.

My GI is great but while its hard to get in to see him, he'll get you booked for a colonscopy/endoscopy ASAP at the clinic he also owns across town.. and the followup appointment to read you the results. All about that ROI and $/hr maximization.

Glad that I’m not the only one who notices this drop off in practitioner quality and focus on upselling. The only thing they even discuss at dentist visits are the optional, expensive cosmetic treatments. When you make it clear you have no interest they end the conversation and leave.

It’s like they have all bought the same practice management course. Once you realize what they are doing it feels very sleezy.

I can't speak to dentistry, but physician income tends to be lower in HCOL areas because they tend to be oversaturated with physicians and thus fewer patients per physician.

The incentives to stay in HCOL areas are usually non-monetary. For example, if your spouse has a tech job, you may find yourself to the Bay Area even though your income potential as a physician there is much lower than they it would be in the Central Valley. Or you might prefer the public schools in the HCOL areas. Or maybe you prefer to be close to family. Or maybe you like to travel and prefer not to be a 5-hour drive from the nearest international airport.

Do you have a source you can point to? This is the opposite of everything I’ve heard or read.

Back in the 80s and 90s, it was projected that there would be a physician surplus about 10 to 20 years down the road, so the AMA advocated cutting the number of residency positions [1, 2]. But those predictions didn't bear out, and in recent years (about the past 10 years), they have advocated increasing the number of positions [1, 3]

In my opinion, a lot of the talk about artificial physician scarcity is BS. We have more physicians per capita than the UK, Australia, or New Zealand, but fewer than most EU countries. So we are roughly in the middle of the pack for developed nations. The problem is not a lack of physicians, but the fact that the US has a much larger rural area than most other nations and that you need a certain density of physicians in those areas. But you can't fix that simply by training more physicians -- you train more, and they'll predominately move to the cities too for the same factors.

[1] https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

[2] https://www.openhealthpolicy.com/p/medical-residency-slots-c...

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

What has changed is most physicians no longer work for themselves or for physician owned groups. Working for private equity will burn anyone out. Physicians also spend more time overseeing cheaper midlevel practitioners. That itself could be a source of increased burnout (got into the job to treat patients not manage midlevels), but the second order effect is that their direct care patient mix has shifted higher acuity (potentially more stressful to handle) patients.

Hospitals can veto any building plans of a hospital near them. This is to “keep the current hospital profitable”

The AMA artificially limits the number of doctors coming out of school (limiting supply).

FDA puts a ton of regulation around producing drugs and equipment.

Insurance companies and Medicare set the price for goods and obviously need to make a profit so they gouge. There’s a long tail there, so the average person pays FAR more than their share to cover the long tail.

When you wrap this all up, yes. But the solution is massive deregulation. Let the market drive down prices similar to Mexico or India. Socializing medicine basically just regulates it to maximize profits, which is why Europe and US has insanely expensive healthcare (I added Europe because they’re subsidized by taxes, not massively cheaper).

Then you don't know what you're talking about. European prices are much cheaper including tax spend. In fact, the US has about the same public spending on healthcare as European countries do. You just don't get covered by it

wow that is absolutely wild and maybe one the most transparent profits over people i've heard of

This is an emergent problem of third party payment. Normal supply and demand mechanisms are not at play.

I’ve seen first hand hospitals “justify” not letting competitors as local hospitals always give input (they need to pull records). What happens is the hospitals generate projected reports and showing they’d be bankrupt if another hospital is allowed.

The group responsible for lobbying for them to be introduced in the first place?

Hospitals.

Health care is a situation where competition cannot be a spur to reasonable costs because individual consumers are simply not in the position to make the kind of "free market" choices that economists (or more often free market ideologues) expect they'll make.

Moreover, the malignant and abusive US health care system is in fact a product of layer upon layer of failed "efforts to create competition" intended to reduce cost "through competition" to the point that by now all the abusers really know the dance and will be profiting next year from any further or replacement layer you add this year. (and "no regulation then!" as the US 1900 results in doctors being just heroin dealers - like my great grand father interestingly enough).

Most other industrialized nations have a state run medical system that's far superior and cheaper than the US system. They didn't solve their problem with "competition".

It was part because costs aren't transparent, but also because the costs were the same to me after deductible.

The only truly cost aware folks in the system would be Amish on community insurance funds or similar odd edge cases

So you shop around for quality? That is still shopping around.

If customers could try to get the highest quality for their money that also works, doesn't have to try to find the cheapest.

Wrong, there is no competition in medical care both because in the end it's not possible for lay person to make informed decisions about the spectrum of treatments available when they are under time pressure and there is no way to have choice when you have a single hospital serving a substantial area (and other ways that health care is a "natural monopoly").

Price transparency works in an environment where a consumer knows all of the choices they have to make. For medical issues we can often only guess when it comes to critical problems, and even other protracted issues that you are aware of can be complex and hard to navigate. If you think price transparency will help then I reckon you're someone that hasn't actually been critically ill before.

Like the reason why insurance companies etc don't care about price transparency is because of the above. You're demanding something that won't work and will never work, unless the government steps in and says XYZ must cost YYY.

Medicare prices for all would be a solution for example but doing so would both explode Medicare and bankrupt the hospitals

Europe arguably has more competition in the healthcare manufacturing and labor sectors than the US.

Europe has the same pharma and device companies. Im not aware of any country that has price controls.

What Europe has is purchasing controls. If something is too expensive, the national insurance plans simply dont buy it and dont provide it.

This is what the US lacks.

Edit: Does looking at all the other way better responses might get you thinking, that "free market" is a harmful ideology, at least in the presence of overwhelming public interest of heath care?

It is not as if there are other nations with formidable health care systems that are way more efficient that one could look into.

Every business, every business has people who go in with the "no matter the cost" situation. But the market sets the schedule of pricing, so if either their status is not "revealed" or the business is simply not allowed to alter the price scedule from person to person, then it is literally no different than

-A rich family deciding they'll eat at the amusement park without asking prices, and no matter what, even when a small coke has reached $10

-A guy who walks into a new restaurant after his first 48 hour fast and after payday atd decides to completely ignore the prices and just order unconditionally

-A taxi driver get a flat outside of a tire shop by pure chance and it is the start of a ten hour planned shift etc. ad Infinitum

- give as many people as possible health care

- do it in a cheap and efficient way

- without stifling innovation

If markets are a good way to do that, sure. But let me ask you one question: Who do you think will negotiate better prices for any given procedure or medication:

1. A nation-wide health insurance that makes up 90% of a companies volume

2. The solitary regular Joe who is in pain and uncertainty about their health

No need to answer me, because the numbers and real world examples already exist and this is a known market dynamic (bigger buyers can negotiate better prices). This is why patients in nations that have such systems pay sometimes multiple magnitudes less than people in the US.

Now let me ask you another question: How would you structure a health care market if your goal was to extract as much money as possible and how would it differ from what you guys already have?

If you ask me, the market for healthcare in the US work as intended. Just not for the customers.

The hard truth is that, ultimately, providers, are to blame. Skilled professionals should NEVER say "I don't know how much it costs" to their clients and get away with it. It's your JOB to know how much it costs and to understand the experience of your patient. I get it that you don't WANT to know, that it's complicated and depressing. I get that because all patients get that. That is not an excuse for not paying attention to the details.

It is providers who regularly make their patients wait for hours after the appointment time. It's providers who order expensive and unnecessary tests for every condition, or who refer to multiple specialists. Each of these decisions increases the cost of care, the provider profit margin, and the stress on the patient. Because the provider is ultimately the one with the skill that the patient needs, I blame them for this systemic failure. If you're a doctor and you give in to the status quo, hire a large staff of billing agents and write scripts for all the tests and drugs you can, YOU are the problem. If you took your oath seriously, you'd never accept the way things are. Instead you advocate to maximize your profit margins instead of patient outcomes, and as a result you make the entire system sick. With any luck, it will get so sick it will die.

If you're unable, we'll take you to the one that best is equipped to deal with your issue.

HOWEVER... the insurer. If you're talking about two hospitals in the same town or part of town, no big deal. If you want to go to the hospital 15 minutes beyond that? Your insurer will deny the ambulance bill. Their argument was that "if you were sick enough to require an ambulance, you should have been transported to the closest facility, stabilized, and then transferred to your preferred facility" versus taking a longer ambulance ride.

How much is scheduled weeks in advance? how much is scheduled months in advance.

His post had a detailed breakdown of all the costs. Here's the post: https://news.ycombinator.com/item?id=5814728

How is this sector siloed against a newcomer that undercuts every incumbent while remaining profitable?

Turns out maximizing profit is not a panacea for efficient system design

Let me guess, are American hospitals a bit cleaner? Are nurses underpaid? Are doctors underpaid like in France, as in, a webdeveloper earns more than a doctor?

What you're describing is probably closer to what publicly funded schools in the US have become, in terms of deviation from base expectations. But no, there is almost no such thing as a doctor who doesn't get paid in the US, and definitely no such thing as a hospital or insurance executive that doesn't get paid.

> In 2022 the combined revenue of the nine biggest middlemen—call them big health—equated to nearly 45% of America’s health-care bill, up from 25% in 2013.

That's 45% waste, and excludes other middlemen. It's unclear if the increase from 25% is due to driving other middlemen out of the industry, or due to becoming even more parasitic.