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I fought insurance over this past summer after they declined covering a life saving surgery for my 6-year-old child at the last minute. We were in despair that my child's life was at risk each day we waited because of insurance incompetence.

ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.

I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.

10 days post denial, I was able to get the procedure approved from these efforts.

21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.

This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.

Relative recently had their baby come several months early. The baby needed intensive care for a couple of months, and breathing support (CPAP) for another two. Mom lived at the hospital hotel for the duration.

Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.

They got billed exactly zero.

Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.

Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.

A lot of folks are looking at the higher US comp but aren't correctly pricing in the long-term risk.

You can be fine for years, but a single, major medical event can zero out those salary gains and lead directly to bankruptcy. It's a systemic flaw that isn't obvious until it's your turn to deal with it.

If one lives in a state like CA, the taxes (income, sales, etc) basically are equal to that of Norway/etc. The downside, we don't get any real benefit from those taxes paid out.

You can be a small business owner, employer and (low) multimillionaire, and still have it go down the drain via an accident, illness or disability that affects you and/or your family. Over time, disabilities can cost millions of dollars. Surviving a heart attack can cost hundreds of thousands to a million dollars. Long-term care insurance can still deny coverage based on pre-existing conditions, and long-term care is very expensive.

I know of Indian immigrants who suffered for decades/years on H1B, endless anxiety and tensions, eventually make it to GC, then a passport.

Then all of a sudden fall ill, lose everything and return back to India.

People keep forgetting the US society is a giant stack/pyramid ranking system, the structure keeps getting narrow as you move upwards. You get pushed off the sides, in the ever narrowing funnel, and you need increasing levels of luck at every level to survive.

BTW, this is not just with regards to health care. You could lose your job, suffer from ageism. Lose your home, run out of money. A million different things can happen, that can cause the above said phenomenon.

Horrible system.

You can use the difference in comp to buy a Cadillac level plan with zero deductible, zero out of pocket max. You won’t be going bankrupt.

Does such a thing exist these days? If so I can't find it.

More importantly, it doesn't solve the real problem. You're still subject to the same system. Fighting for prior authorizations, staying in-network, and navigating all the other administrative friction.

More than likely they'd find a way to make you go bankrupt rather than pay up. That or deny till you die.

This helps with the denials how exactly?

You can pay a lot of money in premiums, have a $0 deductible, and now OoP maximum, and still end up having claims denied.

Do you think countries with even the most coveted universal healthcare just approve everything blindly?

Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?

> Do you think countries with even the most coveted universal healthcare just approve everything blindly?

Yes. Everything that they are trained and able to do here, is covered by the national insurance, at least where I live.

We never even have to explicitly ask them to approve anything, it's all automatic. You don't see the bill.

You might have to pay the difference for "nonessential upgrades", like a plastic cast instead of a normal one when you break your arm. Had to pay 5.00 EUR for that and it was the only time I had to pay out of pocket in my entire life.

Everything? No. But routine stuff will NEVER be denied. If your doctor thinks you need a scan, you're getting the scan. I have quite literally NEVER heard of someone in my country (Australia) going bankrupt from medical bills. It can happen but the rate is so low it's not something anyone ever worries about happening to them.

Routine stuff is never denied in the US either. I've never had one thing denied ever and I even have a weird condition that requires expensive testing to diagnose and even more expensive treatment (narcolepsy). The insurance companies will throw up annoying bureaucracy like prior authorizations, and made me switch medication to generic when it came out (reasonable) and then back from the generic to another brand name when it came out (WTF??), but never actually a denial.

Odd that your experience would be so different from mine. I routinely experience denials.

To give an example, about 60 to 80% of the time, when I visit the dentist for a regular cleaning the charge is denied and I have to submit additional paperwork to convince them to pay it. I can't think of any more simple and basic procedure than that.

I have no idea why your experience with healthcare in the US is so much better, but I can assure you that there are many people whose experience is more like mine.

Never denied eh? Interesting.

I had an MRI denied for a partial pectoral rupture. Which was a routine diagnostic as a precursor to open shoulder surgery to determine the extent and location of the rupture to figure out if surgery was absolutely necessary and to prep a viable surgical plan.

I had to fight the insurance company with the assistance of both my surgical and non-surgical sports medicine doctors.

The good news though appears to be that I imagined the entire thing, because denials for routine things never happen.

This is why insurance plans have out of pocket maximums. To prevent this exact issue.

We can say whether those maximums are still too high (some really are), but the mechanism is there.

The real issue is that most people don't have a rainy day fund to deal with such emergencies. And that they are too expensive anyway.

There are 2 concepts you should always keep in mind.

1. Always avoid the hospital unless you are literally dying. Surgery centers are owned by doctors who will negotiate a fixed fee, because there's someone to negotiate with (unlike Hospitals which run on the CYA principle). Also, most doctors can do procedures in office, if they have the right one.

2. Medical debt will never lead to collections. Hospitals may sue you, depending on the state, but that carriers reputational risk. A good PR push and a decent lawyer to threaten discovery will be enough to fend off even the most aggressive hospitals - this allow you to setle at a very reasonable price vs what insurance would normally pay.

That analysis is flawed because it misses the systemic nature of the risk. The Out-of-Pocket Max is an annual liability, not a one-time fix. A single serious illness, like cancer, spans multiple plan years. A $9,200 OOPM hitting three years in a row, on top of $15k-$18k in annual premiums, is the bankruptcy. This also assumes 100% in-network care, which is a fantasy in a real emergency when you don't get to pick the ambulance or the anesthesiologist. This isn't a "rainy day fund" problem. This is a system that requires a $50k-$100k emergency fund just to handle a single medical event, all while assuming you're still healthy enough to keep the job that provides the plan.

"Always avoid the hospital" isn't a choice either. You don't "negotiate" with a surgery center for a heart attack, a stroke, or a major car accident, which are some of the common events that cause this. And the claim that "medical debt will never lead to collections" is factually incorrect.

It is the number one cause of collections in the United States. The idea that every citizen can just "hire a decent lawyer" or "run a good PR push" to settle debt isn't a functional or scalable mechanism, nor is it reality.

> Hospitals may sue you, depending on the state, but that carriers reputational risk

I'm sorry but if I need a hospital, my first thought isnt, "well how is their reputation".

I don't understand why people defend the insurance system in the US when you're already paying taxes. If it's not the responsibility of the government who you pay to take care of their people in an emergency then what are taxes for. It's like people just accept it because that's how it's always been.

The whole time I was reading this, as someone from the U.S., I was wondering what country the writer was from, because it sure as #$@! wasn't written by someone in the U.S. When I got to that part, I was, "Oh. Okay. That makes sense."

In the US, you'll be billed the maximum out of pocket for your health insurance whether your little one is in the ICU for months or whether it was a easy delivery though, so at least birth is a predictable medical expense.

If you have health insurance... Which is not automatically a thing for many Americans, and it seems even more with current political trends.

If someone doesn’t have health insurance in my state, they get sent to financial counselling/assistance and signed up for Medicaid, CHIP, or HCAP.

I asked one of their counsellors once if they ever have any ultra wealthy people who don’t have insurance and also don’t qualify for any assistance. (This was at a children’s hospital with a Level IV NICU.) She said she was unaware of that ever happening, other than very wealthy foreigners who would prepare in advance, arrange payment in advance, fly in, and have a special procedure done.

Overall, in many states, it is logistically impossible to have an unaffordable bill and also not qualify for assistance. The worst situation actually is the person who has insurance but has high deductibles and copays.

Ah you don’t seem to understand the depravity of the modern American medical system. It’s not as bad in the way you think, and significantly fucked up in a different way.

If you do not have insurance, you tell them you don’t. They’ll give you a bill lower than what you’d pay as deductible if you had insurance. Or you just don’t pay…

This raises insurance premiums and reduces the quality of healthcare in a dystopian AF feedback loop.

Realistically it's much more likely that someone in the US would be telling this story vs someone from Norway.

Norway has only 50k births a year. The US has 3.6 Million, and >40% of those are 100% free to Medicaid recipients. So 1.4 million each year, meaning a story like this is about 28 times more likely to be told from someone in the US than Norway.

That is misuse of statistics if I ever saw it. You could count the people that are screwed in the US and also get a much larger number than in Norway. The US has a relative problem.

Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.

When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.

>Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.

That would be up to their job if they had one of course, but Medicaid does have some cash benefits and if you have a baby on Medicaid you typically get auto-qualified for TANF so that covers a lot of bills.

>When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.

This would only be true if the parents received long-term care or something. And this happens to TONS of people who have otherwise been financially well off, they have to exhaust their assets before Medicaid starts paying for a nursing home. It's got nothing to do with pregnancy benefits.

I just looked it up and I'm wrong, estate recovery is for anyone at any age who is institutionalized and/or anyone over 55 receiving care. States can additionally choose care and populations from which they do estate recovery for their Medicaid programs.

All I know is a family member would get the Medicaid warnings about their estate each month in the mail.

Well of course it will because medicaid is healthcare for poor people, not people with generational wealth. If you are rich and use medicaid that's fraud, and medicaid should take double for that.

> too much oxygen in the blood can lead to problems with the cornea or something

You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).

The norwegian healthcare is really bad at specific sectors if they deem you as a 2nd class citizen (for example trans healthcare, where there is a lot of malicious gatekeeping and multi-year long waitlists)

that sounds like 0.0001% of sectors

I am so glad to hear your child got the care they needed.

I've found that people often forget to call their state senator or assemblyperson. It has consistently amazed me how quickly a large company that's sitting on their butts about a topic will move lickety-split once their Government Affairs and/or PR teams are on the thread...

Another tip from having worked at a regulated entity: a physical letter to the CEO mailed to HQ creates a mandatory-response paper trail that will produce a very, very different (better) outcome than e.g. asking to talk to a supervisor while on a call that's not going well.

Thank you for sharing. I can personally say this same process has driven me to the brink of sanity. 10 years of managing a chronically ill child’s healthcare with multiple surgeries. Being a developer with the ability to navigate complex problems, social engineer people who have turned into robots, and enough income to make it through unforeseen lump sum payments - I cannot fathom how the average person deals with this. I made more $ than I ever did before to cover the costs and afford the best healthcare possible but the system is designed so we still get screwed and have nothing left. Thankful for the people who dedicate their lives to helping others. To everyone else who can justify profiting off of someone else misery, while being the richest and most advanced society on every other level? I have nothing nice to say to you.

How comfortable are you with naming and shaming the company? I don't think things are going to change if we don't call this stuff out loudly and publicly.

That's awful but I'm glad you were able to figure this out. I've had my own problems with insurance companies, but nothing to this level. I can't imagine the frustration, especially with YOUR CHILD'S HEALTH on the line.

Five years back I ended up getting surgery for a herniated disc. I was in immense and crippling pain. Before having the surgery, we decided to go through a round epidural shots. I had done that 20 years previously and it resolved the problem, so why wouldn't I?

Turns out my insurance company (who I will name: BCBSIL) delegated the approval for the epidurals through some kind of extra bureaucratic process with a 3rd party. It took days and additional effort on our end to get approved.

I remind you, I was in crippling pain at the time.

The delays getting this approved lead to me taking more Ibuprofen than I would otherwise have taken, which in turn lead to signs of internal bleeding. I had to ease off the Ibuprofen and significantly increase the amount of codeine (a drug which does not sit well with me) just to get by. Now not only did I have to wait for the approval, but I then had to wait for the signs of internal bleeding to go away before the doctor would give me the shot (which was the right call, even though it sucked).

Delays, compounding delays, compounding delays, all while I was absolutely miserable.

Anyway, I finally got approved and got the shot and it kinda helped, but didn't fix the issue. I had a second shot, got worse, and then decided we had no choice but to schedule the surgery.

The most frustrating thing (but something I am glad for) is that the surgery was approved immediately.

It's so maddening how inconsistent the whole thing is.

> How comfortable are you with naming and shaming the company?

Don't forget about the individuals responsible. Both the ones that made the denial decision, and the ones that instituted the internal system that incentivizes such denials.

A pharmacist once told me that big insurance companies have call centers out in other countries whose job it is to call everyone who has medication approved and any one with misleading line of questioning:"Did you get or approve medication worth $$$$$$..?".

Calling 100's of people Ofc the find one poor guy never heard of such a sum denies this kind of line of questioning. Then the insurance company uses this to deny all claims made by the pharmacy for ALL their patients for that given drug/medication.

The pharmacist told me the mountain of documentary evidence they have to collect to rebut these denials is very large. Once a customer at their pharmacy said he did not want to sign off on a paper that he got a medication, the pharmacist got the customer's ok though to video record his consent, just so he does not have to deal with this mess.

He also mentioned to me that a pharmacist should NEVER pay any kind of reimbursement to an insurance company on a claim that was denied cause that somehow legally can let the insurance company deny future claims. Not entirely sure what exact legal procedure allows them to do that.

In that same vein, I used a public adjuster once after a small electrical fire torched a room in my house. The insurance adjuster was great, his manager was awful and made a difficult experience much worse.

Without getting into details, the moment I realized that he was being intentionally obtuse I started looking into options.

First contacted an attorney who essentially said, “Yes, I can do it but I’m going to cost a lot and the insurance company won’t reimburse you for my time.”

Kept looking and discovered public adjusters were a thing. Did some research, found one who was reputable and he took me on for free. Pretty sure we used net, about 2-4 hours of his time.

He told me exactly what was going to happen, how the insurance company was going to react and it played out exactly as he said.

1. He requested a process to take the valuation of everything damaged in the fire to a 3rd party arbiter.

2. Insurance company will send you a letter saying it’s not time for that yet. We will proceed anyway. And we did.

3. He will nominate 3 arbiters and the insurance company will nominate 3 arbiters. Neither will select either of the others nominees and an independent 3rd party will select one instead.

4. The moment the insurance company realizes the valuation of your things will be outside of their control, they will become extremely agreeable. And they did.

And honestly the only thing I really wanted was another week in a hotel for my family because the company cleaning my house of smoke was short staffed over the holidays. Would have cost them likely $1,000 but instead he escalated the situation dramatically.

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I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.

But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.

I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.

As a non-american (from South America) who lived in both USA an Europe:

Yes, in USA you get much more money, like you said 2x~5x, but then:

University is expensive as fck. Health care is expensive as fck. You have 5 days of paid sick leave per year in most companies. You have 10 days of paid holidays per year in most companies.

In contrast, in Europe: University was cheap or free. Healthcare is cheap and universal. If you are sick you are sick, either the company or the health insurance pay. You have between 20 and 30 days of paid holidays.

This is why quality of life in Europe, is so superior. And again, I am saying this as a non-European.

> University is expensive as fck.

One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $60K/year tuition prices. US universities charge on a sliding scale based on the applicants' families' ability to pay.

For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.

For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.

That said, it's entirely possible or someone to go out and sign up for bad investment private university with no aid and rack up $300K of debt by graduation if they're not paying attention to anything, but it's a myth to think that everyone does this.

The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.

> For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.

As someone from a country (Sweden) that to a larger extent has decreased people’s reliance on their families, and grown the welfare state instead, it’s weird to think that your parents wealth or income should have any impact on things like tuition, once you’ve reached the age of majority

Once I finished high school, my parents had nothing to do with my business as far as any institutions were concerned, and vice versa. But uni was tax-funded and free at the point of use. And when they get too old to care for themselves, it will likely be the government supporting them financially, not me (unless I strike it rich first, in which case I suppose they’ll spend their sunset years in style)

There's always this subtext that Europeans solve these problems just by caring more about human values, but the truth usually involves interesting sets of tradeoffs. So in Europe the norm, besides free university, is extensive tracking: in the US, your choice of major is essentially a consumer decision, where in many European systems it's fixed at a relatively early age by your performance on things like the Abitur.

I'm not saying the European system is bad. Certainly there's a lot to complain about with a system that asks 18 year olds to make life-defining decisions about both their career and their financial prospects. But the differences do go beyond whether or not you're on the hook for your tuition.

I don't quite understand what you mean by "tracking". Speaking of Germany, because you mentioned the Abitur. Yes your ability to enter certain universities and studies depends on your performance during the Abitur. That is to enter e.g. law or medicine at you chosen university immediately (there is a wait time multiplier, so you can wait if you don't get in immediately) requires a certain grade point average. However I don't understand how this is different from SAT scores in the US (except for maybe the ability to bypass SAT requirements by being super wealthy, but I'm not sure that would be a good thing). In my experience kids in the US tend to be obsessed about their university choices much earlier than the ones in Europe.

Also talking about Germany, unless things changed dramatically in the last few years, most natural sciences and engineering degrees don't require a grade point average.

I agree that European schools are heavily tracked, but I’m not seeing the connection between that and the tuition costs.

It seems like these are unrelated issues.

Does the wider freedom of choice in US education somehow cause college to cost more? Because more people want to go?? I don’t get it.

> Europeans solve these problems just by caring more about human values

In the US, to make tuition free, you'd have to answer the question "who gets to enter university programs". In Europe, the answer isn't "everybody".

> For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.

This is an extremely important point that keeps getting ignored. People keep comparing _public_ schools in Europe to _private_ schools in America.

To further your point, just about every place has a community college where you can do the first two years of your education for about half the price of the state school. The total tuition for this route (2 years at community college, 2 years at a state school) is going to average just under $30,000 for 4 years. Which is definitely in the "work your way through college" range.

And this is before any financial assistance, which the majority of students receive.

Foreigners talking about how crazy expensive college is in the U.S., but they're likely mislead by people who took out large loans to go to extremely expensive private colleges. There's an easy way to stop this kind of debt - don't allow federal loans for private institutions. But no one is really interested in stopping it.

>People keep comparing _public_ schools in Europe to _private_ schools in America

Not necessarily the case. In Sweden private schools are paid for by the government, assuming they have been approved by the CSN (central agency for study-support(rough translation))

I don't know how that works in the rest of Europe, because I've never studied outside of Sweden. But in Sweden it doesn't really matter if the school is private or public. The only instance you have to pay yourself is if the school isn't sufficiently good to pass muster.

Also, again in Sweden at least, but possibly other parts of Europe as well, the tuition isn't effectively $0. The government will pay any student enrolled in higher education a monthly support. Back in my day it was 10k SEK per month (roughly 1000usd), no strings attached. Not sure how it currently stands but I imagine it hasn't changed much.

This money is meant to ease the burden on students, so that they can put more focus on studies.

"Working your way through collage" over here means you'll have a 20% job to pay for your cost of living minus the 10k SEK mentioned above.

The difference in cost of study is quite real, even taking your comment into account

Yes, but Americans have an incredible amount of student loan debt too. Something like $1.7 trillion. If you can get into one of the best schools in the world that has a huge endowment, then sure, you'll get grants and whatnot. It may even be free, in the case of Harvard. But then there's a long tail of schools that are honestly not that great, charging only slightly less than the top schools per year, with smaller aid packages, and kids sign up for crazy loans because they think they have to.

Personally I think the government should get out of the business of these loans, fully fund state schools to make them all free, and let the private schools and the private banking market deal with the rest of it. We were going down that path in CA until Reagan killed it when he was governor. [1]

[1] https://newuniversity.org/2023/02/13/ronald-reagans-legacy-t...

Public service loan forgiveness (PSLF) exists and a huge number of people in medical professions actually take advantage of it. I know of multiple medical students and residents with over $500k in debt that are in the process of having all of their loans forgiven after 10 years in training and a total cost of approximately $75–150k for their entire education. Sure, that's still a decent amount of money, but it's very much worth the ROI.

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

How successful are those people being?

IIUC, there was a bit of a scandal where the companies the DoE where paying to manage those 10 year forgiveness plans where giving incorrect advice and so a lot of people aren't going to qualify.

https://oag.ca.gov/news/press-releases/attorney-general-bece...

Lots of hospitals are nonprofits, and doctors can make lots of money working at hospitals. There is no income cap for PSLF IIRC, as long as you're working for a qualifying entity (including nonprofits).

Anecdotally, it's worked out for a number of friends and people on /r/PSLF. There's definitely poor communication around PSLF, but it is a real program.

American student loan debt skews sharply towards the top income quartile.

Yes, granted it was over 20 years ago, but I came from a pretty broke household in the United States, and I went to a cheap state school instead of a nicer university or private school because I couldn’t imagine borrowing for school. The folks I know who were much more well off, seem to have had no problem borrowing what I considered to be exorbitant sums to both pay for school and live off of.

In a redistributive sense it is very much like American homeowners complaining about their mortgage debt.

One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $200K hospital bills. US hospitals charge on a sliding scale based on the applicants' families' ability to pay.

(I don’t mean to belittle your comment about universities which is factual and helpful. I’m just pointing out that US education system is just as fucked up as the US healthcare system the OP is talking about.)

Also very true, and a good point.

Even people in the US don't understand why those $200K hospital bills aren't real.

Insurance providers (including government programs) have a fixed limit for what they pay for procedures. They pay min(billed_amount, allowed_amount) so providers don't want to risk leaving money on the table by having billed_amount < allowed_amount. To ensure this doesn't happen, they bill an arbitrarily high number with the expectation that insurance will lower it down to some much smaller number.

So every time you see posts on the internet where people talk about their "$200K hospital bill" they're always talking about that arbitrarily high value. If you have to pay cash for some reason, they will reduce the value to the cash pay amount which is in line with the insurance paid numbers.

Nobody ever pays those high hospital bill amounts.

That depends a lot on your insurance. For example, our out of pocket for my son's birth was somewhere in the neighborhood of $10k after insurance. I've met tons of people who would be bankrupted by that amount. What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where the employer gets to pocket anything left in the account at the end of the year. My son was essentially unplanned, in the sense that we gave up on trying to have a kid but weren't using birth control because over the previous 3 years we had not had a successful pregnancy. So an HSA would have been no help for us.

HSA funds are meant to roll over. Your employer generally should not be pocketing whatever's left over in the account. The idea is that many (most?) people are better off with a lower premium and higher deductible given that most years (for most people) aren't characterized by high medical expenditures; HDHP+HSA is closer in nature to actual "insurance", rather than a structured financing plan for health care.

HSAs are triple tax advantaged retirement accounts. Not taxed on contribution, gains, or withdrawals for qualified expenses. In the worst case it becomes like a pretax IRA because after age 65 you will not pay a penalty on non qualified expenses - but qualified expenses tend to increase with age. For many it should be their primary retirement account. Even for people with certain chronic conditions (not in perfect health), depending on how good/expensive the PPO offered by the employer, it might still work out better to do HDHP/HSA. You can get as many basically free HSA accounts from Fidelity.

An FSA really has nothing to do with an HSA.

HSA is your money like a retirement account is. It’s one of the most tax advantaged ways to save money.

More or less all high income earners who do not have a chronic health issue are better off choosing a HDHP paired with a HSA - especially if the company provides any sort of matching benefit. Keep that account as an additional retirement account and pay out of pocket for most healthcare needs.

Think of it also as actual insurance vs. a pre-paid health plan.

The math of course changes for folks who are not highly paid, or have expensive chronic health conditions that would result in maxing out the deductible each year.

You are likely thinking of a FSA which is use it or lose it.

FSA's not HSA's are use-it-or-lose-it.

If you have a FSA I strongly suggest that you get an HSA instead.

https://www.fidelity.com/learning-center/smart-money/hsa-vs-...

A lot of people with FSAs will have insurance that disqualifies having an HSA.

I have the paranoid idea that they designed FSAs in such a goofy way for budget scoring and it drives me nuts.

>A lot of people with FSAs will have insurance that disqualifies having an HSA.

Which should be illegal. It should be only HSA across the board. Its nonsensical that this is a thing.

I'd love an HSA, but I can't due to my plan (can't do a high deductible plan for $reasons).

I think there may be some loophole in setting up an independent HSA but I haven't looked into it enough, only recently heard of such a scheme

FSA is just a 30%-ish discount on medical expenses. It is useful for eye glasses and such. A lot of QoL services qualify for FSA, including weight loss coaches and therapy.

Heck my (prescription) meta ray bans were paid for in part with FSA funds.

The preceding comment was discussing HDHPs, which depend on HSAs.

You think it's obvious that "lesuorac" was scoping their comment to people that have an FSA with an HDHP?

Doesn't read that way to me.

It's obvious in that they specifically referred both to HSAs (not FSAs), and to HDHPs, which depend on HSAs, not FSAs. FSAs are not a kind of HSA.

So, yeah. Little bit.

Which they? The comment I replied to literally says:

"If you have a FSA I strongly suggest that you get an HSA instead."

Did you mean to reply to them?

You are I are both commenting on a subthread started by a comment that included "What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where [...]", none of which is true. I don't care about FSAs and am not trying to argue with anybody about them, but that preceding comment is very wrong about HSAs and HDHPs.

If the bills aren't real, why are there half a million medical bankruptcies every year?

Why do 41% of Americans have some form of medical debt?

https://www.kff.org/health-costs/kff-health-care-debt-survey...

Note that another word that straightforwardly describes this behavior is "fraud". Medical bills aren't like a bill from a car mechanic where there is a contract (either written or at least implied because the mechanic will readily give you estimates and quotes).

In the medical context, the only contract in the picture is possibly between the medical provider and the healthcare management organization. It would be fine if providers only sent the fake bills to them as they're both willingly playing this perverse game.

But the problem is when they send their fake numbers to patients as if they're some kind of legitimate bill. Medical bills to patients are presented on a "cost reimbursement" basis - helping you cost them this much, so you are responsible for reimbursing them. By inflating the numbers 3-5x they are straight up lying about the costs they incurred. That's fraud.

>The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.

This is such a weird excuse for bad policy. Making more money[0][1] somehow means its okay to saddle students with an average debt of $30-40 thousand dollars. A downpayment on a first home would be a much better use of that money, for example.

Really, the average US citizen is nickel and dimed to death with this sort of thing, from health insurance, to dental, to lots of other required but not accounted for as required costs (like cars and associated car insurance).

Not to mention, we have little safety net in the US, you're really going to hurt if you have a bad run of luck after job loss. No qualms in allowing people to become homeless as a matter of policy.

If someone were to ask me, I would say that we in the US have it completely backwards in respect to how the average citizenry is expected to live. Its not thriving, its constantly having some kind of lingering potential disaster to plan for.

[0]: which I sincerely wonder about the true veracity of this statistic

[1]: Don't forget too, that more and more struggle to pay their student loans each year and the trend has generally been that its getting worse, not better.

What policy are you referring to? Cost-conscious students can (and most should) stay in-state, do their first year or two at a city/community college (my kids knocked out core STEM classes there --- over summers, not for cost reasons --- and found the teaching markedly better), and then transfer into a commuter university. The "average" student debt owed primarily by the top income quintile in this country and captures the cost of out-of-state selective university, which are a luxury good.

>What policy are you referring to?

The implicit policy that student loans are an acceptable and benign form of debt for the average citizen. Everything said after is predicated on this idea.

I don't think thats good policy.

It's very funny to see the US perspective here. $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA, I would bet. I paid $0 for my university, as did most of my colleagues, but even if I had had to pay the tuition, it would have amounted to $4k total for a 4-year bachelor's degree, or $6.5k total for a 6-year bachelor's + master's, at one of my country's premier state universities (and consider that private universities are a joke here, just diploma mills).

Granted, none of the top universities in my country even makes it to the top 500 in the world, so maybe this isn't a completely fair comparison? Actually, it's expensive by some other EU country standards - public schools in France and Germany, including PSL (ranked 28th in the world) and TUM (ranked 22nd), are free for all EEA applicants, with some nominal yearly registration fees (amounting to $1k in total for a 4-year degree). A more expensive school, like ETH Zurich (rank 7 in the world), is $4500 total for a 4-year degree if you're a Swiss citizen or EEA citizen with a Swiss work permit; it's triple that for an international student.

So yeah, when we say "university is crazy expensive in the USA (and probably UK too)", we're actually talking about the $30-40k numbers you're looking at. $200k and so are almost inconceivable to us.

> $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA

That's the cost over 4 years. Most people will be able to get financial assistance to help pay for that and you easily manage to make 30k (or less with grants) in 4 years to pay for school. People making below 35k per year are going to pay practically zero taxes. You can work about 15 hours a week making $10 per or full time over the summer to pay for that.

There's no need to take on any debt.

People in the US make considerably more money than those in the EU and, generally pay less taxes so there's a lot more disposable income available. I think people here prefer to be able to just get what they can pay for rather than hope the government will let them pursue the education they want (there are aptitude tests and quotas in some EU countries).

It's not really better ir worse, it's just different.

There are aptitude tests of some kind and quotas for all good universities everywhere in the world. Harvard won't admit 100k students in a year if they randomly decide to join, nor will they accept a student without a stellar record (apart from legacy admissions, of course). And I would bet you whatever you want that you'll get a much better salary fresh out of college in Europe with a bachelor's from the Technical University of Munich (total cost: around $2000 if you're a citizen of an EU country), or TU Delft in the Netherlands (total cost: around $9000) than you will in the states with a degree from a random college that doesn't even have to bother with admissions tests.

Sure, if you're a brilliant young mind and can get into Harvard and qualify for assistance with your tuition, you're set for life, basically, in a way no EU university can match. But for the vast majority of the population, the outcomes are significantly better with the EU system.

Also note that the gigantic tuitions at US universities are actually a relatively recent phenomenon (and a similar thing happened in the UK). Even in the 50s and 60s, tuitions were much closer to the current EU norm.

> almost nobody actually pays those mind-blowing $60K/year tuition prices

This is not true at all.()

You quote tuition at the school with the highest endowment in the country. The college cost situation is absolutely still high at the less endowed second tier, and “ordinary” (non-generational wealth, two full time earner) families are paying full price.

() Except in the sense that “almost nobody” goes to any of these schools, comparing to the 50k enrollment at large public institutions.

My mom was a school bus driver and my dad was a laborer retired on disability. I got zero aid except for loans.

I went to a 2nd tier in-state school 20 years ago and even that cost 10k a year by the time housing, food, and books, were paid for.

Plenty of people who can barely avoid it end up paying a large chunk of $.

If this were true, the number of Americans I have known who moved to Europe would be roughly equal to the number of Europeans I have known who have moved to the US. That's not data, that's anecdote. But what is the European country where more people go there from the US than come to the US from there?

USAians are not exactly famous for commonly speaking most European languages at a level that would allow them to resettle to the respective European countries. This makes for a considerable barrier that essentially doesn't exist in the opposite direction.

I have never heard this term before, but to clarify what I mean (it's so weird to bring race into this!): I have worked with dozens of native born dutch, german, french people etc. and lots of latin people etc. But I know almost very few that I grew up with, went to school with, who moved from the US to another country. I am not saying this is good, the US is good etc. I am saying you have to understand the revealed preference vs what people tell you.

I wouldn't be surprised if this changes in the future, I am talking about the period of my life to date.

> I am saying you have to understand the revealed preference vs what people tell you.

And what they're saying is that this isn't just an indication of how awesome the US is compared to other places, but also of how averse Americans are to learning other languages compared to other people.

Very uncharitable way to phrase that, American second language prevalance is similar to other English dominant countries like the UK or the Australia.

Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.

If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.

The two things are not equals. The US has for a western country, relaxed standards for immigration[0], in particular if you were coming from Europe, it's quite a bit easier to establish residency here.

The reverse is not true. European nations aren't very immigration friendly by comparison. On top of that, the US government, assuming you keep your citizenship, does not make it easy to live abroad. US government tax policy for citizens who live overseas is much more aggressive than any other western country, from what I understand.

Combined with the fact its alot harder to go the other way, and the US government does a fair amount to discourage it, I'm not shocked more US citizens aren't moving to Europe.

[0]: At least before Trump returned to office, I'm unsure how much of this has changed.

    > The US has for a western country, relaxed standards for immigration

First, let's start with the "Anglo-American sphere" (my term): US/UK/CA/AU/NZ. Of those five, US is the hardest to get a working visa for skilled individuals. The rest are "points-based" system where you can apply for a working visa even before you have a job (95% sure about this -- pls correct if wrong). They are much more friendly. Also, the rules are simpler, clearer, and applied more consistently.

I know much less about other OECD-level (and G7-level) nations, but anecdotally, overall, the process is much more straight forward compared to the US. What the rules say, the rules do. Not so much in the US where they randomly delay or reject applicants without good reason. (Also: Google to find horror stories of what happens when you lose your job in US as a foreigner who does not have PR. Fucking nitemare.) You hear this much less in (to name a few): Ireland, UK, France, Germany, Belgium, Netherlands, Denmark, Norway, Sweden, Finland. (I don't hear as much about Portugal, Spain, and Italy, but quality of life looks awesome!) All of those countries are wealthy, highly developed and have excellent quality of life. All of them welcome skilled migration and have clear programmes (you can Google about them) to get a working visa. Again, strictly anecdotal: The US immigration system is much more adversarial compared to all of the other countries that I mentioned. Oh, and I forgot to add Japan: After PM Abe changed the rules, it is way easier these days to get a skilled worker visa in Japan.

Last point:

    > European nations

>My comments will only concern skilled migration, e.g., you are a computer programmer or something STEM'ish and you want to work in a different country.

This circumvents the original predicate, which did not have such a limitation. I know many countries have priority / helpful pathways for STEM career individuals as well as capital investors, but that wouldn't apply to everyone.

Even the US has very different pathways to citizenship depending on various factors. Last time I looked into it as research in depth, there alot of common limiting factors across Europe. Their policies are much more strict once you dive into the nuance.

That said, the US immigration landscape is extremely lopsided, thats a fair point.

>Europe is enormous -- like continent-sized -- with ~50 countries.

I realize, though as a US citizen I also realize that when most US citizens say this, they mean a much smaller contingent of countries, rightly or wrongly. I'm sure Europeans dislike how loose we use the term, but as a US citizen, it usually means cold war boundary countries, so Germany and what was considered western Europe before the iron curtain fell. Thats been my experience. People also generally forget about Portugal and a few island nations. Its a safe bet most people mean the Nordics, France, Germany, the UK, Netherlands and Denmark most of the time, conceptually.

However to be specific, France, Germany, Switzerland, the Nordics, all have strict general requirements to have a path to citizenship. I don't think the average US citizen would be able to meet them.

That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California. But I accept that could be the true reason.

>That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California.

That alone is enough to put most people out of grasp of doing this, for a multitude of reasons, of which not having the capital is only part of the equation, as you would also need to have a suitable investment on the other side to put said money, not a promise. I'm sure there are other nuances involved too.

Thats before the fact that the cost of a house in California would price most people out of the equation to begin with.

High fractions of Europeans speak English, eg Poland has 50% of population speaking English (for those of working age it’s probably much higher) whereas the fractions of Americans speaking non-English European languages is much lower (0.25% for Americans speaking Polish).

If 50% of Americans spoke Polish by the shake of a wand, I bet there’d be more Americans in Poland than Poles in Poland.

OK, but by that logic lots more USA citizens should be moving to the UK, Ireland, Spain than the other way around. That's just not the case, at least until very recently.

I could see that the appeal of Ireland can be increasing and Poland sounds cool. I'm not saying that the USA is great, it has tons of problems.

Net migration US/Ireland is positive to Ireland.

UK numbers yes, though maybe gloomy weather plays a role? Just kidding. That said, Brits are slightly more likely to move to Spain than US despite it being a tiny country in comparison and not necessarily easier to move to after Brexit.

Spain, not sure. It’s tricky to compare since non immigrant Spanish speaking population in US is probably significantly lower than Spaniards speaking English. But yeah, you probably have a point on that one.

America has around 42 million fluent Spanish speakers (based on # that speak Spanish at home).

Spain’s entire population is 48 million.

I have never met an American that migrated to Spain.

Well America is pretty freaking cool, so I guess I don’t blame them.

Your wand would also need to erase the reason people speak (or don’t speak) the languages they do, otherwise what you said would already be true for the UK, Australia, etc.

Would it? People don’t exclusively learn English to migrate to the US.

What language do you think Germans and Spaniards use to do commerce with each other? There needs to be a common language, there’s no bandwidth to learn all languages, so due to historical and modern reasons, English prevailed.

Re Australia, Australians have highly preferential options to move to US which is not reciprocated.

Same for NZ, Canada, UK…

> This is why quality of life in Europe, is so superior.

That's very subjective, and I would rather have my freedoms instead of your/their liberties, thanks!

The only major differences I can think of are gun ownership and abortion. What freedoms were you referring to?

Speech?

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> Also please don't tell me your skin color, I already know.

Also, please don't tell me you live in a major city/vote Democrat/are probably white with a savior complex.

I already know.

Perennial “What Armenians should know about life in America (2014)” from days of HN past https://news.ycombinator.com/item?id=22777745

And which today must be read via internet archive

https://web.archive.org/web/20200404172130/https://likewise....

Basically explaining to Armenians at home why their relatives who moved to America don’t send better remittances back home despite their $X pay rate. Here’s why …

> University was cheap or free

Ha! I wish. It's not free. You will pay the same that Americans pay for Uni over your life many times over since tax rates in the EU are really high. Healthcare isn't exactly cheap either.

And everything you wrote is just the result of decades of prosperity that are now coming to an end. This will be a shock for many.

In tech, 3-4 weeks vacation not usual for senior roles. Often “unlimited” but in practice far more than 10 days. That might be for new/inexperienced hires in crappy companies.

For comparison, 4 weeks is the absolute minimum for any full-time worker here in Australia, and that’s less than people in the UK/Europe get.

>> University is expensive as fck.

While healthcare is brought up all the time this is usually ignored. The idea of parents saving a 'college fund' for their child is something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).

> something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).

Like most things learned from movies, you're not getting the full picture. Most US universities charge on a sliding scale based on family earnings. For larger universities, tuition can actually be free depending on parental earnings. At the extreme end, some Ivy League universities like Harvard have $0 tuition for families earning less than $200K/year.

We also have community colleges and state-run universities with subsidized in-state tuition. It's still more expensive than free, but the tuition is in the range where as long as you're smart with your degree selection the ROI of getting the degree will more than make up for any loans you have to take on. That said, you can get yourself into trouble if you take out loans to study for a degree that doesn't translate to a job.

And, in fact, the median amount of college debt for adults who don't hold degrees is sharply lower than the overall median (it's around $10k). It's not nothing, but it's also not a life-changing amount of debt.

(By way of policy bona fides: I'd strongly support forgiving student debt for all for-profit schools, but would oppose forgiveness for degree-holders from universities, which would be a sharply regressive policy).

Implicit in all these stories is that "education" means "access to highly selective universities". In-state tuition at Directional State University is much more manageable.

Not really. I went to a public land grant university 20 years ago and paid about $12k a year in state. That same university is now $44k per year.

Both my kids went to UIUC and we paid about $15k/yr, and both my kids graduated within the last couple years. And UIUC isn't a Directional State University; it's the flagship of the UI system. You can just look this up: tuition numbers aren't secret.

Ok I will. This claims the cost of attendance is $36,930-$42,310 per year:

https://www.admissions.illinois.edu/invest/tuition

This claims $21k per semester:

https://cost.illinois.edu/Home/Cost/R/U/10KP0112BS/15/120258...

You just cited the out-of-state cost of the flagship state university in Illinois as if it were the in-state cost of a Directional State University in Illinois. Again: you have an argument here that depends on people not Googling list prices (the prices that nobody actually pays) and seeing what they actually are.

No I didn't, that is in state, it's right there on the page.

Directly from the page:

> Illinois Resident

> Tuition & Fees: $18,046-$23,426

> Food & Housing: $15,184

> Books & Supplies: $1,200

> Other Expenses: $2,500

> Total: $36,930-$42,310

I literally looked at the exact school you used in your example and you are just wrong

Couldn't have been clearer that I was referring to tuition, including the fact that I said that specifically upthread.

Well then as long as the kids don't need housing or books or food or to pay the other fees they'll be set. Luckily those are all optional

They in fact differ wildly between students and between colleges! UIC and NIU are commuter universities where students generally don't live on campus. Students at UIUC live in campus-provided housing for their first year, but not generally for subsequent years. Everybody, whether they're in school or not, pays for housing. So no, the cost comparison you're offering here is not very useful.

Shortly later

I also think you might have to ask around to find a student paying full price for books.

I set up an education fund for my kids when they were 2 and I still can’t be sure it’ll be enough. It’s really bad.

It's evident that you're saying this as a non-European, as there's no "European healthcare".

Many (most?) European countries have private healthcare systems. Switzerland has it and offers some of the best healthcare in Europe and in the world. Similar systems work great in many other European countries as well. The problems with American healthcare are not because it's market-based, it's because how that market is managed.

Some other countries have public universal healthcare. It can work well, but it requires a high-income country with both wealth in abundance and significant government efficiency. It only truly works well in Scandinavia so far. This is not "socialist healthcare" as some will dubiously claim, it's sort of the opposite, which is why it works.

> University is expensive as fck. Health care is expensive as fck.

University isn't near as big of a problem. That's not something the blindsides you like health care expenses. Nobody is making you spend $300k on university. Got my engineering degree at a public university for ~$100k in total and had it paid off 5 years after graduation. But a $195k hospital bill is something I'd never be prepared for. Nobody chooses to go to a hospital.

For $100k, you could pay the tuition fees for 4-10 (depending on exact school choice) of the best universities in Europe outside the UK combined - and I'm talking of the foreign student fees, not the much lower tuitions that EU citizens get.

> So like these are less serious issues if you are paid an extra $1-200k/ year

Ok but to be fair most people in the US aren't making "extra $1-200k / year" over a person in Europe. They aren't even making $100k / year to begin with.

Almost 40% of the USA is on medicare, medicaid, or entitled to VA benefits or military healthcare. It's only a narrow majority that depends on unsubsidized private healthcare, and those people skew in the upper income levels.

You believe the top 60% of the nation skew in the upper income levels? Median pay is $61k a year for the entire country. The top 1% skews to the upper income levels. The rest are charged $30 for a dose of aspirin and can't afford it.

There are numbers on this, and their comment is probably directionally correct; the median household with private insurance earns more than 400% of household FPL (KFF). By subtracting Medicaid and fixed-income seniors from the picture, you are sharply biasing the median upwards.

I would say if you ignore the poorest 40% of the population, you've got quite the slim margin to go before you are no longer talking about "Most" Americans, which the OP was pretty explicitly talking about.

He was saying "Most people in the US" don't make 100-200k more, and that they probably don't even make 100k. This was in response to the generalization that "people from other countries ... underestimate how well paid people in the US often are".

Now there was talk of getting the political motivation to change things, so I guess everyone is assuming Medicaid/Medicare/VA recipients don't want to change the system, but that wasn't really established, nor was that really being refuted.

I don't think I could be any clearer that I am (1) talking about Americans with private health insurance and (2) not making a normative judgement about which system is better, but rather a positive claim about the political challenge of changing the system (its large group of stakeholders who are better off under it).

Oh I'm clear about the demographic you are trying to discuss, my point was I'm not sure this all stemmed from a discussion about that specific demographic. It started at "people in US", then went to "most", then by the time you got involved in the thread you were defending a statement about people with private health insurance.

I could have made this comment at the level where it went off the rails, but I thought making it at the leaf level would help everyone involved see the deviation between what was said and what was being argued.

People in the US can't afford aspirin? Where do you live? It's just not true

They are referring to the price that hospitals charge for aspirin, which is massively inflated, not the off the shelf cost of aspirin

Where in their comment do you see them referring to hospital care?

The article, talking about a patient's hospital visit, mentions "the $31 low-dose aspirin, of which they'd given him four."

Ahh, good callout. Thanks!

I'm capable of understanding context.

i think in this case, if you're at all familiar with what US hospitals charge for the small stuff, it's a safe assumption that when someone says aspirin costs $30 a dose, they're not talking about buying it at a CVS. of many folks on hacker news dot com i trust you to bridge that gap instead of nitpicking!

That's an odd argument to make in this thread, because whatever the drivers of burdensome consumer health spending are, they're not overpriced hospital aspirin.

maybe so; it's a symptom, not a cause.

So what about this? It is a question, not meant as a counter.

Although I have to say the rosy picture some paint here about the high incomes is counter to anything I ever heard - and saw, although I left the US in the early 2000s, after having lived there for almost a decade (still mostly paid from Germany, never ready to make a complete move).

"Medical Bankruptcies by Country 2025"

https://worldpopulationreview.com/country-rankings/medical-b...

"Healthcare Insights: How Medical Debt Is Crushing 100 Million Americans"

https://www.ilr.cornell.edu/scheinman-institute/blog/john-au...

By the way, Europeans don't quite all have a "nationalized healthcare system". Germany, for example, has "Krankenkassen" but also private insurance, and the "Krankenkassen" are private organizations.

We pay health insurance and get to choose the provider, those with higher incomes can switch to complete private insurance. We also have lots of our own problems and increasing costs because of immigration but more so aging population.

However, I personally know several people who had severe illnesses for a long time, and their normal "Krankenkassen" insurance never made any problems. One person with plenty of money, whose wife was dying, even asked US medical experts if he should come to the US with her, and those US experts said he should stay where he is, the German univ3ersity hospital right next door had some of the leading therapies in the field. She lived five more years instead of dying after less than half a year with the standard therapy, every single expense paid for with the standard insurance, additional private insurance unnecessary. Similar with my stepfather, who had soooo many severe conditions, and yet every single item down to the special medical bed brought into our house so that he could finally die at home was paid without question.

The problems are with more mundane expenses, e.g. glasses, or the dentist, where only some of the treatments are covered. The really expensive illnesses seem to be better covered than the more common and much simpler problems.

Careful there, thats a rightwing propaganda point. Immigration into an aging society does not raise healthcare costs, it lowers it. See https://archive.is/XxfTH (and note that this is a NZZ article, a right-wing publication by now, so not slanted towards being immigration friendly).

Are people ever allowed to criticize migration?

Who's not being allowed to criticize immigration? Critique of a critique is pretty much the furthest thing from "disallowing" critique.

Sure, but it helps to not misrepresent the facts while you do it

Misrepresenting???

The costs DID increase.

I did not try to make a political statement, what happened here, anyway???

I have no idea what there is to defend - even if you assume they will all get high-paying jobs some ay, for the first few years costs will increase while they either learn the language, are not allowed to work (status pending), or get minimum wage jobs (food delivery and parcel services at least in my city now is dominated by immigrants).

Even with your most positive outlook, initially there will be lots more people and the same system (number of doctors), and the numbers of payers increases slowly.

I even wrote "but more so aging population", conveniently overlooked in this strange politicized discussion.

I am NOT against immigration!!! Don't make stuff up people.

[flagged]

> Of course, far-left demagogues like you would advocate for flooding a country with uneducated criminals

We've obviously banned this account. Please stop registering accounts just to keep breaking the guidelines. It's boring and a waste of everyone's time.

Thanks!

And while European countries have various forms of nationalized welfare, their salaries are so low that they would be automatically eligible for the US' welfare too!

our blocs aren't that different

except in the US middle class and upper middle class

It's hilariously out of touch, but it's what you should expect from the HN bros. They live in a bubble.

I'm from the eu and earn far less than these American techbros do, but far more than my American friends who work normal jobs. They work at the DMV, a supermarket, or general office work. You know, normal people. The vast majority.

Yeah, just because the US has 300 billionaires that does not make the median salary anywhere near six figures.

In fact it's quite low, somehow people are expected to survive on several thousand a year, after the rent, utilities, transport costs are all paid.

https://www.fool.com/money/research/average-us-income/

These are official stats, but unofficial employment puts the number lower:

https://investorshangout.com/carlyle-group-unveils-alarming-...

It helps to understand the difference between the mean and the median.

I agree I am not in any way representative. But the forum is hacker news, not my day at WalMart.

[dead]

As with many things, in the US if you're part of the privileged minority you do well. The top 10% of earners in the US earn a lot more than the top 10% in Europe – that covers tech, high end knowledge work, that sort of stuff.

But the bottom 90% do badly. Society is very divided, and most people lack social mobility, they lack a voice on the national and international stage, they lack the security that either a social safety net or high pay would give them.

The UK is similar, although much less pronounced. I moved to Australia about 18 months ago and society here is much flatter, the difference between the top 10% and bottom 10% is much less. There are still problems here, it's not a utopia, but it's very noticeable how most people are struggling less, and how the top 10% of earners aren't living that different a life.

I think you are underestimating the number of Americans who make less than what Europeans make.

In both systems, the upper X% can afford it. But it makes no sense to focus on that. What matters is how many don’t have access.

That number is much larger percentage-wise here than in Europe. And it will only increase the way things are going.

Probably true. But if you think about who votes, professionals and home owners have much higher participation rates. I am not saying this is good.

Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.

So when you're talking about how bad the American system is, you're really talking about a minority of its users. That doesn't make everything OK, but does highlight the political difficulty of enacting seemingly-popular changes.

> about how bad the American system is, you're really talking about a minority of its users

It sure seems that way if a wealth family with top level insurance can still get bankrupt by medical bills. Examples of that are right here in comments.

Are you referring to the comment that roots this thread?

No need. It's a known phenomenon.

https://www.npr.org/sections/health-shots/2022/06/16/1104969...

https://rooseveltinstitute.org/publications/medical-debt/

https://www.marketplace.org/story/2024/03/27/health-and-weal...

As for income distribution

https://worldpopulationreview.com/country-rankings/gini-coef...

State GDP figures are skewed by high earners. The US is massively and systemically unequal, with far less economic mobility than the EU.

I asked a question about the comments on this thread. This isn't responsive to that question.

>the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.

If you had said the median tech worker? I might have believed you, but the median family? No way.

The median family of 4 with private health insurance has a household income of around $115k not counting the gross cost of their employer-provided health care. Remember: being on private insurance puts you in a cohort that:

* Excludes everybody on Medicaid

* Excludes fixed-income seniors on Medicare

* Makes it overwhelmingly likely you have subsidized employer-covered health insurance.

Figure your employer "covers" half the gross cost of your $24k/yr health insurance (they aren't, really: that's money they'd be paying you directly without the distortion of employer-provided health care). Do the take-home pay math. Put them in, like, Ohio, or Iowa, or Colorado; just not SFBA or NYC.

Now move that same family to Manchester, take the wage hit for moving to the UK labor market, and work out the take-home pay. They'll of course pay $0 for the NHS.

Are they better off or worse off?

I'm not valorizing the arrangement, I'm making a point about how political tractable changing it is.

You’re moving the goalposts. How many families have private insurance? Considering both families with and without private insurance, is the median family better off in the US?

Idk, speaking as a big Medicare-for-all supporter, this would definitely explain why MfA always polls well at first, until people start asking if they can keep their current plan. I know at this point in the debate we’re supposed to write those people off as either innumerate, a minority, or too risk-averse for their own good, but honestly if it turned out that that stat was true, that would explain a lot.

And it would be exactly the kind of political engineering minmax scheme large corps in the US are great at: petition legislators to cut regulations so you can cut costs and maximize profits, but keep juuuust enough of the right perks in the right places so that a slim majority of people in Wisconsin, Michigan and Georgia oppose shaking things up.

The people who want to keep their own plan are almost definitionally not innumerate! They would be worse off financially under M4A.

That doesn't make M4A bad policy (I think it's bad policy for other reasons), but it does take "people are being irrational" off the table in a discussion like this.

Even if you keep your plan it's getting enshittified every year.

It's that time of year again - enroll for 2026 benefits. My employer raised employee premiums by 10%, raised the deductible, added more administrative burden such as "step therapy" (the insurance company denies your claim for a drug until you've tried a cheaper but less effective drug, even if you've already done "step therapy" while on another health plan!) Your employer will change the plan premiums and structure every single year. They can lay you off, exclude expensive drugs, exclude doctors, etc. Some specialties like anesthesiology and psychiatry are usually not in network. In extreme cases an employer can change health administrators mid-year and your deductible will reset.

https://www.pwc.com/us/en/industries/health-industries/libra... https://kffhealthnews.org/news/article/workplace-health-insu...

Why does Medicare for all mean I can't keep private health insurance? There are countries that have systems like this in place.

There are countries that have single-payer systems and widespread supplemental insurance. But if you universalized Medicare, you'd immediately do at least two big things to the market:

(1) You'd eliminate the system of advantages and supports that cause employers to offer private insurance, which is where most people get their insurance from.

(2) You'd create a huge adverse selection problem --- the more effective/useful Medicare is, the fewer families will want to spent $24k/yr on private insurance, meaning the families left on private insurance have a reason to want it, meaning the composition of the risk pool would shift dramatically.

Like, if we ever did M4A, we'd probably end up with a widespread system of supplemental insurance; we already have it with Medicare! But that's not the same thing as keeping your existing plan.

I don't understand the obsession some people have with keeping your existing plan. Lots of people can't keep there plan under the current system. Insurance companies update their plans regularly. Sometimes they remove plans or exit markets entirely. An existing plan will get small changes over time. If Theseus has an insurance plan for 10 years and the insurance company makes changes every year can we still call it the original plan of Theseus?

If M4A plus supplemental insurance gives me about the same coverage I have now for a reduced total cost that sounds like a win to me. Even if it ends up costing me the same amount the net improvement from everyone having access to basic health care would still be a win.

Every policy is easy to enact if you just define away anybody who'd object to it. But, more importantly: it's unlikely that M4A by itself (let alone with the supplemental plan you'd likely end up with) would reduce your total cost!

> Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.

The US spends nearly as much in taxpayer funds as a share of GDP as other developed countries (and vastly more on a per capita basis), with even more in private costs on top of it. It is simply dishonest to say that the "wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays", because neither the US wage premium nor any lower tax burden are attributable to differences in healthcare systems, but rather are in spite of the far greater burden of the US healthcare system.

OTOH, it is true that a major challenge is that people respond with this line to any proposed major structural changes to the US system.

Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance. That family would likely (in fact, almost certainly) be worse off in a single-payer system.

I'd appreciate if you'd avoid using language like "simply dishonest" with me in the future. It's easy to tell me I'm wrong about something without accusing me of commenting in bad faith. This is in the guidelines. Thanks in advance!

There is a middle ground here. Many European countries do not actually have single-payer, but still perform better than the US.

It's a bit out of date now but the book The Healing of America found that Germany, France, and Japan had world-leading healthcare results, measured by things like survival time after major disease diagnosis, but spent much less of a percentage of their GDP on healthcare. None of them had single-payer. Their systems were pretty close to the ACA, with private insurance companies and a mandate.

They were also different than the US in certain ways. Probably the biggest was a national price list for services. A lot of healthcare isn't really a functioning market; in many cases you're in no position to comparison shop. A result of the price lists was that doctors made a lot less money, but this didn't seem to affect quality.

Other differences included: no claim denials allowed for anything on the price list (which saves a lot of administrative staff), effective national digital records systems (ditto), and the insurance companies had to be nonprofits.

All three countries actually got better bang for the buck than Canada's single-payer system. Japan was the cheapest, spending only 5% of their GDP on healthcare, despite an aging population of heavy smokers. Germany was the most expensive at 13% (compared to US 18%) but covered things like week-long visits to the spa for stress relief.

The author did a spot check on the user experience by seeing a doctor in each country for a shoulder problem, and those three countries worked out really well for him. In Japan the doctor offered surgery the next day, at a very modest cost. They did make do with simpler equipment; the MRI machines were bare-bones but they got the job done and a scan cost $100.

I agree. I'm a fan of the non-single payer European systems, and, especially, of the Australian system. Nobody can look at the American system and say we've got it right! I do like the private->Medicare compromise we have, but we also have the original sin (a strange and I think unintended consequence of the mid-century tax code) of employer-sponsored coverage.

> Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance.

Yes, you can just do the math, and changing nothing about the US except transition to a European style universal system, the median family would face lower aggregate tax, out-of-paycheck, and out-of-pocket costs than they do now, with less health insecurity around unexpected events (either health or employment), unless the tax increases necessary were deliberately and perversely targeted to avoid that.

That’s a direct consequence of the difference in the macro-level costs: they aren’t separate, orthogonal concerns. People just have a hard time accepting that the US health care system is structurally constructed right now to waste vast hordes of money preventing people from accessing health care, but that’s exactly what it does.

Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.

I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.

> Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.

Not tax penalizing non-capital income is sort of an essential reform in the era of increasing automation anyway; I'm not sure what point you are trying to make there. The average middle income family isn't making a substantial share of their income in forms taxed as long-term capital gains, so that seems...unrelated to the focus of your argument.

> I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.

It does both (particularly, in the “actual care” angle, as regards low-benefit, high-cost measures near the end of life.) We have a system based on denying and economically incentivizing younger people to avoid and defer care, but then doing much less of that with (most of) the elderly.

You're contradicting yourself. You took me to task earlier for factoring in the wage penalty for working in the UK market --- fair enough, though really I'm making the simple descriptive point that people in the US are accepting of a dysfunctional status quo in part because they would be worse off in Europe.

But taxing capital gains at the level of ordinary income would be an immense change our tax code. All sorts of things the broader economy would change as a result. If you accept Sanders plan, you're not holding to your original constraint of changing only the health financing system.

I want to be clear that I'm not stipulating that families would be better off under M4A if you didn't do this: I still think your argument has the fuzzy end of this lollipop. I think it's unlikely that you will come up with a set of numbers for any proposed single-payer health system that leaves the median family with private health insurance better off on a take-home basis. I'm making a strong claim, so you should be able to knock it down straightforwardly if I'm wrong, and I'm interested to see if you can.

The counterargument is simple - it works in other countries.

Other countries have healthcare systems that don't generate medical bankruptcies, and don't put a slaver's chain around the necks of employees who risk financial destruction if they have to give up an employer-funded plan.

You're essentially arguing that 500k medical bankruptcies every single year, out of a population of 340 million, is a small price to pay for an imaginary financial benefit that you're convinced exists, for some loosely defined demographic, but which you've failed to quantify.

This is, very specifically, the problem that destroys your argument.

Some people in the US are better off until they aren't.

One serious medical crisis - like an extended bout with cancer - is enough to wipe out the benefits, and leave people who used to be prosperous out on the streets.

Literally. Not as an exaggeration, not as rhetoric, but as a cold, hard reality that affects half a million people every year.

You're responding persuasively to somebody's argument, but it isn't mine. I'm talking about the large cohort of American voters who would be worse off under a single-payer system.

I don’t know if the median American would be worse off with a European style system. Certainly the 1% don’t need it. I’ve been on the Google health insurance before and it made me feel like I had $10 million in the bank.

Can I ask what the Google health insurance is like?

I've been lucky with my health so I don't have a huge list of interactions:

* Free tele psycho-therapy. Not sure what the limit is but it's >= 2 hours per week. I even cancelled same-day once with no fee. The quality of the care was also very high.

* I developed wrist pain from typing, holding a Steam Deck, starting pull ups. I was able to see a physical therapist at the Google office (through an embedded One Medical) after 1 week. No referral needed. Saw them once per week for 5 weeks paying $20 co-pay each time. They fixed my issues permanently.

* I also occasionally used the Google One Medical locations (and public ones) for injuries from a low speed bike crash, vaccines, etc. Don't think I ever paid more than $20 for anything. On a Google income that amount is completely inconsequential.

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Wrong - sorry. The reason is that politically the US public is very skillfully managed from above via divide and conquer strategies and beaureaucratic techniques (i.e. identity politics, gerrymandering voting districts). The public polling is very clear about US citizen preferences, but US Govt policy is rarely aligned that way.

No, it's not clear at all: it's been tested in actual referenda and failed. What's actually happening is people don't intuitively grok the distinction between opinion polling, where questions are asked in the abstract (and often in the best light preferred by the org sponsoring the poll) versus actual voting, where the questions are very specific and include details like "your taxes will increase by X%" or "you will lose access to your current insurance plan".

Oddly enough the big rhetorical push against a universal system from prior decades was about "death panels" deciding what care somebody would get. And guess what's happened with insurance? Death panels!

The propaganda spin on the health care system in the US has been on overdrive ever since Hillary Clinton wanted to implement some reforms in the 1990s, leading to absolutely massive resistance to any change whatsoever. Even the changes implemented by Obama, which were a HUGE improvement in access, barely made it across the legislative line, and dismantling that access to the health care system has been a huge rallying cry for one of the major political parties. I won't say which one because mentioning that fact results in people turning off their brains and downvoting.

The US healthcare has optimized for availability and higher access to the most treatment options. This does not mean evenly distributed treatment options, but that people have the chance to get access to things more quickly.

And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.

>>> And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.

As an individual who has lived in multiple countries in three continents, I dispute that “the care most people get is better than adequate”. Perhaps better than the world average, but certainly not better than in most first-world countries. And that’s not even counting the impact of delayed decisions and denied care, and the stress of dealing with the system overall.

And if you’re looking for more than anecdotes, there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.

While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change.

> there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.

Americans aren't dying earlier of diseases that are solvable with a doctor visit, surgeries, pills, or other easy medical interventions. The medically related early deaths are primarily because of overnutrition and lack of exercise leading to pre-diabetes, diabetes, high blood pressure, and heart disease. That comes from public policy mandating car dependence throughout society and huge subsidization of empty calories in the food system. Overeating and lack of exercise are problems that have been stubbornly resistant to the medical system's efforts to change behavior. There's also other heightened early death risks like car crashes, drug overdoses, and suicide, but few of these deaths could be prevented by increased access to the medical system.

>While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change

This ignores the outsized influence of lobbyists, especially post Citizens United.

The majority (depending on which polls you cite, seems to range anywhere from 57% to over 70%) favor a universal healthcare solution for all citizens. Yet like many other majority opinions, this doesn't translate into legislative action in that direction, in large part thanks to lobbyists and dysfunctional partisanship. None the less policy is not reflecting the majority.

What lobbyists are opposed to universal healthcare?

It seems to instead be merely a wedge issue in culture war. Republicans firmly oppose it, Democratic politicians fight for it, and apparently voters don't care enough to advocate for what they say they want in polls.

Off the top of my head:

- The Partnership for America's Health Care Future

- American Hospital Association

- U.S. Chamber of Commerce

- Various lobbying organizations related to private insurance and adjacent systems, like pharmacy benefit management organizations

Politico has a great article about the Medicare For All fight[0]

The opposition spent hundreds of millions of dollars fighting it.

[0]: https://www.politico.com/news/agenda/2019/11/25/medicare-for...

Thanks for this article, it's great! Back from before Politico became so one-sided partisan...

Life expectancy tells you basically nothing about the quality of health care in the US. It's dominated by car accidents, homicide, and then CVD --- but CVD varies dramatically across the United States (from states in the south with drastically worse CVD outcomes to states in the north with outcomes on par with the Nordics) despite the same health care structure across all those states.

There are plenty of other countries with car accidents, homicide and cardiovascular disease. They also do worse than the US in life expectancy.

Do you need a cite to back up the analysis I just gave you? Because it will be easy to provide.

> And guess what's happened with insurance? Death panels!

The insurance death panels already existed at the time. It didn't even happen after.

That's what made the whole thing so ridiculous in the first place.

Like Ticketmaster, health insurance companies get paid to be the "bad guys". This is a reasonable function since Americans can't seem to understand that someone must decide where limited resources go. However, there's no reason their cut should be so large.

Their cut is in fact very small; it's around 6.5% of total US health care spending.

https://nationalhealthspending.org/

But for what? Why not something closer to credit cards, like 1%?

I don't know how to answer that. I think the system is pretty inefficient in a variety of ways. If you universalized Medicare, eliminating insurance entirely, you'd get costs somewhere in between Medicare's current admin overhead and the overhead of private insurance (you mechanically would not get Medicare's current overhead, because the majority of your customers would have much lower claims than Medicare's all-seniors patients do, and overhead is a ratio).

But the largest inefficiencies are all on the providers side. We simply pay practitioners too much, enforce artificial scarcity of practitioners, and prescribe too many services.

So if we're talking about "The American System" as a whole --- which is what the thread is about --- it behooves us first to consider the question "how much better would things be if we simply zeroed this category of expense out". The answer is, to a first approximation, we would get a 6.5% price break. I would not drive even a couple blocks out of my way to get a 6.5% price break on a pack of chicken breasts.

> But the largest inefficiencies are all on the providers side. We simply pay practitioners too much

I agree. The complex insurance billing system enables his by obfuscating prices and limiting ability to comparison shop.

That's true, but it's a problem single-payer doesn't fix; that's my big issue with it (it locks in rapacious rates and preferences for the health provider industry, making them palatable to consumers by hiding the payer).

The complexity is far higher than credit card processing, including extensive price negotiation with individual health care providers. Though we call it "insurance" it's just as much a "buyer's club" for health care services.

Large employers (e.g. Google) are also generally "self-insured" meaning that the "insurance" component is offloaded to the purchaser, the employer of the insured individuals. In those cases, the health care insurer processes the claims from health care providers, determines if they were justified, or if the treatment/diagnostic/drug is justified by coverage determinations of the provider, etc, but the employer (e.g. Google) just pays the claims in the end too.

Health insurance companies have had their profits capped at a percentage of revenues. That means that to grow profits, they must increase revenue. Which means incentives to increase care and increase costs.

Oddly enough, all the plots I have seen of cost increases don't show a massive skyrocketing of costs since the profit caps were introduced. If anything, they have been somewhat reduced.

However a reckoning must happen at some point, health care can not consume the entire economy's efforts.

You could offer me 10x my current salary and I wouldn’t take it if it meant I had to stress and be terrified about the life of my 6 year old daighter because a company wants to make more money.

That is the definition of not worth it.

> people know it is a problem but ideologically they really disagree about what to do about it

Can we really say this is true about individuals in the US?

I think it's pretty clear the propaganda machine has successfully privatized health care to the great detriment of the populace and have the clamps on it.

After all, if you told everyone you had a solution where insurance rates would be cheaper, their healthcare system would cost less overall, and the health outcomes would be superior, they would all be like "sounds great". Then, when you reveal this solution is the complete destruction of the insurance "industry", insurance payments are "tax", and the health provider is the government, they would balk, scream about socialized healthcare, and say how they don't trust the government.

That's a trained response, not a real thought.

In fact, US Americans are paid so well, the GDP per capita of the poorest state (Missisipi) is about the GDP per capita of France. In fact, the gross average wage of Missisipi is just barely lower than the average salary in Germany. Americans are paid really, really well.

> they really disagree about what to do about it

What is there to disagree with? Are there any option other than introduction of universal healthcare?

There's already a soft alternative many people use, which is the deregulation option via geo-arbitrage, go to Mexico and get the same thing for 10 cents on the dollar.

Universal healthcare is a very different thing from controlling costs.

Obamacare attempted to make the US healthcare system into a universal system by mandating that people purchase coverage, heavily subsidized to become affordable to every income level, in addition to massive expansion of Medicaid to those with the lowest levels of income or no income at all. Automatic enrollment in health insurance exchanges, even if people did not make their own choices on the health insurance exchanges, is what would make the US system universal health care.

Universal means that everyone has coverage, that the question to the patient is "what insurance plan are you on," rather than "do you have insurance." And making coverage universal has no connection to lowering costs. We need larger structural changes in the logistics of how care is delivered and how the money flows.

Single payer is another choice to be made, but that doesn't necessarily mean that health insurance is cheap, that all the care gets delivered that people want delivered, etc. Medicare is often cited as one direction for this, but most don't realize that private health insurance costs are partially high because they help subsidize the care of those who are covered by Medicare, because Medicare reimbursement rates are far lower than any of the private insurers have been able to negotiate.

Other routes are full decoupling of insurance from employment, full price controls that normalize Medicare and private insurance rates, which either make health care more free market or less free market depending on how you define those terms.

However every year that passes makes any of these reforms more difficult because administration of the costs and billing is getting more complex each year. ICD codes, PLA codes, all that stuff grows in complexity.

HMOs, like Kaiser, may provide a route towards greater simplicity of administration of health and costs.

But implementing any large change will require political buy-in of people, and when we have our current low-trust, high-misinformation political system there's been no way to make any political traction for changing anything. Until we regain a functional democracy or turn to full dictatorship, it seems unlikely that we will see structural changes that improve anything. Hell, we had Republican states actively trying to prevent poor people from receiving coverage from federal dollars. How can we ever come to terms with a change unless that sort of attitude no longer has traction?

> ideologically they really disagree about what to do about it

I really don't understand this sentiment. It's not like the current state of the US insurance market were based on the principles of a free market. On the other hand, not coupling your health insurance to an employment contract that can be cancelled at will has nothing to do with socialism.

A Princeton study showed over a decade ago that the policy preferences of the vast majority of Americans have no correlation with actual policies. That you put forth these completely detached theories is quite impressive.

I don’t know if this a case of ideological delusion to go along with political impotence or just the usual upper middle class playing their part in obfuscating the on-the-ground realities. Structurally the latter is more likely.

The United States is a democracy, but more specifically, a representative democracy. That means citizens don’t directly vote on most laws or policies—aside from certain state or local measures—but instead elect representatives to make those decisions on our behalf. The idea is that we trust them to act in our best interests.

You can probably see where the problem comes in. Take, for example, a politician who campaigns on Medicare for All or universal healthcare. To win an election, they often need massive campaign funding—much of which comes from wealthy donors, including those in the medical or pharmaceutical industries. And once in office, they’re targeted by powerful lobbying efforts worth billions of dollars from those same industries.

In the end, the issue is that politicians can legally receive millions in donations and support from industries whose interests might directly conflict with the needs of the people they’re supposed to represent.

Ultimately though, it is known by most people irrespective of party affiliation that medical costs are out of control. One recent example of this collective understanding was when the united healthcare exec was killed. Before there was even a suspect, people generally knew why he was assassinated. Most people in the U.S. have either been directly affected by the insanity that is our healthcare system, or one of their loved ones has. Those that haven’t yet, it’s just a matter of time. It’s just so pervasive.

As Lawrence Lessig put it: before the general election and before the primary election, there is a "Lester" election where donors choose who is able to mount a campaign. Candidates are effectively pre-qualified by 0.0005% of Americans. It's probably an even smaller crowd than that as that includes Joe Nobody who gives $20. Those who "bundle" $1 million in donations or write a mega check themselves have exponentially more access.

> The United States is a democracy, but more specifically, a representative democracy.

As your following explanation makes clear, it's actually an unrepresentative democracy.

There are very few countries in the world that are not a representative democracy. Switzerland is a well-known example of a country where citizens directly vote on most legislation, but in most other countries, you have a parliament, congress, etc that represents the people.

That doesn't really have anything to do with the ways in which the US is an unrepresentative democracy.

unfortunately, they represent a party before representing the people

Ah, so Americans are okay with that system as well. Got it.

As stated near the end of my comment, most Americans are not okay with the system as it is. It’s legalized corruption that perpetuates the system.

For further reading, I recommend learning about the Citizens United vs FEC case that vastly increased the amount of money going to politicians, far over individual donation limits.

https://en.wikipedia.org/wiki/Citizens_United_v._FEC

We're not okay with it, but it's so entrenched by the wealthy that the only way out will eventually be violent revolution which nobody wants.

How did you come to this conclusion from the previous answer/comment?

Because they don't want/don't change the electoral system

The problems with the electoral system are just one symptom of a deeper issue: unlimited political donations. The wealthiest individuals in the world can funnel endless money to politicians through Super PACs, and that influence shapes policy more than an individual voter ever could.

Even if we magically fixed the electoral system tomorrow, the results would be superficial. Sure, we might see more Democrats in office—but if they’re still beholden to massive, uncapped donations, how can we expect them to enact real, meaningful change?

This problem with money in politics is not something that only affects one party. It's a systematic issue that needs regulation. Without real regulation on money in politics, everything else is a band-aid on an open and festering wound.

It might be worth mentioning that a massive propaganda campaign against universal healthcare has been conducted on the American public for decades by interests that benefit from privatized healthcare.

Not Americans OK with it, just that right-wing wants hypercapitalist low-regulated helathcare while left-wing wants basically "free"/communist health care.

Both of which are infinitely better than what we have now, which is bastardized worst elements of both.

But because both sides will never agree we'll get neither, only the current hellscape.

No one is "putting up with it." We don't have a choice.

The way our government is designed right now, the populace doesn't really have elected representatives. More accurately, they have a corporate bought-and-paid for stooge that managed to be more likeable in a political race than their opponent, so we don't actually have anyone representing our interests _as a country_ at the federal level.

Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.

It's largely a side effect of a couple things... first the ACA (ObamaCare) limited the percentage of profit that insurance and medical providers can make... so they instead just grow the pie larger by inflating everything. Second is that they are allowed to have effectively vertical monopoly investments controlling multiple layers of healthcare as a whole from insurance, providers, pharma and pharmacies.

Trust busting and multiple supply lines really need to be established in order to have a chance at restoring normalcy. Which is all but impossible as Pharma alone is the single biggest spender of advertising alone, let alone policy influence over politicians.

> so they instead just grow the pie larger by inflating everything

So why would they deny coverage? All they have to do to earn more money is keep paying for more and more healthcare.

Because they make more by not paying than by paying... When the payouts are larger, they raise premiums, make money on both sides.

Not to mention, if they can delay payment for a month, that's a month worth of interest on the money in an interest bearing account.

How exactly do they make more money by not paying? They're required to spend 80% of their funds on provider expenses. The only obvious way to sustain the narrative that insurers are distorting the system for profit is the preceding comment's hypo that they'd be over-paying (and then driving rates up as their expenses increased). You propose the opposite fact pattern here.

(Net cost of health insurance, all expenses, is around 6.5% of total US spending, as against 51.5% of direct provider costs for doctors, nurses, and procedures, not counting prescriptions.)

They keep the 20% that they don't pay out... what they do pay out, they get the invested fraction of, which is less than than what they paid out.

Even if they only get to keep up to 20%, doesn't mean they will pay a dime of what they can get away with not paying.

"What they do pay out they get the invested fraction of"?

If an insurance company owns 20% of the service provider, they only make a fraction of what the insurance arm pays to the provider arm.

The problem is that the insurance is provided by private companies whose incentive is to earn as much money as possible, at cost of the people in need of medical care. In my country, I never heard of anyone going bancrupt over a hospital bill. It just isn't a thing.

Here's a fun story: my sister was living with an exchange student from the US. Some day the student was complaining about intense intestinal pain she's had for the past few days. My sister told her to go the hospital. The student asked her if she was crazy. My sister then had to explain her that hospitals are free and won't bancrupt her...

In fact many of the largest insurers are nonprofits, and insurance itself is a small faction of our total expenditure. People believe a lot of weird things about US health care economics.

https://nationalhealthspending.org/

There's another aspect: In my country, hospitals and (public) health insurance are both operated by the state and work together. If I break my arm, I go to the hospital, show my e-card and that's it. All the financials are directly handled between hospital and the (public) insurance provider. I don't have to worry about cost of treatment because I know it will be fully covered.

Right. The mainstream progressive proposal for comprehensive health care reform in the US is single payer, so-named because it does not nationalize the providers. But the providers are where all the cost is!

Add a French and American person, in the US you hear "insurance did not approve", in France it's more "you can't get an appointment / the surgery provider does not have any spots unless you go to their spots in their private hospital".

The French system is more predictable (because any vaguely sane healthcare system has a price for a code instead of negotiated rates, negotiated rates is the most inefficient way to run this market) & you can get cost estimates though. And in both countries, if you live in a small town in both systems, the healthcare you will receive will suck.

Do negotiated rates not affect quality of care? I work in contracting and negotiated rates allow me to add quality, while systems like price codes incentivize minimum effort/outcomes.

I know doctors probably take their jobs more seriously, but I'd be surprised if it doesn't bleed over into healthcare quality.

Ideologically, just enough voters in the right places believe that unless you’re old, or a military veteran, in which case government healthcare is just fine, your sickness should not be their problem, even if it means they pay more for their own care.

Also, if healthcare wasn’t tied to having a job, then the inherent laziness and moral degeneracy of people without jobs would be encouraged by letting them not be sick. (BTW, being self-employed does not count as “having a job” in this mindset.)

This frame assumes several things:

1. Americans are not displeased with the situation. Ironically, I think this is one place most Americans agree there is a problem. The solution is the hard part because:

2. This presumes a drop-in solution where no one loses. This is where the fight is.

3. This presumes that democracies do what is logical or beneficial for the vast majority, which is a very naive view of democracy.

Great question. No one "wants" insurance. Everyone wants to be able to get covered for care. The problem is that Govt decided decades ago that Health Insurance is the only way to get care even for mundane things like a regular doctor visit. To make it worse, they tied it to Employers needing to provide insurance. Insurance companies love this bureaucracy and became too powerful over the last few decades.

It is a sad state and I have almost given up on the hope that someday it will change. I m lucky enough to afford healthcare and feel for those who can't.

> I m lucky enough to afford healthcare

Up to a point, I guess? Correct me if I'm wrong.

Yes and it still sucks because I hate wasting my hard earned money because of a random number thrown at me for the so called "Claim". Fk the entire insurance industry especially health insurance mafia.

And don't get me started on the inefficiencies and waste of time that you have to go through to fight a "claim" that is incorrect.

To the extent that U.S. voters want to maintain the status quo, which many (though not most) voters do wish to do, it's largely driven by an individualist mindset in which the worst thing that can happen is somebody else getting something that they didn't "earn".

I’d love to see a poll asking Americans: “Do you want to maintain the status quo?”

In European countries the procedures that are denied or very expensive in the US are often simply not offered. There is a national health budget, and not everything fits in it. The doctors have to tell the patients that there is nothing they can do, and that's that.

The patient ends up just as dead, but there is nothing to get furious about like when the doctors could fix it, but only if someone pays for it.

In part because hospital bills are monopoly money and most people just play a game of chicken with debt collectors, and the only actually sue a small fraction of the time and mostly either settle for a small fraction, give up besides annoying phone calls, or it gets discharged in bankruptcy.

Almost no one gets a bill from the hospital and just pays it, and in most cases if you do it's totally financially illiterate.

We are a "binocracy", where our democratic function has been reduced to a binary choice, and unfortunately both choices have been fully captured by the healthcare industry.

One thing also to keep in mind, is that this experience is not uniform throughout the US. Many Americans like -their- employer based insurance, even if they don’t like the system. I personally pay nothing for visits and nominal fees ($1-10) for prescriptions. I have not been hospitalized while on this insurance, but my understanding is that it is relatively low cost. I also have no monthly premium. Meanwhile, my mother works at a small business, pays a significant percentage of her income for insurance from the ACA marketplaces (the public marketplaces created during the Obama administration) with the current subsidies, subsidies that are in question under the current administration. The American healthcare payment system is broken, but we aren’t all living through the worst case scenario experiences that get the attention. Add to that the amount of money and effort that went into turning healthcare reform into yet another partisan issue, and there’s a good recipe for maintaining a broken status quo for a while yet.

Edit: just saw an earlier better comment saying the same thing: https://news.ycombinator.com/item?id=45737190

Countries with “free” also healthcare ration it and don’t cover everything.

Socialized insurance is still insurance, and at least in Canada it’s the only game in town, so if you have a procedure that is denied or not available your choice is basically to go to the US and pay for it and be in the same position as an uninsured American.

> I have heard the US is a democracy.

It is certainly not a direct democracy where each individual policy is resolved by separate independent voting, no.

> So then insurance-based healthcare is what American people truly want?

Pretty consistently, no, but there is not any single alternative that a majority of the American people prefer recently (for a while, as far back as the 1990s, there was a clear popular majority for universal single-payer), and more importantly, it is not the only issue that factors into people’s voting decisions.

America is trapped in a cycle where political parties have discovered that fear and anger drives voters whereas contentment with status quo does not motivate turnout. This leads to a scenario where parties will actively sabotage the resolution of painpoint issues such as immigration, healthcare, gun control etc. so long as it continues to create anger and fear that they can successfully blame on the other party. This behavior extends to voting against their own proposed policies in the interest of seizing/maintaining power over problem solving. And now deliberately creating crises (both real and fictional ones) has become the game-theory dominant strategy in American politics.

Even for politicians who are not absorbed in wedge issues, meaningful reform is a long term task. It would require multiple elections in a row showing that there is a durable political coalition for universal healthcare.

So much this.

Also, this works for every people, not just American.

A lot of employed people like the status quo for the healthcare that they receive.

"In contrast to their largely negative assessments of the quality and coverage of healthcare in the U.S., broad majorities of Americans continue to rate their own healthcare’s quality and coverage positively. Currently, 71% of U.S. adults consider the quality of healthcare they receive to be excellent or good, and 65% say the same of their own coverage. There has been little deviation in these readings since 2001.

Compared with their counterparts, older adults and those with higher incomes register more positive ratings of the quality and coverage of their own healthcare."

https://news.gallup.com/poll/654044/view-healthcare-quality-...

So basically they accept and approve of them being bankrupted by an unfortunate medical event no matter how top tier their health insurance package. Right?

Are there not out of pocket maximums on most plans?

Why do you put up with long wait times and lower-quality care in your home country?

It is very interesting that you do not where they are from but you assume longer wait times and lower quality of care. This suggests you believe the US has the shortest wait times and highest quality of care, which is objectively not true.

US person here.

I have insurance through my employer as do most Americans. And most are happy with their insurance. I can go to the doctor often same day, I can see a specialist and pay just a co-pay of between $25-50.

I had some bills but my out of pocket max is something like $5k, which I have saved up. The benefits of living in the US is that the same kind of work (engineer) pays about 3x as much here and you pay a lot less taxes (save many multiples of my out of pocket max).

So I prefer to live in a vibrant economy and take care of my own insurance.

> Though why do you Americans put up with all this? I have heard the US is a democracy. So then insurance-based healthcare is what American people truly want?

It's because our politicians are largely owned by our corporations and spend a ridiculous amount of money protecting their interests [1]. We almost had a public option with the original "Obamacare", but it was forced out of the bill [2].

Also, just turn on Fox News for an evening and realize it's been the number one news channel in the US for 20-something years. They've been a right wing corporate propaganda machine for a long time, all while brilliantly portraying themselves as the "underdog" fighting the mainstream media. Americans aren't very educated and take pride in their ignorance, unfortunately. [3]

[1] https://en.wikipedia.org/wiki/Citizens_United_v._FEC

[2] https://en.wikipedia.org/wiki/Public_health_insurance_option

[3] https://www.youtube.com/watch?v=QFgcqB8-AxE

FoxNews has only been the number one TV news channel for the last 20 something years because almost everyone under 40 doesn't watch TV anymore. Yes, there are a lot of conservatives in the US, but the demographics is really skewed if you just look at people who watch TV and have cable.

Yes, but older people vote and young people don't. I haven't owned a TV my entire adult life (in my 40s now), so I agree with you, but it's hard to imagine Trump and the current Republican party without Fox News.

> I have heard the US is a democracy

It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins"). It's a constitutional republic where basically you have 50 mini countries each with different weight in the house of representatives and in the electoral college and a bazillion checks and balances that make repealing existing laws and enacting new ones very difficult. I think the majority of Americans do not like the current healthcare status quo, but getting changes that everyone is on board with through the political machinery is very difficult and Americans are polarized and tend to distrust change plans proposed by the opposite party (since parties tend to propose legislation that favors their own first).

> It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins").

But it's worth remembering that, if it were, Trump would still have won. He won the popular vote. So, assuming that enough votes were legitimate, a majority of Americans actually do want the current health situation in the US, in fact arguably they want even less coverage.

We don't know if that's really accurate, because you're conveniently ignoring 2016. If Trump were never initially president, would he have ever become one?

Maybe, maybe not. But 2024 surely would have looked very different.

This only serves to reenforce the fact that the US is not a functioning democracy, if the will of the voters is not reflected.

Yes, but we also want universal healthcare. What we don't want is only universal healthcare with death panels like the UK and Canada has. Give us universal health care where we can also get insurance if we want, and we'll vote it in. That's never what comes up though. I firmly believe we could gut medicare/medicaid and the savings from the bureaucratic administration costs alone could pay for universal healthcare.

Note that Massachusetts and San Francisco have universal healthcare. Mass. is also home to one of the best healthcare systems and children’s hospital in the word.

UK/CA healthcare sounds like hell. Every doctor is under the government, so even if you have money for a procedure the government doesn't want to cover, you can't get it done. And of course because there is no rationing by price there is rationing by time, so you end up with 13mo waits for an MRI.

Leaving aside the subjective impressions, the objective parts of that description are only accurate for CA, not UK, healthcare; the UK has optional add-on private insurance and care on top of the universal public system.

The US is gigantic. Imagine if every EU member, however rich, poor, or corrupt from Bulgaria to Germany had to enact one healthcare system.

India is larger and yet.

And yet even its major cities are filled with sewage, 400 million are without healthcare and less than 50% of its people have reliable access to clean drinking water?

Well there is lot of shit we Europeans put up with, for instance EU moving court every few weeks voor 200m per year. But systems are hard to change.

Hum.. At least where I live in europe, you still need to battle with insurances for any non trivial problem.. We get a health care coverage for the common stuff, but many things are not covered, or not covered enough.. Then you need insurances.. And it's always a battle..

Same for other kind of insurances such as issues with the house, etc..

The US money machine has one of the most sophisticated propaganda networks in the history of the world working to make sure nothing ever gets better for working class people. In George Orwell's vision of a dystopian future, "The party told you to reject the evidence of your eyes and ears. It was their final, most essential command." In the US, the party didn't even have to issue the command, they just asked a few thousand talking heads to do it.

You've implied the answer to your own question. The USA is not a democracy. The opinions of almost all Americans have no impact on policy. It's a well researched fact.

Having an election day where people vote doesn't mean you live in a democracy.

Then what sort of feel good stories about AI would we have . The US needs to adopt a single flat income / corp tax, government provided healthcare, and move on to the rest of life.

Non-US person here too. From what I understand the majority of Americans want a single-payer healthcare system, but too many people in government are paid by insurance companies and affiliates to not change how things work.

Without making a claim about whether it's what most people actually want or not, there's not much that an individual can do about this by changing their voting preference. The US doesn't have proportional representation, and the overwhelming majority of elections are "first past the post" rather than one of the more "modern" alternatives like ranked choice votes, so in practice very few elections ever swing to anyone outside of the two major political parties (neither of which have a particularly large contingent of politicians who have come out in favor of something like single-payer healthcare). Even for a purely single-issue voter who only cares about this, from a game theoretic perspective you're likely to be essentially throwing your vote away if you vote for someone outside of those two major parties because it's unlikely enough others will.

Presidential elections are even worse because they're determined by electoral college vote rather than popular vote. Even ignoring the potential for "faithless electors", all but two states allocate the entirety of their electoral votes to the candidate who wins the majority of their vote, which means that if you live in a state with a majority who reliably vote for a specific party's candidate every four years, your vote for president is effectively meaningless.

The only obvious way to fix these issues with how elections work would be to elect people who make different decisions about how to run them, which is hard to do because of the issues themselves. The system is self-reinforcing in a way that makes it extremely difficult for the average person to do anything about it, and any desire to do so gets weighed against the concerns about the policies that you might actually get to influence by voting for one of the two candidates who might actually win. At the end of the day, people who are concerned with the fundamental systemic flaws in things like elections and healthcare still likely end up picking pragmatism over principle (with the expected value of a vote for a candidate who is almost guaranteed not to win being lower than one who is might be less desirable than a third-party one but still has an actually realistic chance of winning and is preferable to the other major party candidate) or just check out of the system entirely (with people not bothering to vote at all already being a fairly common phenomenon in the US).

Its too easy to convince enough of the population to actively vote against their own interests.

It's not a democracy. You were told wrong, it's a republic.

Well it was a democratic republic. Now it is an electoral autocracy. He fixed it so good those christians will never have (or be able) to vote again. Just like he said he would. A Republic where the representatives are chosen by a popular vote are still democracies.

-Democracy in name only

-Currently a dictatorship

-Historically more of plutocracy

-Our history has effectively yielded the current healthcare situation especially since those who would be most vocal tend to have better coverage and thus are less invested especially since the high costs are largely obfuscated

Just Pharmaceuticals not even all medicine is literally over half of all advertising spend in the US. And that is just the tip of the iceberg and doesn't go into the incestuous and conflicting interest relationships between pharma, pharmacies, medical providers and insurance companies all inter-invested in each-other to simply grow the pie larger since ACA limited profit percentages.

It's the single most powerful lobbying group as a whole, and nearly every politician is bought and paid for by them. Good luck getting a majority or super majority to work against them.

Pharmaceuticals are only a (high) single-digit percentage of medical spending in the USA, and the (likely) reason for the ads is the highly competitive nature of the market. Most of healthcare spending is on labor, specifically doctors and nurses, who are protected by highly effective trade and lobby organizations.

My point stands... as a whole, they (medical industry as a whole, including pharma) are the single largest lobbying group and nothing you've said refutes that. My use of pharma ad spend was an example of how much money they put out as an indication of how much lobbying power all of medicine as a whole has.

One can argue what people wants is to be ruled by old convicted felon dictator.

As soon as someone introduce these ideas people think they're a communist. See Mamdani in NY right now.

I don't think this has much to do with being a democracy. I, for one, wouldn't trust our federal government to competently run an efficient, most uncorrupted healthcare system for all.

The incentive structures that have built up around US politicians simply doesn't leave any room for it to realistically happen. Until the incentives are changed I'd vote against nearly any major government program.

I hope you refuse Medicare at 65 under those same principles

That would entirely depend on the coverage I could get and how it compared to private. If Medicare is changed over the next few decades to look more like Medicare Advantage, aka Plan C, you couldn't pay me to deal with that.

Edit: its worth noting that your question for whether I'd take medicare is a separate issue from my original point. If the existence of Medicare as it is today was on the ballot, I would vote to get rid or drastically change it. If the program exists regardless of my opinions of it, my choice to take benefits from it is entirely a question of means and comparative benefits of all the options.

The same way European people put up with the insane NHS and its refusal to care for the people who support it financially and supposedly support it politically.

https://edition.cnn.com/2024/03/13/uk/england-nhs-puberty-bl...

The NHS and its bizarre political agenda is an example of what can happen when a government controls access to health care.

A good example that "public" campaigning can work, but not necessarily for the better - there's been a systematic campaign to delegitimize trans healthcare.

There's comparable examples from other places; Ireland has come a long way in getting the church out of reproductive health, but there are still problems. And of course it doesn't matter whether it's public or private, abortion care is at risk in many US states.

The UK does allow you to go private, remember.

It's precisely as many have said over decades at this point: the poor in our country hate themselves to the extent that they view being poor as a personal failing, and voting for free services for everyone is therefore dishonorable. I talk to people like this every day and it's frustrating.

I think the root cause of the problem is not insurance companies but they definitely do play a part. The real reasons are multiple but can be listed as below.

1 A very high cost of drugs due to no intervention by the government as part of free market philosophy. This means that the same insulin that costs $25 in Canada can be sold for up to $1000 per month. New introduced drugs for Alzheimer's or other diseases can cost up to 50k per year - again because no price controls.

2. Insanely high prices of services due to a captive market - example a ten minute ambulance ride can cost up from $1000 to $5000. The private ambulance companies know they can charge a high base rate because they are connected to a city or municipality via contracts. Bribes as campaign funds are popular here. E.g. a new York based ambulance operator paid 45k in campaign funds to NY's governor elect and got a contract worth one billion dollars

https://www.wkbw.com/news/state-news/report-nysdoh-awards-mu...

3. Overcharging by hospitals for medicines and services again due to a captive audience. The hospitals are free to maintain various price books and you are not told what each service will cost at the time of administration of service. lately the hospitals have been forced to open up their price books but they are so convoluted that no normal human can decipher those prices.

Thus a ten cent aspirin would cost you $25 in the hospital and a MRI can run up to 15k.

4. Very high charges for doctors due to strict control on the number of MD positions and no increase in colleges or D seats over multiple years.

https://www.aamc.org/news/press-releases/new-aamc-report-sho...

5. Insurance companies have a for profit motive and need to extract their profits from premiums paid. Thus they fight tooth and nail to deny procedures and medications and set up convoluted processes for appeals.

6. Extensive fraud on Medicare and other government run health programs especially in durable medical goods and fake billing. In fact one of sitting US senators medical care company was involved in the largest Medicare fraud fines in the US and he still holds his seat.

https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....

Infact fraud billing Medicare for services not rendered is so popular that even Insurance companies do it

https://oig.hhs.gov/fraud/enforcement/united-states-interven...

Combine all the above factors and you will see why the US consumer gets so little while paying so much for his healthcare.

The US is only ostensibly a democracy. It's not a functioning one, due to widespread voter disenfranchisement.

Voter ID laws, voter roll purges, registration barriers, polling place accessibility, early and mail-in voting restrictions, and perhaps most importantly gerrymandering, misinformation, and intimidation all serve to reduce the power of the ballot box.

And that's before we even get to US citizens in Puerto Rico, Guam, the US Virgin Islands, and American Samoa being unable to vote in Presidential elections at all.

Most other countries have voter ID, and the controversy surrounding it is puzzling to most foreigners. Additionally, parliamentary systems which result in majority governments are much more ‘dictatorship-like’ than the US system where individual representatives retain some autonomy.

A large number of Americans do not have ID's, which is strange to many people. If the need for voter ID and risk of fraud were so great, the efforts would be to make it trivial for these folks to get one, rather than preventing them from voting.

The are advertised as a democracy, but ever since Citizens United was passed we became an Oligarchy. Money now takes the place of votes since the rich can donate unlimited funds to a candidate. Candidates have zero incentive to serve the public.

The alternative is no surgery and no choice, which is what happens with government-run healthcare.

I doubt this comment is true, given that other countries with government run healthcare have surgeries and choice. Do you happen to have any evidence that every country with government run healthcare has no choice or surgeries at all? Your comment seems to imply as such.

No, we all hate it, but the number of senators and members of congress who would vote to replace it could be counted with one hand. The reason is simple: the insurance companies give those senators millions and millions of dollars and nobody has the cash to beat them. And we've given up at this point.

As the song goes:

"Everybody knows that the dice are loaded

Everybody rolls with their fingers crossed

Everybody knows the war is over

Everybody knows the good guys lost

Everybody knows the fight was fixed

The poor stay poor, the rich get rich

That's how it goes

Everybody knows"

We have a lot of people being constantly brainwashed that we have the most amazing system in the world and that any attempt to change it is communism.

Decades of right-wing propaganda, unfortunately. They tend to have an emotional reaction against any sort of socialized anything, including healthcare.

Left wing won't solve it either. They profit from the crisis by promising each election and not delivering.

That's true. I wouldn't even call them left-wing, to be honest.

I think you’re just believing whatever the author says, and not considering the fact that reasonable people can disagree and be wrong and make mistakes. For all we know the procedure was entirely unnecessary and they agreed because he pushed for it. Also, what’s the alternative? The only system where you can go get procedures that authorities think unnecessary is a free market where you self-pay. A government-run system could equally decide that the procedure isn’t recommended.

Medicare has a total enrollment of approximately 69 million people, while Medicaid has around 83 million people. That is 152 million people. We already have socialized medicine we just run it poorly and don't apply it to people that can pay.

Moving our system to 340 million people + letting our corporations out of paying would put the US into an economic death spiral. US corporations would love this plan. But at 340 million... I don't see doctor visits but once every 2 years -- many would just die waiting for appointments.

Medicaid is apparently 77MM including CHIP. The underlying compromise in the system that you're describing is sane: people's health care costs rise dramatically and unpredictably at retirement age, just as their ability to pay plummets, so socializing health care at that point makes a lot of sense.

Is this a comment for or against socialized medicine?

We fucking hate it don't worry

Non US as well. Life saving saving surgeries get denied, delayed and otherwise screwed all the time. Not sure where exactly it is worse since absolutely atrocious cases can be found in every G7 country never mind the rest

Yes, it is what they want.

In the end there are more of them who want to "own the libs", or "not pay for freeloaders" than those who want to contribute to another's child surviving.

not sure why you're getting downmodded. People will say M4A ("medicare for all") polls at super high levels, and they're right, it does. But poll those same people telling them "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on, and that poll turns right upside down.

> "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on

No, that's just the condition for one proposal for Medicare For All.

As much as Americans complain about healthcare in general, most people don't want to give up their own health insurance once they have it. This is a known political trap that the previous M4A proposals walked right into, before crashing and burning.

When you say "Medicare for All" to people without details, they assume it means a Medicare option for all. When they start reading the details and realize they have to give up their current insurance, they don't like it.

what are the other proposals? I like everyone else would love the option.

though at the moment I'm super happy DJT does not control my healthcare.

Every actuarial study about the switch projects total cost savings even during the first year. This scarsity of providers is artificial there haven't been enough medical student slots ever in America. American life expectancy isnt in the top 25 nations, while having the largest percapita GDP.

> Every actuarial study about the switch projects total cost savings even during the first year.

This is missing the point about why people don't like the past M4A proposals: It's not about cost savings, it's about losing access to their existing health care with scarce details about what would change.

The surprising reality about American health insurance is that many people's plans cover a lot of things, procedures, and medications that would be harder for them to obtain under Medicare or even in other socialized medicine systems like the NHS.

If politicians would lay out a Medicare buy-in option and let everyone opt-in to it, it would be far more popular. The past proposals that involved shutting down the private insurance industry and handing it all over to the government is resoundingly unpopular.

[dead]

> incompetence

No, that's the goal. Denying coverage is how insurance companies make money. The less money they give, the more money they keep.

The other side of this is that your LLM interaction can be leveraged to train adversarial models that find ways to still deny or delay your claim despite your LLM-advised actions.

Insurance companies, or the companies they pay to launder their involvement, would pay a lot more for that than the public would be able to.

I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.

There's a difference between immediate stabilization, required by law, and life saving surgery in general, not required by law.

If you come in with a gaping head wound and can't pay, by law, hospitals are required to treat you.

If you come in with brain cancer, no one is compelled to give you the radiation, chemotherapy or surgeries you may require, even though it is literally life saving. You are stable, albeit slowly dying, so too bad.

> I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.

Maybe I'm just too skeptical, but

a) This is a very new account with exactly 1 other posting 3 months ago, and

b) They don't refer to their child with any sort of gender. They even used slightly awkward sentence construction just to avoid gender. Few parents think of their child as an "it".

So either this is a sleeper bot, or the surgery in question was gender reassignment.

Or this poster routinely refers to their child as an "it", not a "he" or a "her".

Or they value privacy? Especially regarding their children?

Many people nondescriptly don’t gender themselves in online discussions.

Happy to hear this all worked out. Have you thought about reaching out to local news to get the word out? That insurance company should be called out.

Insurance companies have become cartoonishly evil. It’s going to get really nasty out there at some point.

A few of the sentences don't make sense to me. Who is "they" and "their" in the last two paragraphs?

Seems like GP is trying to refer to the child without reference to sex.

This is why AI is an equalizing force.

Eventually, we'll just have a free (or at least much cheaper) psychiatrist in our pocket.

Sure, AI advice is workse than the advice of a competent professional, but it's very often better no advice, and that's what you get if you can't afford the professional.

I shudder to think when insurance companies use AI to counteract customers using AI to navigate through their system. They'll eventually catch up, and people who don't use any kind of AI will be disadvantaged.

That is, until someone sells them a turnkey AI service to do insurance claims... and decides to play both teams so resolutions come back at pre-AI levels, and the free market(TM) is happy because a new equilibrium has been reached.

Maybe I just need more sleep.

I am not sure it's that simple. Thing is many costs are due to information assymetry: you not knowing something that they do.

For example them counting on you to big hire a lawyer for collecting medical debt or mortgage debt your spouse or parent owes. As a general rule you aren't responsible for it. There are exceptions. e.g. Filial laws(children responsible for parent's debts) exist in many states, but are difficult to invoke. Community property laws https://www.irs.gov/publications/p555#en_US_202502_publink10... in 9 states that can link your income to your partner, when the state you were domiciled in with your partner in a home/condo you bought together.

So in general, adverserial use of AI cannot bring claims "back to pre-AI" levels. Much more likely is the fact is reduced debt collection activity and illegal billing will reduce to a new baseline.

Amazingly happy to hear you were able to drive the process! FWIW, surgical centers usually have to do the exact same thing for their patients (typical role: coordinator), and they do it the same way you did (plus knowing a few counterparties because they work together regularly).

The lack of data standardization in health insurance is atrocious. (In the US, CMS/Congress pushing what it can, but at a glacial pace)

The strongest argument for single payer is that a diverse marketplace has demonstrated a fundamental inability to interoperate.

I'm glad you were able to use these tools to help your family though such tough times!

> The hopeful part of me is that many others can use similar techniques to win.

And the realistic part in me says that these tools will be used to deny appeals without a human ever looking into them and making sure you will never get to talk to a human or get approval for anything ever again.

(this thread paid for by OpenAI)

Great story, and encapsulates what I find most powerful about LLMs.

I was under the impression that if you were to go to an emergency room, life saving surgery would be scheduled regardless of who is paying (or not paying), due to EMTALA. I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.

Is this incorrect?

if the kid has a steel spike through his abdomen then they will perform that surgery. If he's having seizures because of a brain tumor all they're required to do is stabilize and release.

Presumably parent is describing a non-emergency situation.

Good reminder that "life saving" and "elective" are orthogonal.

The American Medical Association owns copyright to all the codes and their descriptions. They have an extremely restrictive and expensive licensing options and they strictly forbid training models with the codes.

This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.

The AMA (a nonprofit!) clears ~$300M/year revenue from the codes, which is the direct cost passed through to consumers, but the indirect costs are the byzantine nightmare of OP.

A code is not an artistic expression and so can't be copyrightable. The layout of a book of codes, for sure, but the information in it... might be protectable with other IPR but not copyright.

Does not stop people threatening you though.

This is my opinion only, not legal advice, and does not relate to my employment.

>A code is not an artistic expression and so can't be copyrightable.

that was changed

https://www.bitlaw.com/copyright/database.html

Databases are generally protected by copyright law as compilations. Under the Copyright Act, a compilation is defined as a "collection and assembling of preexisting materials or of data that are selected in such a way that the resulting work as a whole constitutes an original work of authorship." 17. U.S.C. § 101. The preexisting materials or data may be protected by copyright, or may be unprotectable facts or ideas (see the BitLaw discussion on unprotected ideas for more information).

(I did not use AI, but this appeared at the top of my search and I think the search engine used AI to generate it):

In the European Union, databases are protected under the Database Directive, which provides legal protection based on the originality of the selection or arrangement of their contents...Some countries offer additional protections for databases that do not meet the originality requirement, often through sui generis rights.

That means the organization and selection of data is copyrightable, and only if they are creative. If you write your own tags for the codes, and makes a compilation of them all, none of that will cover your database.

Also, I think the bitlaw interpretation is incorrect. “Sweat of the brow” doesn’t magically produce copyright protection, and they don’t mention that.

Taking their example, if you had a collections from quotes from presidents, and I got a bunch of similar collections, then made my own ultimate definitive collection based partially on your list, then there’s very little chance I’d be liable for violating your copyright. If I copied the list and typesetting verbatim, you’d have a better case.

Also, modern rulings about LLM training (the topic of this thread) certainly mean copyrights on compilations of facts don’t survive training + inference cycles.

Judging by Judge Alsup's ruling even if the codes were copyrighted it would most likely not be copyright infringement to train on them either, and as such even if they are copyrightable and they do own copyright on them it remains beyond their abilities to forbid training on them. (Also opinion, also not legal advice, I'm also not a lawyer and sort of doubt the person I'm responding to is).

> not be copyright infringement to train on them either

Copyright is about reproduction. It does not cover uses. Once you bought it, it's yours, as long as you don't reproduce it outside of fair use.

The problem with most language models is they will often uncritically reproduce significant portions of copyrighted works.

If you buy the codes, yes. If you only license them (which is what the original comment claims is the only way to get them legally), and that license explicitly forbids training, that seems to be less clear-cut. I have no idea if such restrictions are legal or would hold up to challenge, but it's less clear than the case where you buy a book and can then do whatever you want with it.

IANAL, you're right.

Software I write at work is not artistic expression yet is covered by copyright.

This isn't a counter argument, just pointing out how absurd copyright is.

Copyright under US law does not require "artistic expression". One of the requirements is called "creativity", but it's very easy to meet. The key phrase is literally "some minimal degree of creativity".

The fundamental policy choice was to protect computer software under intellectual property law, with exclusive rights and market compensation. There were a number of ways that could have been done. Other jurisdictions toyed with new, software-specific laws. But in the end the call in the US was to bring it under existing copyright law with some tweaks to definitions and a small handful of software-specific rules.

Your software is definitely artistic expression. You signed over the rights to those expressions to your employer.

(IANAL)

My software is definitely not artistic expression. I signed over the rights to the software to my employer. These statements are not codependent in any way.

Always disappointing to hear creative writers denigrate their craft just because their main audience happens to be computers.

A code in this sense is something different. It's a shorthand for a longer description of an object. It'd be like a hotel copyrighting the relationship between a room number and its physical location within the building, or copyrighting resistor colors.

I understand. The different meanings of "code" in this conversation is why I said "software" in my comment instead of code.

Copyrighting software is as absurd the other things you listed.

In the US copyright just requires a level of originality. The bar isn't very high, but for example simple logos, like IBMs blue lines logo is not copyrightable.

There are examples of software code that is probably not copyrightable, but that's limited to very simple code that has only obvious implementations.

>Copyrighting software is as absurd the other things you listed.

I don't really agree, and for context I think copyright in general is nonsense.

Consider these thoughts: https://wiki.c2.com/?SoftwareIsArt

Our role as programmers being closer to artists than engineers does not make code closer to paintings than bridges. We do have highly repeatable patterns. Nearly every program can be essentially boiled down to some subset of CRUD + tranformation.

Even if it is art (I'm not convinced), the recent artificial scarcity on art is absurd. Some other thoughts to consider:

- https://drewdevault.com/2020/08/24/Alice-in-Wonderland.html

- https://drewdevault.com/2021/12/23/Sustainable-creativity-po...

I've never seen a bridge I wouldn't consider a work of art either.

Also the collection of essays carrying the name "Hackers & Painters" is of relevance.

Artistic expression isn't the standard in US law.

> The layout of a book of codes, for sure, but the information in it

Are you talking about copyright here? It sounds more like design protection.

Wouldn't the book be as copyrightable as any other non-fiction work?

The work I know of, I'm not in USA only have an interest in copyright laws in general, is Feist v Rural Telephone (1991) -- which appears to mirror codes for health procedures quite closely; but not exactly.

There's old but more recent law from Practice Management v AMA (1997) supporting that AMA's codes can't be copyrightable as they're part of legislation.

Berne's Art 2(8), to which USA are signed, related to non-copyright of facts.

I'm afraid I'm not appraised of the full situation, however.

No - see https://en.wikipedia.org/wiki/Feist_Publications%2C_Inc._v._....

And yet people are collectively paying $300M licensing these non-copyrightable codes? With that kind of money somebody must have looked into not paying for licensing

I’m sure it’s crossed the mind of many people in the industry. But it’s a comprehensive taxonomy of all diseases, medical conditions, causes, procedures and treatments. Starting from scratch would be much more expensive than just paying the licensing.

Here in California, Senate Bill 478 bans many junk fees, such as the mandatory "service fee" to buy a concert ticket. It's a stretch, but I could see an argument that if hospitals use a billing system that's incomprehensible without licensing an expensive codex, then the hospital is on the hook to provide the codex to you.

Fight fire with fire.

What I mean is using it without paying the license, because if GP is accurate there is no copyright preventing it.

In that case its probably cheaper for most organisations just to pay the license fees than risk paying legal fees which would probably be more, even if they won.

It's important to understand that a "nonprofit" can be just as greedy as any other organization.

It can't pay out profits to shareholders, but it can hire its owners as employees and pay them any number of millions.

Doesn't the AMA serve the medical industry? They don't have to make profits themselves. If a byzantine coding process raises medical treatment costs, they'll do it. Just like how they intentionally cap med school admissions to keep doctors in demand and inflate their salaries.

Any non-profit can always claim to inflate their expenditures up to (and above) their expenses and pay lavish bonuses to their employees, like you said.

Doesn't change what it basically is - aka Scamming the Public, and privatising the gains.

Reading between the lines, it seems like this is a threat made to bring AMA in line with the administration's policies around medically supporting transgender people.

I would expect that if (when) the AMA folds on the matter, concerns around the codes will be somehow forgotten

>This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.

So you think the same Senate that is planning on gutting healthcare for millions of Americans is going to go after the AMA billing codes? Is this real life? They MIGHT demand some donations to the ballroom, but I doubt they care enough to even do that.

Ahh, here's the correct link and as I suspected, this has absolutely nothing to do with reducing healthcare costs for the average american. It is a direct attack on the AMA for advocating for supportive care for transgender citizens.

https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...

With opinions like this, you can rest assured Cassidy is concerned with healthcare costs for the average citizen:

>This comes after Cassidy denounced the AMA for defying President Trump’s Executive Order by promoting gender mutilation and castration of children.

Google tells me that the AMA made about 468 million last year in revenue. If they made that much from the codes it seems like they wouldn't necessarily pass the IRS Public Support test. (Unless somehow this licensing counts as "public support."

I seem to remember this test is why the Mozilla Foundation and the Mozilla Corporation exist, but I could be mistaken.

Edit: Seems that the AMA is a 501c6, which is a different kind of non profit.

> extremely restrictive and expensive licensing options

The license is meaningless if training AI is considered fair use, and if you never agreed to the license.

They might be able to lean heavily on medical researchers and the like (who probably need a license for other uses), but when push comes to shove I suspect Google and OpenAI would win.

So what you're saying is the AMA is openly hostile to Americans.

It has been forever, what planet are you on? Their official policy would be to make any native american cure (upon which many of the medications we use from big pharma, are based on in origin) to be illegal. They would want all profit going through them, whether that is good for you or not.

It’s quite literally a cartel and it acts like one. They heavily restrict the supply of doctors, which means our medical costs are higher in favor of higher doctor salaries.

Anything related to healthcare (except some genuine minority of doctors and staff) is almost openly hostile to Americans.

I used to think American healthcare was in part expensive because Americans have poor health (e.g. high obesity).

Now I am beginning to think that Americans have poor health by design for the healthcare industry to be able to maximize their profits. Making some Americans healthy just seems to be a side product.

I will throw a story out here because I don't know where else to put it and want it off my chest (I will leave a lot out of this):

Daughter tried suicide a few weeks ago. "It was not a serious attempt," but obviously it is. We go to only local hospital; they don't have a pediatric unit, so ER basically just looks at her and aren't sure what to do because it's not like she's bleeding out. They clean the cuts and ask if I want county behavioral health involved. I'm in over my head and need help, so I say yes.

Behavioral health mobile response person comes out -- good guy, made me see something I hadn't prior -- because I've had her in therapy for half a year prior but we weren't really making much progress on anxiety/depression issues -- but he says we weren't going to get anywhere with therapy before drugs, that she was too far out, and in retrospect that was absolutely the right call. Anyway, he puts her on 72-hours mandatory hold. Here, this means the child must be transferred to a pediatric health facility with suicide watch and psychiatric services. This became a big problem.

Cincinnati Childrens Hospital had no beds (and I have ill will toward them anyway). Dayton had no beds. Charge nurse was calling people for hours and hours, and I joined in calling places (we stayed at hospital the whole time without sleeping), and it wasn't until 24 hours after admission we're finally transferred. My mom was/is a social worker for those with developmental disabilities, and spent about a decade working at long-term facilities for juveniles, where it was almost always court-ordered. I spent a fair bit of my time there for economic/childcare reasons while she was working -- awful place for the kids (not for me; I hung out in staff rooms and watched movies). Doors, by law, could not be locked, and they were terribly understaffed; violence and rape was expected. We had a second person from county behavioral come out, and once I realized the only kinds of places open to us, started pleading and insisting to have the hold lifted, but they refused. I wind up with one out-of-state option, and one in-state; both about an hour and a half away, and both the kinds of facilities I was terrified of. I later talked to other parents and was surprised to find time to find a facility, lack of beds, and travel time were all common issues between us. I went for visitation every day, and at least one adult would almost always come out of visitation crying, not realizing these places are poorly-staffed, unsafe prisons until they first visit and talk with their kid.

Anyway, so the 72-hour clock starts only once daughter's transferred to this pediatric psych facility (she wound up staying for 5 days; this is a whole other issue where they had no social worker available to provide AMA paperwork, they claimed). -And this place is a long-term juvenile psych facility, so it tends to have a lot of kids who were sentenced by courts to be there; violent offenders, but it was a mix (daughter has a story about playing Uno with a kid experiencing "weed psychosis", which'd I'd never heard of before; interesting stuff). You know, so I'm going to bed every night, and I've got some wild nightmares I could share -- BUT everything turned out mostly fine. At one point, daughter witnessed staff slam a kid against the wall hard enough for him to bleed from the head, and didn't clean the blood off the wall; the toilet in her room didn't work and the room smelled like feces; they couldn't lock doors, and the facility was severely understaffed. A recipe for disaster, but it could have been a LOT worse than it was, though trauma is there nonetheless from the experience.

Now, the reason the county insisted on sending her to this hellhole is because it's the only way to unlock county behavioral services. You must first have committed an attempt to harm yourself or someone else, or be ordered by courts. I wrote at the beginning I was able to get a counselor before all this, but this took a lot of emails and phone calls, and the place I found with help required 2 hours on the road per visit. The person I got was new in the field and didn't specialize in pediatric; he was not a licensed psychologist nor psychiatrist, but he was the only person I could get and I was grateful for any assist. There were/are no available pediatric psychiatrists or psychologists EXCEPT through county behavioral; they have them all locked away from the market, basically.

The total bill for all this, by the way (uninsured, cash, including the ambulance) was $8,709.45. I didn't negotiate; I've planned for this, I took out $20k from broker on the first day I got to go home. Money isn't the issue; it's the non-availability of service which's the real problem here, for us. I was surprised to walk into county behavioral and be told while registering at front desk they don't accept self-pay; that they aren't set up for it. I've never run into this before, and it got a morbid chuckle out of me because this's been a heck of a roll of the dice up to now, specifically to get in county services, and now I'm told they don't offer anything for us.

I ask for the people who insisted on the 72-hour hold (and btw, the facility which held daughter prescribed nothing but an antihistamine, with trauma inflicted, though minor; worthless experience except to unlock services) to speak with me, and I get one of them. She talks to supervisor, and apparently nobody knows their own policies because they do, in fact, accept self-pay. I had to fill out a Medicaid form, which we don't qualify for. Now, the strange part about this is if you have insurance (and this is why they have you apply for Medicaid), they charge you on a sliding scale, but if you don't have any insurance and get rejected by Medicaid, they really don't have any system set up to bill you, so everything's free. The psychiatrist and counselor both are free; it's crazy, so I'll kick some money to food pantries while SNAP's cut off in the state due to federal shutdown, but it's like nobody's ever really thought through the systems we have for healthcare; it's inefficient and brittle from every angle, not just the providers/insurers screwing people over for capitalism angle; like a proof-of-concept someone slapped together over a weekend where everyone's spinning their wheels without a clue what to do, except it's something we've had for centuries and are spending $trillions/year on. -And every time the government provides new weapons or issues new mandates, it somehow seems to get worse.

(Things are going well now, btw; we got a real psychologist scheduled same-day, and first appointment with psychiatrist was 2-3 days after intake. She's doing better, but the journey here was straight Hell.)

You could argue the lawmakers that granted copyright protections are openly hostile to Americans. Many fine people are saying that Congress values profits over people.

A subscriber of the code can use it agentically by using snomed,icd,cpt etc.. in their official capacity to look up meanings.

It would also be permissible to search existing records and prices (if an actor has them) to cross check average prices for some procedure.

Insurance companies get a lot of (deserved) hate, but the doctor cartel seems to skate on by in the eyes of the public.

The white coats are far from blameless here.

I have heard this also how some state law works. That it’s difficult to directly reference state law or relevant information which define the meaning of state law.

$300M/year is less than $1 per person. This is not why healthcare is expensive.

The opaque costs add up. If nothing else all the layers make things slow, when time is the difference between life/health and death/illness.

The codes are data. The restrictions are empty threats.

It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.

It's pretty clear that even access to a potentially buggy and unreliable expert is very helpful. Whatever else AI does I hope it chips away at how institutions use lengthy standards and expertise barriers to make it difficult for people to contest unfair charges.

having hired an expert in this field, I can tell you they aren't really that sophisticated. I found myself with an absolute mountain of cash after an accident as part of a settlement. My medical insurance won't pay claims until I've exhausted that cash. The claims I had were much higher than even the mountain of cash. The lawyer I hired use a pretty effective strategy: he contacted all of the claims against me and told them we could engage in N-way negotiations amongst all the parties until we came to a settlement so everyone got their nibble of the pie. Or they could get X today, where X was some amount that was a bit less than the rate the industry actually gets paid for those services. They all accepted.

The discounts he negotiated left me with tons of cash & were in excess of the fee he charged me.

He literally did a prisoner's dilemma on them. Love it.

The thing is the prices are all made up anyway. The hospital hallucinates prices, so they don’t blink an eye when an llm does the same.

Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k. His response was, "lol I'm uninsured and don't give a fuck about my credit score, so, fuck you basically." The bill was revised to $500, which he paid just to not have that debt on his record.

>The wider implications of this are left to the reader.

IMHO, it's actually worse than we realize. The Medical Loss Ratio requirement is good because it requires insurance companies to spend 80% or 85% of premiums on health care. It's bad because one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums so they can get 80% of a bigger pie. It also gives them incentives to provide care themselves so they can capture some of that 80% spend.

> For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k.

I experienced this personally with my own insurance. My bill was over $20k, and it took a year to convince the insurance company that removing a few feet of my intestines was actually emergency surgery. I ended up paying $800. My roommate in the hospital had no insurance and ended up not paying anything (which I did not begrudge them at all, since the reason for no insurance was debilitating back pain that led to unemployment)

> one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums

This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.

The truth is though, healthcare providers are ultimately responsible for prices.

> This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.

This assumes the competitors are not all colluding to raise prices across the board

Then they must suck at collusion, given they can't even beat a risk-less broad market index.

SP500 10 year annual return: 14.6%

UNH: 13.59% Elevance: 10.79% Cigna 9.42% Humana: 6.1% CVS: 0.55% Molina: 9.42% Centene: 0.9%

Or, the likelier explanation, is that health insurance prices are highly regulated and have to get their prices approved by a government official(s), and B) they don't have a lot of pricing power due to the competition and they are not colluding.

Executives earn more based on revenues and thus prices and not stock returns.

See almost any of the proxy filings and you will see much of the compensation is based on hitting targets other than just revenue, and most of the compensation itself is equity:

https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...

https://s202.q4cdn.com/665319960/files/doc_financials/2025/a...

The executives seem to have a heavy interest in equity returns.

[dead]

Insurance companies are required to spend something like 80% of premiums on claims.

This sounds like a really good thing, almost everything coming in has to go back out…

What it really means is they love high “allowed” prices. They live on the 20% and want to see the pie as large as possible.

Healthcare costs go up? They raise premiums — win-win.

The road to hell is only paved with good intentions.

> since another insurance company would just steal their customers by having lower

LOL. Meanwhile, in real-life America, there are only four or five major carriers that control the market, and none of them are incentivized to do this "competition" thing you speak of by engaging in damaging price wars. Why would they when continuing to be part of the problem makes them more and more profits each year? See also: military contracting. Do you see them constantly undercutting each other? No, they buy each other, reducing the number of bidders on every contract.

Four or five competitors is plenty for a healthy market.

Where I live, they do compete on price - prices vary by about 30% for similar coverage. They can't engage in the kind of price war you're thinking of since insurance companies, by law, have to maintain a fund able to cover costs, have to get rate changes approved by regulators and are largely banned from price discrimination.

I understand the desire to shift blame entirely onto insurance companies rather than providers. After all, one is all about money and the other is seemingly all about healing.

Heck, when a provider does bill people directly because an insurance company refused to pay, we blame insurance companies - even when the charges on those bills are highway robbery - like those in the article itself.

The fact is, the net cost of health insurance was about $279 billion in 2022. Meanwhile, $3.7 trillion went to healthcare providers, pharmacies and the like for care. The ones who stand the most to gain from higher prices are providers.

Frankly, decades of lobbying from the healthcare provider lobby to enrich themselves should have made it this obvious, but sadly, people see doctors as selfless angels and it blinds them.

Providers have certainly gotten greedy but still can’t compete against hospitals when it comes to ridiculous billing.

I practically damn feel sorry for surgeons when I see what they get from insurance versus the hospital for providing the operating room or bed.

The military encourages them to buy each other because it's much easier to regulate an industry with fewer companies in it.

>Why would they when continuing to be part of the problem makes them more and more profits each year?

In real-life America, they don't even earn enough profit to earn their shareholders a better return than SP500:

https://news.ycombinator.com/item?id=45736978

And in real-life America, the only people health insurance companies engage in price wars with is the state insurance regulator who gets to deny requested price increases.

Fascinating observation, thanks for challenging my assumptions here. Just seems to further point out how useless health insurers are, even to their shareholders.

My most sincere wish is that all insurers would be nationalized, every last employee summarily fired, and their HQs all imploded and replaced with memorials to all the people whose lives they have cut short over the years. Not a thing of value would be lost IMO. Worse than paying people to dig holes and fill them in again.

Aren't they doing some kind of turf non compete agreement like isps do?

I had read that comcast won't go into century link territory and viceversa, and something along those lines for the major isps, in order be local monopolies and set prices as they like.

Fuck those assholes!!! From 20k to 500… how do you name that?

> to justify increasing premiums so they can get 80% of a bigger pie.

Wouldn't it be 20% of a bigger pile?

I used to live with a guy from Guatemala, who at some point or another wound up at the ER. At the time his insurance apparently had some huge deductible for ER visits so he got the whole bill in excess of $1000. He was going to pay it, so I suggested he just call and tell them he was planning to leave the country and not come back. I told him to tell them there was no way he could pay the full amount, but didn't want to leave a debt out there like this. They lowered the bill to $150 after a few minutes on the phone.

Many years ago, I managed to stab my face with a screwdriver (not my proudest moment), and had to go to the ER. After the stitches, I was asked whether I wanted to pay with insurance. If I did, it was something like $2,000. If I didn't, there was a 75% discount off MSRP. My deductible was like 25%, so it ended up basically being the same out of pocket either way.

The fact that there seems to be a 4x markup means makes me think insurance companies are in bed with these hospitals. If you can mark up prices arbitrarily high, the insurance "discount" is fake.

There's all kinds of shenanigans that these prices enable: https://archive.is/jPE3n

From what I heard, doctors’ bonuses rates per unit of work are entirely calculated based on the specific hospital’s revenue from medical insurance claims; smaller hospitals can’t get as many patient payouts so their rates are lower and so are not as attractive to doctors compared to hospitals that can scalp well. So the prices do relate somewhat to what the hospital must spend on personnel, even if it’s arbitrarily engineered in the first place.

There are cases with prescriptions where its actually better to claim to be uninsured

At Costco Pharmacy I stopped using my insurance plan as the co-pay was more than the no claim cash price. I learned later that my health insurance company owns its own pharmacy and they design the claims process to bias you toward their own pharmacy. Since medical loss ratio must exceed 85% on employer health plans they realize their excess profits by jacking up prices at their pharmacy subsidiary and using their pharmacy benefit manager subsidiary and insurance product to steer you toward overpaying if you just take their suggestion (e.g. $100 if you use OptumRX mail order Pharmacy for the "savings" versus $20 cash price from Costco).

> Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

Don't leave out the part where the consumer doesn't even shop (or sometimes pay) for the insurance policy either, it is determined by their place of work.

So the consumer of healthcare is doubly shielded from any price signals the market might supply.

I know a couple that avoided marriage so she could negotiate the childbirth bill on the basis that she was an uninsured single mom who didn't own property, etc, etc.

Health Care Sharing Ministries (HCSMs) are an interesting loophole in healthcare regulations that excepts uninsured people that participate in an HCSM from paying the tax penalty.

HCSMs are membership organizations in which people with common religious or ethical beliefs share medical expenses with one another. They are not the same as traditional health insurance.

Because patients are considered "self-pay", they negotiate their own prices with providers and they are likely to get an 80% or more discount on "list price" for the service. They are reimbursed by the HCSM if the HCSM approves the reimbursement.

As of 2025, approximately 1.7 million Americans participate in Health Care Sharing Ministries (HCSMs), which amounts to about 0.5% of the U.S. population. In Colorado alone, HCSM enrollment (at least 68k) is equivalent to 30 percent of Obamacare enrollment.

Because HCSMs often exclude essential health services and are therefore more attractive to people who are relatively healthy, enrollment of this size, relative to marketplace enrollment, may increase premiums for marketplace plans.

I am not promoting HCSMs but I did research it when I lost my COBRA coverage a few years ago. I do find it an interesting alternative approach to paying for healthcare. We really do need to explore options in this country.

I can definitely see AI being applied in the HCSM context.

https://www.commonwealthfund.org/publications/fund-reports/2...

https://www.youtube.com/watch?v=oFetFqrVBNc

Warning! As grotesque as health insurance companies are, in theory they are obligated to pay valid claims under your policy. Health sharing ministries can exercise discretion to deny payment because they disagree with your lifestyle choices. Or for any reason or no reason given at all. They are subject to far fewer regulations and audits and in some extreme cases the administrators just pocketed the money.

More and more states are auditing them. But yes it's a faith thing. And definitely not insurance. Works better for tight-knit communities where there is trust.

So you're saying one solution is to get rid of all insurance and make hospitals charge a reasonable price. Sounds good to me. You sound conservative!

> Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged.

Not quite: US hospital billing is based on the idea that the insurance company does the haggling for you.

Insurance companies negotiate (cough) "the best rate that the hospital has to offer," therefore: What the insurance company pays is confidential, and the official unnegotiated price is highly inflated. That's why hospitals will always negotiate with uninsured patients, because they're deliberately inflating their fees.

---

In 2011 I had surgery. The first bill was for $100,000, which was sent to the insurance company. Then the insurance company got a letter (cough) "reminding" the hospital of the negotiated rates. The next bill was $20,000. On a follow-up visit, they did an X-ray, and sent me the bill. I sat on it, and then called my insurance company. The insurance company called the hospital to (cough) "remind" them that the negotiated rate for that kind of X-ray was $0.

this looks like shopping in Moroccan bazaar with no price labels. But here you bargaining not for couple fruits but for your health and price range is in thousands. WTF :)

Yeah at this point this is more like a cultural ritual. You know like howin some cultures you have to refuse a gift 5 times with increasingly stubborn facial expressions, and the gift giver has to insist through it all, and then accept and say thanks. As the default.

Or where you as a guest announce that you now go home, and the hosts have to insist you stay for some more tea or whatever and then you have to again and again say you're now going really and they insist you stay so you chat more in the hallway etc. And it's just how it always is and it would be super rude to just leave or if the host didn't demand that you stay.

Similarly the US developed this traditional ritual that the first bill is outrageously expensive and everyone knows that everyone know, but the ritual protocol say you gotta start with that, we are civilized people, we say hello, so in Healthcare the hello is the huge price, and the interaction always ends in a lowered rate, because that's also part of the protocol.

It's just a cultural difference.

It’s worse than that. In a bazaar there are only 2 participants and they are looking out for their own interests. Most Americans don’t choose their own insurance their _employers_ do.

The insurance company has no reason to make the health recipient happy and the health recipient has little agency in pricing.

In a bazaar you can examine the fruit or rug yourself.

An average person cannot call up $750K in a year to pay for cancer treatment. But for-profit businesses (and any organization for that matter) treat you much better if keep the carrot of another payment in front of their face. If you've forked over the whole wad of cash upfront they immediately de-prioritize keeping you satisfied.

> Most Americans don’t choose their own insurance their _employers_ do.

I don't have an employer, but I still only have one company selling health insurance in my county, so... that's all I can buy.

It's even weirder than that, because in healthcare you consume the product&service before anyone even starts to talk about negotiating the price!

A large portion of the US economy is based on this entire grift pipeline (settling before getting to court). And it's very costly and pushes up insurance costs and costs in general for everyone else.

When people talk about government inefficiency, I always think of how prevalent these kinds of shenanigans really are. I think they are more costly than inefficient government.

The private sector is more efficient at extracting a profit. That doesn't mean they will be better at providing a service, however.

It's incredibly costly, and I think it's also incredibly costly in difficult to measure ways. The main method that the average American (read as: not incredibly wealthy person who has lawyers retained) uses to deal with the early stages of this pipeline is engaging in interminably long phone calls, going back and forth between multiple stakeholders, and trying to negotiate as to what actually needs to be paid or done individually. The incentives are aligned for various members of this process to make it a complicated and frustrating experience for customers, because they often benefit from increasing friction for the insured party. I think if you measured working hours lost or impacted by this it would be startlingly high.

The government does it too.

Pretty much every 4+ figure civil violation, fine, etc, etc, is assessed on the basis of "what's the most we can get away with that won't have them taking us to court where it'll get knocked down or cause a public outcry if they tell the news"

Having to settle because court cases take too long to resolve is due to inefficient government.

Not only does the actual court case and appeals process take years, but even after you “win”, the collection process takes years after it has already been determined who owes what.

See Alex Jones for a ridiculous example. He should have been homeless and shirtless a long time ago.

While you're not wrong that most "justice" processes are expensive, I think the parent-poster is referring to a different kind of "government inefficiency", things like:

1. Single-payer health insurance.

2. Laws that insurance-companies must actually use X% of their premiums on payouts.

3. Laws requiring disclosure of negotiated prices, to encourage competition via free-market forces.

We are self-employed in the US and buy our own high deductible plan on our state's marketplace. One of my family members needed a fairly routine planned surgery, so I went through the effort to try to determine in advance how much I would be billed. What a waste of time. My favorite was the hospital who told me the fee for a one night stay would be 73k. But, good news! Your insurance has a contracted discount that brings it down to 13k. So what does the 73k price even mean? At this point I shelved the effort as I correctly concluded we would hit our household max out of pocket for the year, so anything above that would not affect us.

And hey! Silver lining: in a year when we max the out of pocket limit, no more cost-sharing on any other services for that calendar year! Time to pack in some care we have been deferring mostly due to cost. Except the care providers and insurance company are well aware of this, so they don't bill you for up to a year from the date of service, so you can't be sure you "hit your max" until the subsequent year.

It is enough to induce strong negative emotions.

The “full” prices are basically just made up. If this was like the insurance company negotiates a 15% discount than OK. But the reality is crazy stuff like the “full price” is $7,623 but “your insurance company paid” $34.12. It’s totally bonkers and should be illegal.

The Surgery Center of Oklahoma publishes all their prices, and do not take insurance:

https://surgerycenterok.com/surgery-prices/

They're the pioneer, but there are other clinics like that.

What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).

The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."

That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.

Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)

Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.

That's basically the way all medical billing to private and government insurance providers in this country works.

"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.

I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.

> What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

Interestingly enough, the FBI considers double billing and phantom billing by medical providers, to be fraud.

https://www.fbi.gov/investigate/white-collar-crime/health-ca...

Yes. Though I think technically none of that happened here.

If I sound like I'm defending the morality of the hospital for billing a private individual $190k for services they'd expect to be paid $37k for, please know that I'm not. But it helps to understand WHY the hospital billed that much, and whether it's legal for the hospital to bill that much.

The biggest semantic "mistake" the author makes in their thread is saying, "Claude figured out that the biggest rule for Medicare was that one of the codes meant all other procedures and supplies during the encounter were unbillable."

The Medicare rule does not make those codes "unbillable" - it makes them unreimburseable.

The hospital can both bill Medicare for a bigger procedure code, and the individual components of that procedure, but Medicare is gonna say, "Thanks for the bill, you're only entitled to be paid for the bigger procedure code, not the stuff in there."

Neither the FBI nor Medicare is gonna go after the hospital for submitting covered procedure codes and individual codes that are unreimbursable under those procedure codes. That's not crime, that's just medical billing.

Actual double billing would occur if, say, your insurnace paid the hospital for a procedure, and then they came after you for more money, or billed a secondary insurance for the same procedure. Or if they'd said, "Oh no, the OP's brother in law wasn't here for just 4-hours, they were here overnight so now we're billing for that as well."

NOW - a much better way for the hospital to handle this scenario would be to see that the patient is cash-pay, and then have separate cash-pay rates that they get billed that essentially mirror Medicare reimbursement. That's essentially what the author got them to do, and it absolutely sucks that's what he had to do.

And yet Florida elected a Senator who earned over $100M doing just that.

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

I briefly worked in adjacent space. While I hate the way it works, it makes a lot more sense when you understand that the billed amount is essentially just a negotiation tactic that represents a price well above what they ever expect to be paid (and a bit added to that for safety).

Then, they negotiate with all of the in-network providers for some number that’s well below the billed amount. That number varies a bit based on how effective various negotiations are.

Realistically, OP simply found the number that insurance was going to pay out anyways.

I think the argument is that it’s criminal to take advantage of the patient without insurance and ask them to ruin their life trying to come up with 195k when your system is setup to reasonably profit off the 37k you get from the insured patients. I firmly believe that even in a capitalist society the idea of profiting off of anything let alone healthcare in the thousands of percentage points is criminal.

I think he meant literally criminal.

The hospital double billed for over $100k worth of services on the original invoice.

At a certain point a pattern of issuing inaccurate invoices crosses the line into negligence.

If a business just have a habit of blasting out invoices that bill for services never received, and they know that they keep doing this, and only correct it when the customer points it out, at a certain point it turns into a crime.

From a quick Google query, it says that ~%90 of Americans have health insurance (which seems higher to me than I'd expected). I'd be very interested in knowing the number of uninsured, negligent/nefarious, and exorbitant invoices that are issued as a percentage of all invoices, for the purpose of determining the scale of criminality with respect to your description.

double charging on purpose systematically sounds slightly criminal to me

Exactly. You can do this with anything where the racket is based around the layman not being able to take in the amount of arcane subject matter info they'd need to argue their case, not just medical.

Tons of institutions that specialize in screwing people are built this way because it's pretty hard to "overtly" build an institution to screw people.

This! People underestimate the extent to which lawyers are negotiable also. “I’m not paying that” is a surprisingly effective method; they’re often willing to compromise on payment terms, work at-risk subject to a successful outcome, significantly reduce their rates, etc.

In my experience, most people underestimate what's negotiable across the board. Especially those making enough to do most of their business with mass-market operations, like big-box stores and retail service providers, that profit by doing many, many standardized transactions every day, with minimal discretion or even personal involvement.

Below that, lots of haggling and informal trade often help people get by. The costs of that process can be another burden on the poor. At the high end, it's worth involving people with discretion on the sell side. Additionally, sales are often one-off and customized. They may also bundle a bunch of different items and benefits without clear line-item breakdowns.

When hiring a lawyer, I'd nearly always recommend getting terms down in a written and signed engagement letter before work starts. That is very much a negotiation, but it's fine to ask questions and comparison shop.

If you're starting with a call, it's perfectly normal to start by asking whether initial consultation will be billed or not. If it will be, ask the rate. If it won't be, expect some limits on what can be discussed. The best lawyers I know aren't cheap or easily tricked into giving free advice on consultation calls with speedrunners, but they are up-front about what they charge for and how.

Disclosure: Am lawyer. Negotiate professionally.

Not just arcane subject matter, but numbers so high any sane person panics.

Hospital: "Here's your bill for $1,000,000." (a figure which is 100% fictional) Patient: <panic> "Oh shit, I don't have $1,000,000!" Hospital: "Oh, we'll reduce it to $30,000. Aren't we nice!" Patient: <slightly less panic> "I don't have $30,000 either, but it might not bankrupt me immediately, so I guess that'll do..."

Never mind that the same procedure in most of the EU was either "free" (to consumer at time of care) or a fraction of the cost.

The whole system is fucked.

In the EU you can also generally look up the cost, even in cases where the patient doesn't pay, there is a bill and fixed costs. The costs are what the government pays or what a foreigner with no medical coverage and insurance would pay. It's also generally a tiny fraction of the cost in the US.

> it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

Im increasingly of the opinion that AI gives people more confidence than insight. The author probably could have just thought of the same or similar things to assert to the hospital and gotten the same result. However, he wouldn't have necessarily though his assertions would be convincing, since he has no idea whats going on. AI doesn't either, but it seems like it does.

I've found LLMs helpful for figuring out what I don't know, then I can go and look up how those things work, again together with an LLM.

But in the past, once I got to the point where I know I could maybe do something about it, but not exactly what, and I don't know any of the domain words used, you got pretty much stuck unless you asked other people, either locally or on the internet.

At least now I can explore what I don't know, and decide if it's relevant or not. It's really helpful when diving into new topics, because it gives you a starting point.

I would never send something to a real human that a LLM composed without me, I still want to write and decide everything 100% myself, but I use more LLMs as a powerful search engine where you can put synonyms or questions and get somewhat fine answers from it.

Absolutely. It's cheap (as far as the user is concerned) to just fire off a question. And it can even be really fuzzy/ambiguous/ill-defined sometimes. It's a great starting point.

"But fight with knowledge. My $20/month subscription to Claude more than paid for itself. Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right. I also had ChatGPT, to which I subscribed for one month just to do this, read the letter and fact check it. No notes."

> The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

This will always happen, especially if you don't have health insurance. I had to have surgery without insurance in the early 2000s, and I was able to knock off a large percentage of the bill (don't remember how much, it's been decades) by literally just writing back to the hospital and asking them to double check and verify the line items I was being charged.

(edit: more stories along similar lines in this thread: https://news.ycombinator.com/item?id=45735136)

Totally agree that even this buggy expert can empower patients.

But you better believe that hospitals all over the place are also using AI to find ways around Medicare/Insurance rules to maximize their profit too.

The rules are probably going to get WAY more complex because they will rely less on a few humans, and more on very powerful AIs.

Old poker adage: "The more wild cards and crazy rules, the greater the expert's advantage."

Poker has nothing on Commercial Lawfare.

This reflects a common complaint in social engineering.

People keep trying to enact rules to stick it to the elites and make the downtrodden better off.

And as the rules get more and more complex, the position of the elites gets more and more solid.

Adding complexity is just one aspect. Everywhere there is someone whose job is to ensure the bottom line never changes and status quo for the powerful is preserved. Insurance, taxes, rents.. in the absence of effective regulation, the average number of successful appeals will simply get factored in and average costs go up so that profit stays the same and grows at the same rate as before. Similar to how chains factor in losses due to spoilage or theft.. of course they don't actually take a profit loss, they just price it in.

I really don't get people who see this kind of thing as empowering because in the end your (now strictly necessary) appeal with lawyers or AI to get a more fair deal just becomes a new tax on your time/money; you are worse off than before. A good capitalist will notice these dynamics, and invest in AI once it's as required for life as healthcare is, and then work on driving up the costs of AI. Big win for someone but not the downtrodden.

Exactly. The elites hire experts to do it for them, while everybody else has to deal with the complex rules themselves.

It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.

>It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.

The IRS disagrees every single year.

They say they can easily recover significant revenue from tax cheats if they were staffed and funded enough, to the point that every dollar you fund the IRS recovers 1.6 dollars.

The rich people who say they are just getting their fair deductions then refuse to fund the IRS.

If they weren't cheating, they wouldn't have to kneecap the IRS.

I suppose a saving grace there is that Medicare is incentivized to help people or at least not incentivized to provide the minimum amount of value for maximum profit.

Lol. Who do you think makes the Medicare rules?

CMS?

So what you're saying is we've injected a whole smorgasbord of electrical dumbasses into a system already rife with corruption, greed and exploitation that provides services no person can do without and is frustrating to use at every juncture.

Yaaaaaaaaaaaaaaaay.

> Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right.

The funniest bit about all this is that this is all just laziness all the way down. People complain about AI-written articles. When the article is written about a human, they fall over themselves to point out potential flaws, like "well it looks like AI hallucinated" and it gets voted to the top. Then it turns out that they themselves did not read the article. Just a damning indictment of the quality of online discourse in year 2025.

>It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

What exactly do you think negotiating is? Real negotiation in business transactions is more often based on agreements around certain facts than emotional manipulation.

I guess I would think that negotiating at least involves communicating with your counter-party. Its role here feels more similar to being a billing consultant. There are plenty of people (and systems) that pass messaging over to the actual AI - which was my expectation from the title and why I noted it didn't happen.

People want so badly that AI won't be useful that I feel like they will diminish everything they do. I also get that they probably feel like it's all hype, but there are plenty of examples of real value that AI brings to the table.

> the hospital came back with a much lower offer.

Yes, because, there is an entire department _dedicated_ to this function. You just call them and say "I can't pay this" and you'll get the same result.

The author mentioned in a reply in threads that most of the fees was Facility Fees. That might be just wrapped up in a code for cardiology sure, but its just profit chasing hospitals because that practice can wildly inflate the cost and billing and that can be fought.

> I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.

I'm a cofounder of Turquoise Health and this is all we do, all day. Our purpose is to make it really easy to know the entire, all-in, upfront cost of a complex healthcare encounter under any insurance plan. You can see upfront bills for many procedures paid by various healthcare plans on our website.

The information posted in the thread is generally correct. Hospitals have fictional list prices and they on average only expect to collect ~30% of that list price from commercial insurance plans. For Medicare patients, they collect around 15%. The amount the user finally settled for was ~15% of the billed amount, so it all checks out.

The reason for fictional list prices (like everything in US healthcare) is historical, but that doesn't make it any more logical. Many hospital insurance contracts are written as "insurer will pay X% of hospital's billed charges for Y treatment" where X% is a number like 30. No one is 'supposed' to pay anywhere near the list price. Yes, this is a terrible way to do things. Yes, there are shenanigans with logging expected price reductions are 'charity' for tax purposes. But there isn't a single bad guy here. The whole system that is a mess on all sides.

Part of the problem is that the US healthcare billing system is incredibly complex. Billing is as granular as possible. It's like paying for a burger at a restaurant by paying for separate line items like the sesame seeds on the bun, the flour in the bun, the employee time to set the bun on the burger, the level of experience of the bun-setter (was it a Dr. Bun Setter or an RN bun setter?), etc. But like the user said, some of these granular charges get rolled up into a fixed rate for the main service.

However, the roll-up rules are different for every insurance contract. So saying the hospital 'billed them twice' is only maybe true. The answer would be different based on the patient's specific insurance plan and how that insurance company negotiated it. Hospitals often have little idea how much they will get paid to do X service before it happens. They just bill the insurance company and see what comes back. When a patient comes in without insurance, they don't know how to estimate the bill since there is no insurance agreement to follow. So they start from the imaginary list prices and send the patient an astronomically high bill, expecting it to be negotiated down. In some areas, there are now laws like 'you can't charge an uninsured patient more than your highest negotiated insurance rate' but these are not universal.

If you find yourself in this situation, there are good charities like 'Dollar For' that can help patients negotiate this bill down for you. We are trying to address this complexity with software and have made a lot of progress, but there is much more to do. The government has legislation (the No Surprises Act) that requires hospitals to provide upfront estimates and enter mediation if the bill varies more than $400 from that amount. But some parts of the law don't have an enforcement date set yet, which we hope changes soon.

I was going to say please use and donate to 'Dollar For' [1] which provides this service, which is likely a better choice for this type of problem than trying DIY.

[1] https://dollarfor.org

EDIT: adding in a link to 'Dollar For'.

Thanks for your insight!

Often with these kinds of things it's not even as much about being specifically accurate as it is about presenting yourself in a way that makes the other party believe that have sufficient understanding of the issue at hand and the escalation paths available that you won't just go away if they don't play ball. That is, make yourself credibly as a Dangerous Professional, in patio11 parlance.

I just did this with a pet insurance bill, and ChatGPT was very helpful. They denied based on the pre-existing condition exclusion even where it was obviously not valid (my dog chipped her tooth severely enough to need a root canal, and they denied because years before when she wasn't covered under the policy, she had chipped the same tooth in a minor, completely cosmetic way).

I was sure they were in the wrong and would've written a demand letter even in the pre-AI days, but ChatGPT helped me articulate it in a way that made me sound vastly more competent than the average consumer threatening a lawsuit. It helped make my language as legally formal as possible, and it gave me specific statutes around what comprises a pre-existing condition in CA as well as case law that placed very high standards on insurers seeking to decline coverage by invoking an exclusion (yes I checked, and they were real cases that said what it thought they said).

Gave them fourteen days to reverse the denial before I filed in small claims court, and on day fourteen got a letter informing me that the claim would be paid in full. It's of basically no cost to them to deny even remotely borderline cases, so you have to make them believe that you will use the court system or whatever other escalation paths there are to impose costs, and LLMs are great for that.

> even access to a potentially buggy and unreliable expert is very helpful

Which is a great description of the American health care industry, even before its involvement with AI in any capacity.

We suddenly woke up in the Kafka-esque purgatory of critical American healthcare billing. We’re in our 50s and had been perfectly healthy, then suddenly we got diagnosed with what will be over $500k in treatment over the next 12 months— and multiple millions for the foreseeable future. We have insurance, but many of the required procedures are “out of network” and there’s no way to tell (we have “the best” insurance, supposedly). Even with insurance it will be at least $50k/yr out of pocket

But the raw numbers like $200k for this poor gentleman’s heart attack or $500k aren’t the most alarming. It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question. Even though one of my providers just recently started offering estimates, those are off by 100-200% , and completely missing for about half of what has been ordered.

We are both very strong accountants, and despite trying to do audits of these services, it’s impossible. There are 3-4 levels of referred services, bundled codes, nested codes, complication / technical / professional codes , exceptional status codes . Providers overbill, double bill. On accident and on purpose. When we call to get it corrected there is no way to make corrections.

You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.

The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.

Supply and demand and finding a better vendor doesn’t work. There are some rare exceptions like elective MRIs – but those aren’t the norm. Nearly every service is something time sensitive or your disease will get significantly worse. Moreover, signing up a new provider has $1000+ in billing and a few hours in paperwork to make the transfer. is it worth saving $500 for one MRI when $250k worth of services are unaccountable?

The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .

The stuff you are describing is what bothers me the most. There is a lot of talk about how we should have a free market system. But there is no real market for patients. Most people can't pick an insurance plan for themselves because the employer picks. Then it's extremely hard to get an estimate for anything. And even if you get an estimate, it's most likely wrong. Then the billing is totally opaque. Insurance and providers constantly make mistakes or lose things.

I went through this with my ex after a surgery. It was totally insane to figure out where the numbers are coming from and basically a full time job.

Even if we don't want to go to single player or similar, I don't understand why it's not at least possible to mandate clear and binding estimates and billing a normal person can understand. And let the market work its magic through competition.

Matt Stoller, a journalist who blogs about monopolies, just wrote all about the pricing issue this week: https://www.thebignewsletter.com/p/monopoly-round-up-obamaca...

America has doubled down on middlemen controlling the prices of medical care and making sure that there is no set price for anything. With the ACA effectively falling apart in the new budget, we do have a chance to move to a different reality, one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries. Instead, we are stuck in a situation where companies get to dictate prices and access to care while we get diminishing returns in health quality and longevity.

I’ll look into it. From what I can tell it’s not a simple hero vs villain story. It feels more like an industrial disaster or the AWS outage where there are like a dozen compounding system failures leading to where we are today.

Medical billing is like a massive centuries-old tenement building with a patchwork of legacy plumbing, electrical , framing, sewage all patched together with decades of duct tape, wood shards, and rusty couplings. But in this case there’s massive incentives to keep it all bodged because each pipe and crevice hides billions of un-audited income.

Matt Stoller is properly described as an insane person who thinks every single problem in the world is caused by monopolies (yes, including whatever random problem you're thinking of now).

His most notable attributes on Twitter are he constantly lies about everything and that he spends all his time promoting Republicans who are clearly not going to implement his anti-monopoly agenda.

I haven't paid a lot of attention to Stoller particularly, but the rest of that line of thinking frequently correlates with also believing that monopolies are exclusively a result of active government regulation, a belief which is naturally attracted to Republican deregulatory rhetoric.

Oh, I don't think that applies. He's part of a movement called "neo-Brandesian" aka "hipster antitrust", which basically thinks government should promote small businesses by explicitly bullying large businesses, and that the customer welfare standard was a cop out to give up on this.

So not only would they be against deregulation (they think painful regulations are good because pain for the sake of it is good), but the previous admin actually tried this with Lina Khan and it didn't really work.

The issue here is Democrats are "mainstream" coded, so all populist politics works by fighting them even when they're trying to do your own policy.

> one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries.

You're missing the part where the Stated and objective goal of popular politicians from one party is not to let that happen.

They don't get elected because someone scheming to control their funding (though that is a proximal cause of Republican candidates getting more extreme: Align with MAGA or get primaried)

They get elected because a huge portion of the USA are divorced from reality and utterly deny said reality. They say "government is less efficient" as we sit on top of this atrocious system, a system where we already have the government version and it's radically cheaper and we could literally just sign up everyone for that, save everyone time, money, and headache, and then improve service quality.

These people deny that nearly all developed countries and lots of undeveloped countries have vastly better healthcare outcomes than the USA, extremely better healthcare access, and pay way way less overall, taxes included.

These people just consume propaganda, and purposely refuse to engage with any clear or obvious evidence that contradicts said propaganda.

i don't really disagree with you, but i do think it is funny given that the single largest policy targeting medical price transparency came from a republican admin.

i'm potentially on board with signing up everyone for medicare, but only if we actually can get voters to vote for the taxes necessary to fund that. i doubt we will be able to given we can't get voters to vote for the taxes necessary to fund existing medicare consumption.

I feel a great deal of sympathy for you. A medical event wiped out my meager life savings - I’m a tad younger but I worked my whole life for much of it just to go “poof” because of exactly what you are describing. I don’t feel I have a hope at retiring anymore and it makes me really depressed.

thank you for saying that and I share your sadness / anger . A lot of people do. It’s not your fault, or ours. Healthcare is a truly evil bureaucracy staffed with some of the most loving and capable people I’ve seen. So I’ve been able to admire the beauty of the situation while remaining angry at “the system”.

1. There are assistances available for low-net-worth and low income individuals. Have you tried those options?

2. Refuse to pay. Medical debt doesn't count against your credit and, based on my own experience, is almost impossible for the other party to collect, except some annoying phone calls.

I make a good living. I have some of the "best" available health insurance. It's just bordering on scam/fraudulent. Not aware of what programs you're talking about other than medi-cal (medicaid). Which I do not qualify for.

As I alluded in another post I do often let debt go to collections. The issue is often not the collections calls, but that your provider will be even more aggressive about demanding up front payment to continue receiving care. Or stop seeing you. I have a rare neuro muscular disease that only a handful of doctors are even very knowledgeable about where I live.

> Not aware of what programs you're talking about other than medi-cal (medicaid)

I was talking about individual hospital programs. They typically have those programs as part of whatever hospital system that is.

Something like this:

https://www.adventisthealthcare.com/patients-visitors/billin...

But you would probably not qualify for something like this due to income. I happened to have a minor accident while unemployed (<$10k income that year) about 10 years ago, and the hospital financial aid forgave most of the cost.

I am sorry to hear that. A friend of mine who moved from US to Canada moved after his mother had cancer on her 60s. She was retired by then after having a very successful career (C level on some manufacture company).

His mom died poor.

Crazy country.

It's probably unsaid that she died with a good credit rating as well.

You don't necessarily need to pay back those loans, and most of the time the hospital has to negotiate a feasible repayment plan.

Medical bills have to lowest life-improvement rating of them all. That is to say paying off someones medical bills will have one of the lowest impacts to their lives compared to another financial intervention.

We had felt invulnerable until we weren’t. I’m sorry about your friend’s mom it’s vile and even more infuriating that there’s no clear “villain”. But you reach a point where you focus on what you have. Good doctors, admirable and compassionate nurses , loving and supportive family. The money is toilet paper really – we conceded that a long time ago. Make the most of it while you can but you can’t hold onto too tightly.

> Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question.

> You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000

I feel this in my bones and it makes me irrationally (or maybe it's rational actually) angry. Find me any other industry where you can get away with not telling how much something will cost (or even a realistic range) before services are rendered.

I had a medical procedure a year or so ago and when I asked how much it would cost I got an eye roll, a lengthy and exasperated lecture, and in the end the number they quoted was wildly different. I knew I was going to hit my out-of-pocket maximum so I gave up after a while and moved on but it makes me so mad. I _wish_ I could "vote with my wallet" but good luck doing that unless you have unlimited time and energy. By the time I finally got to asking about the price I had been through multiple appointments that took forever to schedule, were weeks or months in the future, all while I needed relief. After being strung along for 6 months I gave up and rolled the dice even though I disliked how they treated me when I asked for the price.

People talk about how you need to be an informed customer but I have to assume those people are lying snakes, have never used the system, or just too stupid to understand that it's impossible.

"I don't know" should _not_ be a valid answer when asking how much something costs, it's ridiculous.

That’s exactly what we experienced. There is no way to be an informed customer or “vote with your wallet”. For many diagnostics and services, the “provider” is 2 referrals downstream – the patient never elects or engages with them.

Plus, your life is on the line. If they don’t run the test, it means the wrong treatment and your prognosis goes from 80% survival to 80% mortality

> I got an eye roll, a lengthy and exasperated lecture...

This is the part that is galling to me. Apparently no healthcare worker I've ever spoken with about billing has ever had the same considerations I do re: finances. My inquiries have almost always been met with zero empathy and contempt that I would even be so gauche as to ask.

(It's 1000x worse when you're talking to them about your child's medical care. My daughter, at 3 y/o, had a short fall and received a small cut on her face. It bled profusely so we took her to the ER. We ended up with x-rays because I couldn't successful "negotiate" that we didn't want that. The shaming was intense.)

I share the exasperation about the lack of empathy. I know these providers are humans and would ask the same questions. They probably negotiated their car, housekeeper over a few hundred dollars. But when I ask about $10k here or there for critical care suddenly I’m greedy or unrealistic?

A family member had a procedure a few years ago. Provider told the patient that they had contacted their insurer and received confirmation it would be covered. Went ahead with the procedure.

Bill arrives and the insurer denies coverage. Provider says "oh well <shrug> you owe us $$$ now".

Since I am the resident argumentative asshole in the family I dig into the situation a bit. After many phone calls I am eventually told that the hospital routinely records all phone calls with insurance companies and furthermore has found the recording where they gave advance guarantee of coverage for the procedure.

At this point I realized we are being shaken down by a corrupt/criminal enterprise. Even with the recorded phone call the insurer refused to pay and so the patient had to pay off the $$$ over many months.

Similar situation with me and a procedure back in 2014. Practice took me on with my pre-ACA insurance. Post-procedure my insurer decided it was a pre-existing condition and didn't cover the procedure. For the practitioner, who went into the deal expecting the reimbursement rate from my insurer, it was a 10X windfall (and he refused to negotiate, citing that he was within his rights to demand the full fee).

Last time I had blood work done, my doctor and I decided on a set of cholesterol related markers beyond your typical cholesterol assay.

It took me a week and hours of phone calls to figure out what would be covered, and how much the non-covered tests would cost. The doctor pointed at the lab, the lab pointed at insurance, insurance pointed at the doctor.

Finally it was the lab that was able to produce numbers.

And when I was finally billed those numbers were still incorrect! (and thankfully cheaper)

It’s just so insane that the entire industry accepts that no one knows how much things are. Even the “financial services” team will just say “yeah that estimate is wrong” and not blush. What are you guys all doing?

But then somehow they know how much things are when they send you the bill?

my exact curiosity. They seem to have a rough scope on CPT codes ahead of time, with some buffer. It's baffling that the cost per CPT changes between estimate and billing. Id like to talk to a billing administrator to ask how that process works. Does the admin pad the doctor's figures with additional codes and markup?

> And we all just accept the bills and pay them.

I got a bill for $250,000. Uninsured at the time. I have refused to pay it (due to inability), consequences to my credit be darned.

I recommend making a good faith effort to negotiate and start a payment plan (reading the fine print on the overall commitment). But bankruptcy is a viable option if you don’t have a ton of assets at risk.

From other comments, it sounds like you could rescue your credit by simply telling them you can't, but you'd like to pay something more reasonable.

Aren't medical debts not supposed to be on your credit score?

Yes, it is a huge mess. For patients who do have health insurance it's worth checking your health plan's online cost estimator tool before any elective treatments. Most payers are now legally required to offer an estimator to members under federal cost transparency rules. It can be confusing to know what to search for but at least worth a try for something like an MRI.

in every single case those estimates have been wrong. In most cases by 200% or more. And a many case there are no figures.

> We have insurance, but many of the required procedures are “out of network” and there’s no way to tell (we have “the best” insurance, supposedly). Even with insurance it will be at least $50k/yr out of pocket

I can see them being out of network this year, but can't you change insurance in the following year to one where it will be in network?

There are two “provider networks” in our region: BCBS & The United Healthcare network. BCBS is supposed to be better. Were we to switch, let’s say they did cover the 1/10 out of network cases, we risk losing the 9/10 that we currently have . The “whack a mole” is a good example. In this case it’s whack a mole and one could be $50-$100k worth of coverage gone. And more importantly, when you find a good doctor, you need to hold onto them. The difference between a good doctor and a bad one is life or death for this condition.

Ouch.

Is this a somewhat remote location? With all the insurance options I've had from work, the "in-network overlap" was something like 90-95%. People didn't change insurance to get access to providers - it was mostly a better rate, etc.

So there’s nuance to this. We live near Portland —- great provider & insurance networks.

The common perception of “providers” and “network coverage” are the frontline doctors you visit.

But in this case, and what is common, is that there are many degrees of providers. Your doctor refers to pathologist refers to lab 1 refers to lab 2.

So 95% doesn’t tell you much. If only 1-2 of your providers are out of network (e.g. specialized labs ) , that’s $10k+ right there.

Does that

- turn into whackamole every year?

- expose someone to "preexisting conditions aren't covered" issues?

I can’t help but think there is a huge opportunity here for a health care provider that provides routines scans and such with fixed transparent pricing.

You’re right and there are some provider segments like MRIs that have succeeded with this model.

From our perspective the real blocker is the “lock in” due to timing and the referral process. We’re paying bills to providers like specialized labs that are 2-3 degrees down the chain from our doctor (e.g. radiologist refers pathologist refers lab1 refers lab2 – we only see radiologist) .

Even if there was a “amazon for labs” we wouldn’t be able to order this stuff because the decision is 2 degrees away.

Fun fact is that most such obvious innovative solutions are prohibited by law. There are many layers of turtles the lowest two are: corrupt politicians and, population that doesn't care about corrupt politicians.

That's bad news. Medical billing in the USA is utterly insane. What really gets me is that if they do list the prices they seem quite reasonable, and then after the fact you get hit with a bill that is 10x or even more of what the listed price was due to all of these factors you mention.

>>It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question.

Here in India when my dad underwent bypass surgery, I checked the bills the breakdown is insane. This how a charge goes, Nurse comes to see you, so she wears a pair of gloves, that gloves is billed. And often something like 10x the price those are available in the regular pharmacy. Each and everything is billed, and you would be surprised just how many things like these can be be billed.

>>You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.

Often some 'visiting doctor' comes to see you. Like in the case of my dad we were billed for a diabetic consultation, despite clearly telling them he wasn't diabetic, even more so, the same doctor came in the day before and had to told the same. We didn't need it. But you will see they bill you like 2000 rupees just for the person to enter the room say 'Hi' and exit.

>>The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .

In these situations most people are so stressed and anxious often people just have no mental bandwidth to fight side battles.

Its really a corrupt system to the core, and I don't see hospitals and doctors giving all this up anytime soon. Or even ever.

For such sums, you're probably better off calling the best private hospitals in France, UK, Germany, whatever, taking the trip, doing whatever treatment there and paying out of pocket, having some holiday, and you're still ahead.

Of course that would only work if you can take the time off from work, have the same treatment available elsewhere, and being able to actually travel with whatever illness you have.

you’re right it’s a great idea for a hip replacement and many other procedures. Our condition doesn’t fit into that model well because of the duration and frequency of treatments.

I’m guessing there has to be a queue on that. Even those countries must be getting backlogged right? I haven’t looked into it besides what I’ve heard on social media.

our healthcare system is so fucked up, someone needs to burn it to the ground and start over.

Phase 1 is well underway, no worries

I had an odd but successful experience with medical billing recently. My daughter went to urgent care for an urgent problem; after things were mostly cleared up, they transferred her by ambulance to an ER (even though there was no emergency). Both the urgent care and ER were handled by our insurance but the ambulance company sent us a large bill ($4K for a short drive) which felt too large to us (they had already tried to get my insurance to pay, but insurance said it wasn't covered). My wife was going to call the ambulance company to try to negotiate it down, but I recalled that I had recently received a random piece of mail saying that my employer subscribed to a service that could negotiate medical bills.

We contacted the service and provided our info (the context of the situation, the billing information, the actions we'd taken so far, etc) and a couple weeks later, the service reported that they had converted the ambulance ride from an uncovered insurance to covered by insurance (since the transport was between a covered urgent care to a covered EHR) and had our insurance cover the majority- we ended up paying $500 to the ambulance company.

While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.

If there is anything that will bankrupt the US, it's excessive medical charges and a lack of knowledge of how to address them. Maybe AI will help, but I really doubt it long term.

I hear you that you didn't have to pay something crazy but the fact that you ultimately paid $500 for a short ride and you think it was "successful experience" is how they fool us. You think you got a deal when they are still laughing all the way to the bank for charging you $500 for a short ride.

I don't know, I don't run an ambulance company- what should the cost be (either to me, my insurance company, or to the government)? Can't be cheap to fully staff an ambulance with EMTs.

Zero to you. Whatever it reasonably costs to government. A bit from you later in tax, but much more from Bezos.

What's "short" in your context? 20min?

Yes, but I'm talking about the costs of actually running a 24/7 emergency vehicle operation- even completely idle, the emergency vehicle has significant costs that they need to cover.

> had an odd but successful experience

> we ended up paying $500 to the ambulance company

I get where you’re coming from but that’s still a loss to me from the perspective of the broken system.

as long as we have a significant portion of healthcare users who are basically fully price insensitive but not subject to any rationing, absurd US medical costs will continue.

Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.

You should see some of the proposed rules. Pre-authorization will start to use a medical language called CQL and there will be literally thousands of queries EHRs will need to implement to ensure their customers can get the care they need.

> Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.

If you want to see true rationing, look to the UK (especially) or Canada (less so) where I know plenty of people who have to wait over a year to see a specialist even after doctor referral.

Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.

> Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.

I live in U.S. and know people on ACA Marketplace plans, employer HDHP, Medicaid, Medicare, Medicare Advantage, people who are uninsured, people who are overinsured, and people who have crazy expensive fly-me-out-of-the-jungle emergency plans (one who actually used it in the U.S.).

I have never heard any of them get an MRI or CT scan same day "just in case." And for the one who got an MRI close to same day for stroke symptoms, it wasn't free. (And even in that case, the earliest appointment with the specialist to assess the MRI was nearly a month later.)

Someone getting their first colonoscopy had an appointment two months out.

Someone getting shoulder surgery four months out.

A person on Medicaid with Stage 4 cancer waiting a week and a half for a fentanyl patch because the pharmacy couldn't get approval from the Medicaid subcontractor for whatever reason.

People from the U.S. who post on HN: please tell HN which is more common:

* my stories

* your parents getting free MRIs and CT scans "just in case"

First, I didn't say same day and specifically caveated for the MRI. That said, the CT was either same-day or next-day, I forget which. It was for hyponatremia and was in the Washington, DC region.

My primary point was comparative - wait times are considerably longer for the NHS than in the US.

> My primary point was comparative - wait times are considerably longer for the NHS than in the US.

So we're talking about a situation where a doctor thought a patient required an MRI-- using your word-- "immediately."

In the NHS when a doctor requests a patient get an immediate MRI, what are you claiming is the average wait time?

Edit: clarification

Fun fact:

In the UK, you can pay more (say 30%-40% the cost of a US health insurance plan), get treated like royalty in private care, skip all the lines for specialists, still be covered by the NHS to pay 0 for anything catastrophic, and still never get a bill in the mail from anyone.

It's not an either/or situation. The US has the least efficient healthcare system of any country in the world. It provides less treatment per dollar than anywhere else. You can provide universal basic coverage and still provide luxury insurance plans.

True of the UK, not true of Canada (where providing services covered by the public sector is illegal AFAIU). I think this is exactly the sort of model to move to, price sensitivity for routine care - government insurance and forced saving for the catastrophic. Healthcare should be entirely untied from jobs.

US healthcare is a mess and I'm not defending the cost - but it does have the highest number of top specialists in the world & strong R&D.

I waited over three years to get a routine colonoscopy in New Mexico and finally just got one after moving out of state. More standard waits for a specialist there are 9-18 months, if you can even find someone competent in the specialty. Many people have to go out of state for care.

Provider availability is non-uniform across the US.

thanks for that datapoint and that is crazy. were you in a rural area?

In the middle of Albuquerque. Rural areas offer hardship pay to attract medical professionals, but it’s really touch and go. IHS has its own host of issues.

In the US care like that is rationed by wealth rather than by need. Your parents are getting MRI scans that they may not really need, while uninsured Americans aren't getting MRI scans that they may actually need.

I bet we could cut down NHS waiting lists a fair bit if we arbitrarily decided that ~10% of the population were no longer entitled to a wide range of non-emergency treatments.

This is true to an extent, but with the massive age-based confounder that is medicare, which renders the elderly close to price insensitive as well as by far the largest utilizers.

I think there are lessons to learn and improvements from both systems - for instance, catastrophic healthcare is a disaster in the US (in terms of cost), but we are better at timely care and providing incentives for pharma R&D.

Medicare has pretty good negotiating power, rather like the NHS. Medicare patients may not care how much Medicare is paying for their treatment, but the US government cares how much it spends on Medicare, and the IRA has given it some additional powers to negotiate drug prices in recent years.

Imagine if the U.S. government gave out free smartphones to some segment of the population. Over the years, they’d get used to replacing their phones for the smallest reason — a scratch, a tiny crack, dropped it a little hard — because it costs them nothing. Some might even start swapping phones every month or every week.

“Ah,” someone says, “but the government negotiates huge discounts with the phone makers since it buys in bulk!” I think this misses the forest for the trees when it comes to cost control.

We don’t have to imagine how Medicare works because it exists, so I don’t see the use of such analogies.

I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.

My analogy is not with socialized healthcare but with the medicare scheme. Socialized healthcare works in lots of other countries due to a combination of rationing and (in the case of drug prices) prioritizing accessibility over R&D.

> I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.

Doctors would recommend fewer tests if their patients were more price sensitive, I think. I'm not sure a more direct route to making doctors price sensitive when they are on the provider-side, why would they want you to utilize less? There probably also needs to be malpractice/tort reform in the US.

I edited my post to say Medicare shortly after your reply (sorry). But if there’s evidence that Medicare is especially profligate with unnecessary tests and treatments then you should give that evidence, rather than arguing by strained analogies.

I think that analogies are helpful for elucidating the point but in terms of concrete evidence, there are two gold standard studies that really reveal this issue. These studies are very hard to come by because it is typically difficult (for good reason) politically to experiment with people's healthcare, but we are lucky to have two: the RAND healthcare study and the Oregon medicaid lottery.

My understanding of both of those studies is that (particularly for pre-registered analyses), we saw that adding some sort of cost-sharing substantially reduced utilization of healthcare services (~30%) without any impact on health indicators even multiple decades down the line, with the possible exception of mental health indicators. Nowadays people try to p-hack their way out of these conclusions, but it is pretty strong high-N experimental evidence.

>Imagine if the U.S. government gave out free smartphones to some segment of the population.

Obama phones were literally a thing and

>Over the years, they’d get used to replacing their phones for the smallest reason — a scratch, a tiny crack, dropped it a little hard — because it costs them nothing.

Did not happen because this is absurd and not how any entitlement program anywhere has ever worked, and more importantly, in healthcare you WANT THIS TO HAPPEN

It's cheaper for someone to go see their doctor when they "think I might have something wrong" then once they actually know something is wrong, and so substantially cheaper that even US insurance companies try to entice it by making yearly physicals free or other preventative care, but it doesn't work as well for the US because even with insurance incentivizing it, you still end up with all the billing BS that can leave you harmed by going to the doctor

> I think this misses the forest for the trees when it comes to cost control.

Sorry, the actual empirical evidence is that the government setting prices has done better all over the world than whatever the US does. This magic belief that allowing the government to control access magically produces bad systems is just wrong. Government is capable when you vote for people who want to make good government

I live in the US in one of the largest metro areas. I've had to wait nearly a year to see a specialist in the past, and that was with "good" PPO insurance (see my comment history for trying to find a dermatologist for what I thought was potentially skin cancer). Its really not that uncommon to have long waits. I've had insurance deny prior authorizations over and over delaying care many months despite actually meeting their own documented criteria for approving the surgery. My kids have had to wait months to get an important, medically necessary surgery multiple times, because the decent in-network providers are massively booked out.

Comparing getting imaging work done to actually seeing a specialist is comparing apples to oranges. They're both healthcare related things but are massively different.

There's tons of imaging clinics staffed by people who only needed an associates degree from a community college, radiologists work remotely all over the place spending little time on each patient and writing a report. Overall its really cheap and easy to build and staff an imaging location.

Seeing a specialist requires actually going to the doctor in person, that doctor had to spend many many many more years and limited spots for an education, and probably only sees patients in clinic a few days of the week. You'll have a whole staff of nurses & PAs (who quite probably had more education than the rad tech) and office staff to support the small handful of specialists.

As a personal example, I had an issue with my knee, locking up from time to time bending with weight on it. I looked up kinesologists in my area covered under my insurance. Dozens within a short drive, awesome. Calling up, "sorry, we're not taking new patients", "we can see you in four months", etc. A few months go by, I finally get in to see the doctor. He has me do some motions, asks me a lot of questions, takes a quick x-ray in the clinic, recommends I go get an MRI and come back. I am able to find an MRI clinic that's covered and can get the imaging done that same day. However, its several more weeks until I can see the doctor again to actually review the radiologists notes. I finally go back, the doctor recommends surgery, a prior authorization gets filed. We wait. We wait. Denial, no MRI, imaging required to determine medical necessity. Huh, they paid the bill, didn't they wonder what the MRI said? Resubmit. We wait. Denial, MRI was inconclusive (it wasn't). Resubmit. We wait. Denial, physical therapy is recommended instead (except the thing they call out as a reason to have surgery is verbatim what the radiologist notes say). Resubmit. We wait. Denial, same response. Its now been almost a year of intense joint pain every time I crouch down, walking is starting to be difficult. I'm in a brace and crutches and the pain is getting worse. I finally just wait at the clinic all day, we spend hours and hours on the phone with the insurance company to try and get an approval over the phone directly. I finally get approval, and manage to get in for surgery several weeks later. I have the surgery in the morning, and I'm back to walking without any pain and without crutches or the brace by lunch.

And in the end, after the surgery, the insurance company complains they shouldn't have covered the procedure because supposedly I didn't have an MRI of that knee. Idiots.

This is just one of several shitty stories I have of dealing with health insurance companies. Multiple over the years.

And that's on the insurance side, not even the care side of things! One time, while waiting multiple hours in an ER complaining about becoming massively lightheaded and weak and barely able to sit, I finally passed out and fell on the floor out of my seat. The shock of hitting the floor woke me up a bit, and the first thing I heard was "sir, you're not allowed to lay on the floor, stand up." Uh, I would if I could!

All in all it took over a year of joint pain before I managed to get surgery to fix my knee, all because the insurance company was rationing care. A year I won't have playing with my toddler at the time (I couldn't easily crouch down to play and expect to stand back up easily). Arguments of "bUt RaTioNinG!" ring extremely hollow to my ears. We already have rationing in America, you just haven't experienced it yet.

>While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.

100 years ago I used to work for the fruit company in phone support.

My KPI's were 100% customer satisfaction. However, I needed to get approval from another team to advance any kind of free/gratis repairs replacements or gifts.

That team's KPIs were opaque to me, but my understanding is that they were find as long as they offered some resistance.

Between those two pillars we got a lot of good done for customers. I dont think theres anything necessarily wrong with having internal friction like that if its designed correctly. Its probably better than having both responsibilities in a single person.

In terms of health insurance however it seems ghoulish.

Whats the service that negotiates medical bills?

> we ended up paying $500 to the ambulance company.

I'm sure people from first world countries would be stunned by this number. And that makes it even sadder.

> Maybe AI will help, but I really doubt it long term.

I'm guessing it will help up until the point where hospitals start using AI for this process.

The idea of an injured patient having to pay at all for an emergency ambulance ride to a hospital should stun any normal human being living in a civilized society.

Then who pays? If your argument is that we should socialize the cost of that ambulance ride across all Americans, they won’t go for that. Americans don’t want more taxes, but more importantly, Americans deeply mistrust their fellow citizens, and don’t want to feel like they’re paying for someone else’s life decisions.

America doesn’t have the same kind of social cohesion as most countries. We’re a nation of individualists. The general feeling here (rightly or wrongly) is that healthcare costs are largely driven by your choices in life, and Americans don’t want to feel like they’re on the hook for other people’s bad choices.

> Long story short, the hospital made up its own rules, its own prices, and figured it could just grab money from unsophisticated people

This is the core truth that all of healthcare in the US spins out from. A few personal experiences which back this up:

1. I received a $1500 bill because an ambulance that was sent when I called 911 was an "out of network ambulance". I looked it up: One small ambulance company in SF is in-network with that insurer. The SFFD runs the vast majority of ambulances and is "out of network." Insurance companies of course are not allowed to penalize you for accepting the first ambulance that arrives in an emergency. I filed a formal complaint with the California regulator that regulates that insurer and within 2 weeks the bill had been properly taken care of.

2. Our family has met its family Out of Pocket Maximum this year. Twice in the past month I've had doctor's offices lie to me and say that we still have to pay a copay. The last one claimed "well, you still have to meet your individual one though." Lie. That's literally the opposite of the way it works. We've paid copays to these people accidentally in previous years and they would never give the money back, they just keep it and also double dip since insurance pays them anyway.

In all cases, both hospitals and insurance companies simply ask for the maximum possible thing they can ask for, knowing that a frightening majority of people are afraid of them, and will pay whatever they're told. In OP's case, an unsophisticated payer would have gotten a $195k bill, been sent to collections, the hospital would have sold the bad debt, and then the person would have maybe "gotten a good deal" by getting it cut down to $50k over many years of high-interest payments and having ruined credit.

Insurance and hospitals are both filthy, money-grubbing machines. To paraphrase a famous cartoon character, their business is bad and they should feel bad.

I find it curious that people are celebrating when they manage to not pay (part of) an absurdly wrong bill that can only be either the result of gross incompetence or- much more probably- an attempt at fraud. The actual happy ending of such a story would be that the healthcare provider is sued for damages and/ or attempted fraud, and has to pay back a large multiple of what has asked.

Can you elaborate a little on point 1? I also somewhat recently had an expensive ambulance ride in SF that I'm dealing with - Insurance told me it was out of network, but would negotiate down on my behalf. They were able to negotiate away most of the bill, but since then the ambulance company has just come back to me asking for all of the money that the insurance company had told me they negotiated out of the bill.

I'm always happy to help people stick it to crooks. Here's what I know:

The California Department of Insurance may be the regulator for your health insurer, but it may not be. If not, it's the Department of Managed Health Care. You should be able to find a reference to who their regulator is in their plan documents.

# DOI:

complaints start here: https://www.insurance.ca.gov/01-consumers/110-health/50-h-rf...

list of who they regulate here: https://www.insurance.ca.gov/01-consumers/110-health/20-look...

# CDMHC:

complaints start here: https://www.dmhc.ca.gov/FileaComplaint.aspx

list of who they regulate here: https://wpso.dmhc.ca.gov/hpsearch/viewall.aspx

My original ambulance thing was with an insurer regulated by DOI. Much more recently than my original story, I went to file with CDMHC, which requires that you first file a formal grievance with your health insurer first. I would definitely recommend to file a grievance. In my case, I filed a grievance and also contacted the office of the CEO, who emailed back and miraculously made another made-up problem go away even faster than the grievance process did.

But anyway, yours is an interesting case here. I can't be sure if the insurer is the one who screwed up here, also the ambulance company may not be allowed to balance bill you. The only thing I'm pretty sure of is that you shouldn't be responsible for more than an in-network ambulance would cost you, presuming you didn't just take an ambulance in a non-emergency, just for fun (as they seem to always assume).

Surprise ambulance bills are mostly (but not completely) illegal in California as of Jan 1 2024. Ask the LLM of your choice about AB 716 and whether it applies to your situation (it likely but not certainly does). Have the LLM draft a letter and send the physical letter to the ambulance company. If they are bothering you, request they only contact you by US mail.

I'm too european for this.

I was hospitalized about two decades ago, before ACA passed, so my insurance was limited to 500k, I was on the hook for about 180k beyond that... because I was making decent income I was ineligible for Medicaid or any other assistance... I worked extra jobs for a number of years after, every tax return, the couple bonuses that I'd earned all went towards paying it down... Anyone who was willing to negotiate the amount or take reasonable payments got paid... the rest could wait... after the 7 years before it was no longer eligible for being on my credit statement, I stopped (still owed about 40k iirc).

The past few years, I've been receiving some very expensive treatments for my eyes... given the job market, I've been without and switched jobs a couple times... been caught with a few unexpected bills for around $15k... it just sucks. I'm currently making about 2/3 of what I was a couple years ago, with no better job prospects, the insurance I have is "emergency" based and doesn't cover my regular doctor bills... I'm at my max at this point, thinking about bankruptcy for a while now.

The system sucks... the billing system(s) suck and the fact that it's as messed up as it is, is so much worse. From monopoly positions, to messed up billing, to everything else... I don't even know. Even on a six figure salary, I cannot afford private insurance and the multiple $300-400 doctor and pharmacy bills each month are seriously destroying me.

And it’s going to get progressively worse for everyone. My rule of thumb is that for every perceived 15% increase in care outcome, cost doubles for patients. This is how drug or procedure costs exploded over the past two decades.

The real treat would be using AI to stop regulatory capture so you don't end up in a country where it's okay to be presented with a 195K bill that can be magically lowered if you insist hard enough.

It seems pretty messed up when a $30k bill is written up like a big win.

Their brother presumably didn't have insurance, and it sounds like some pretty major procedures involving specialists, equipment, and hospital intake. While the outcome was horrible, all of those people need to get paid for the services rendered somehow if we want folks in the US to continue receiving this standard of care.

> Another was a code that was inpatient only and because it was an emergency he had never been admitted.

The threads says this was 4 hours of work and they billed for things that weren't even used.

> While the outcome was horrible, all of those people need to get paid for the services rendered somehow if we want folks in the US to continue receiving this standard of care.

Food for thought:

- this approach produces systemic outcomes that are worse and cost more than other approaches

- there are lots of ways for people to get paid to provide medical care. Medical professionals do not work for free in other countries, and they buy the same equipment and drugs from the same suppliers as Americans do.

- we are allowed to look at how other countries have solved this problem without hitting people with giant medical bills. We are allowed to apply those solutions here.

- the US standard of care is overall not particularly high in the global rankings. We may decide that we don't want to continue providing this standard of care, we may decide we want to be in the top 10 globally.

Except everything in America is ludicrously priced. The cost of supplies and equipment is not even close to being realistic in America vs what you'd be charged for equal care in another country.

$30K NOT counting some expenses (cardiologist, ER docs)???

> Bills were a few thousand here for the cardiologist, another few there for the ER docs, a bit for the radiologist. I helped my sister-in-law negotiate these down but they weren’t back breakers. Then the hospital bill came: $195k. This is a story about that.

To a lot of people, that's out of the fire and into the frying pan.

I think there's more than just regulatory capture at play here, unfortunately. America is an odd place.

I think a public option is the only feasible path forward.

Hospital billing involves the 'mafia'-like influence game of having good insurance (which means being hired at the right company, with the right 'influence' over the hospital network in question) and covering the costs of the other patients who cannot afford it and refuse to pay. Hospital billing has the least teeth of any debt in the US. If you haggle a billing department long enough, they'll desperately take anything you give them.

As someone with medical conditions from a country with universal publicly funded health care, while it may not be flawless (though in terms of actual medical treatment, no complaints either) it sure does seem to be a whole hell of a lot better than the alternative.

Not once have I had a sleepless night since been diagnosed over a decade ago about insurance, co-pay or how to afford my drugs/medical treatment.

I’m on two prescriptions per month, total cost to me is £114 a year (about 150 bucks).

Folks over in the US are getting hosed, twice the per capita with a worse outcome and it costs you a fortune on top personally.

That healthcare is tied to employment is just the insane cherry on top (I’m aware of the historical reasons why that happened but should have been fixed not long after).

Are the outcomes in the US worse? Not that long ago (a couple months ago in fact), I looked at public data comparing cancer survival rates, which put the outcomes in the US at least 10% better than those in the UK. That was additive, such that a 20% survival rate in the UK for a type of cancer is at least a 30% survival rate in the US. The 10%+ better outcome in the US applied to all types of cancers for which I found public data.

I believe the reason for higher US success rates was that the US used more aggressive treatments that the UK would not, since neither does the NHS pay for them nor do their doctors offer them. It is easy to complain about the US system, but the reason that the per capita cost of health care in the US is high could be because the US will try expensive things that the UK’s NHS never would have attempted (since spending exorbitant amounts on aggressive treatments with low chances of success to attain US success rates would drive the per capita cost of medicine to what could be US levels). The high US pricing of those treatments could be further amplified by attempts to take advantage of ignorance. Amplification to take advantage of ignorance was clearly the case in the article author’s case.

I feel like the opposite viewpoint in favor of the US system is not well represented in online discourse, which could very well be because those who were not served well by the UK’s NHS are dead. There are anecdotes about people coming to the US for treatments that they could not receive in the UK or Europe, which is consistent with that.

That said, I have only looked at data for cancer survival rates and not other illnesses, but the cancer data alone contradicts what you wrote. Perhaps reality is in the middle where the UK system is better for routine issues (i.e. you avoid sticker shock), but the US system is better for anything that falls outside of that (i.e. you have a better chance to live). There is evidence both systems have plenty of room for improvement.

You're taking quite a small view of healthcare in the end looking at only cancer outcomes. Just ignoring things like maternal mortality, infant mortality, cardiovascular issues, etc.

You are right, but blanket statements only need one counter example to be shown to be false. I had looked into cancer data because I read some remarks made about cancer between the US and Europe and I was curious if they were true.

For what it is worth, I take a prescription medication for a non-life threatening condition. I had once called Costco in Canada to find out how much the price is there out of curiosity. They do not sell it. I then discovered that the drug my doctor prescribed is exclusive to the US and is not sold anywhere else in the world. Presumably, nobody else is willing to pay the exorbitant price that is charged for it. Even the generic is expensive. The US system is expensive, but it gives people access to more expensive treatments that simply are not available elsewhere.

That said, I might have an elective operation in the future. It would have been covered by insurance as a necessity when I was young, but my parents never pursued it and the underlying condition’s severity decreased when I became an adult such that it is now elective surgery. I expect to engage in medical tourism to have that done.

Look at when all the "No Kings" protests are happening: on the weekend. Because there is no way the vast majority of Americans can go on strike, because healthcare is tied to employment. This is why healthcare is never getting "fixed" in America--it's doing its job quite well.

I’m not sure there is regulatory capture at play necessarily.

I notice regular doctors and dentists do this too. They’ll bill my insurance for extras in case they’ll pay and when insurance says no, the doctor doesn’t bill me either.

Everyone is just trying to suck the most money out of everyone else. It sucks if you’re self-pay because you don’t have the weight of a whole company to do that due diligence for you.

While it's an interesting story, I doubt they needed Claude to work a hospital bill down to that amount. Hospital billing folks are acutely aware that the initial bill is outrageous and indefensible from their end. I've heard a ton of cases where folks basically "pay what they can" for the bill and that's good enough for both parties. I doubt the reasoning Claude provided was ultimately what got the hospital to knock the bill down, probably more around the legal action and PR threats. Ironically, the hospital will probably count this as charity even though OP didn't want to be considered charity, as they had to write off part of the bill.

> While it's an interesting story, I doubt they needed Claude to work a hospital bill down to that amount. Hospital billing folks are acutely aware that the initial bill is outrageous and indefensible from their end.

OP agrees: "Ultimately, my big takeaway is that individuals on self-pay shouldn’t pay any more than an insurance company would pay—and which a hospital would accept as profitable business—than the largest medical payer in the country. I had access to tools that helped me land on that number, but the moral issue is clear. Nobody should pay more out of pocket than Medicare would pay. No one. ... Hospitals know they are the criminals they are and if you properly call them on it they will back down."

> I've heard a ton of cases where folks basically "pay what they can" for the bill and that's good enough for both parties. I doubt the reasoning Claude provided was ultimately what got the hospital to knock the bill down, probably more around the legal action and PR threats. Ironically, the hospital will probably count this as charity even though OP didn't want to be considered charity, as they had to write off part of the bill.

I read that OP refused to sign something that fraudulently said the full price was $195k but rather insisted on signing on a bill that said the full price was $33k or $37k or something. (Maybe $4k was called charity.) They might have presented a completely different bill to the IRS to justify tax-exempt status, but that illegal action would be totally on them; OP is not participating in their tax fraud. I applaud OP for that and hope this becomes the norm.

IMO the pro move is not to get the hospital to accept what an insurance company would pay, but get them to accept slightly more than what a debt collector would pay.

I’m confused why - if this is indeed common practice - it’s not considered fraud on the part of the hospitals?

The hospitals and insurers are locked in a Red Queen Race. The hospital bills for 10x actual market value. The insurer touts they are getting you a 90% discount. The individual who got sick or injured gets crushed in the middle.

I'm getting that most people don't know the sticker price is fraudulent (e.g. the overlapping "master procedure" and component codes) and/or are so relieved to have the charity out that they agree to it without any further questions. But OP points out that the charity out is just further fraud, victimizing tax-payers.

the medical insurance industry and the hospitals do this whole song-and-dance charade where they pretend that they are charitable, public-protecting institutions who serve noble goals of helping sick people.

in truth, they are doing nothing but racketeering.

Where are the class action law suits?

It's insane that somehow a 195k bill can change into a 34k one, without putting serious doubt on the validity of that final bill. How does this work in court? Are they going to claim their 34k bill is all correct while starting at 195k? Or would it be equally plausible if the debtor said "I've not received any of the care billed for, so I'm not paying"

They can't really claim their records are any kind of proof if apparently they now agree that 82% of it was wrong?

> Hospital billing folks are acutely aware that the initial bill is outrageous and indefensible from their end. I've

I'm sure they also have a long arsenal of various legal tricks they bundle into offerings like they did in the linked thread with respect to attempting to relabel it a charitable donation, etc.

How do the hospital determine how much you’re able to pay though. You could say $20k is the max I can afford or $2k is the max

Google and friends has made sure the hospital knows among other things how much you make, your life insurance policy payout, the value of your home, etc.

When UnitedHealthcare CEO was killed the public sentiment was that the health insurance companies are the bad guy—and the CEO deserved what he got. Then when stories like this come out we realize no, it is actually the hospitals. In reality the whole system is broken. Some people think single payer system is the solution but then when they talk to Canadians they realize that's not the solution either.

I think the correct solution is stronger laws for price disclosure, strong penalties for the kinds of abuses mentioned in this thread, and incentives for patients to question every charge.

> Some people think single payer system is the solution but then when they talk to Canadians they realize that's not the solution either.

I don't know a single Canadian who would swap their system for the USA's. Theirs might not be perfect, but nobody argues that it isn't at least better than the literal worst system the world has ever come up with.

Canadian here; our system has some pretty extreme issues. The vast majority of Canadians still prefer it to the U.S. Wealthy Canadians (>$500M net worth) would likely prefer the U.S. system in all cases though. Even moderately wealthy Canadians ($1M+ net worth) would likely get better treatment from the American system 95% of the time (when they don't have extreme issues which result in exceptionally costly treatment)

One thing to consider is that doctors seemingly prefer things about how the U.S. system works (I'm not just talking about the amounts charged, but inefficiencies and red tape in the Canadian system, some of which seem to be a consequence of socialized health care). Ultimately this does lead to some brain drain which then compounds the issues with our system.

>Some people think single payer system is the solution but then when they talk to Canadians they realize that's not the solution either.

I'm sorry but I don't understand this discourse. While we have gripes with the state of some hospitals that fall short of first world standards (e.g. Gatineau Hospital) and wait times for specialists for non-urgent care (it can take 2-3 months to see a dermatologist after referral for non-cancerous skin conditions in Manitoba for example), I really can't think of more than 3 Canadian residents having ever said in my lifetime that they prefer the US system (and for all of them, their objection had to do with the fact that the government funds treatments they don't like for gender dysphoria and abortions, not that they felt the US system was an effective economy of scale).

On top of that, there is a myth perpetuated in the US that we are constantly at the brink of a healthcare system collapse. We are certainly not - there is room for improvement and health inequalities that we must address, but to say that we're all an ER wait away from dying is simply untrue. [1]

I have been on the receiving end of health care inequalities here in Canada (in Manitoba and Quebec), but I don't go as far as to write off the achievement of having set up an effective single payer health system in a federal state.

[1] https://www.npr.org/2020/10/19/925354134/frame-canada

Many Americans desperately want to believe that other countries' healthcare systems are "just as bad" as a form of coping.

The wait time you alluded to is indeed the issue. The issue is not limited to dermatologists.

Then it'll come down to an individualist vs a collectivist take.

Triage priorities in referrals are an acceptable trade-off for broadly improved access to health care. The reality is that my eczema doesn't need to be seen before someone else's melanoma.

While I appreciate being able to see a specialist earlier in the US with my health insurance, I know that many ordinary American citizens aren't able to at all and that my insurance displaces incentives to serve underserved communities. I'm not yet an American citizen so I will not preach what the US should or should not do, but I do think it is unfortunate that is the case and I hope that improves.

They're both the bad guy, but from the sound of it, the insurance companies are worse. They will delay cases and deny claims which result in people dying sooner rather than going through a long, costly, but ultimately life-saving treatment, to save themselves money in the long run.

The alleged shooter was clearly referencing this book which talks about it: https://en.wikipedia.org/wiki/Delay,_Deny,_Defend

I haven't read the book, I'm just recalling what I've read about it.

> health insurance companies are the bad guy

using AI to deny claims to maximize profit seems bad enough to me. More Luigi please.

the canadian system might suck but it's infinitely better than what we have in the USA.

we have a capitalist bastard child of for-profit "insurance" companies who are heavily subsidized (yet are still allowed to profit massively and turn profits over to shareholders) and in cahoots with hospitals who often employ more "billing specialists" and lawyers than they do actual doctors and nurses.

the whole thing is a racket.

For all my constant freak-outs about AI in general, it turned out to be a godsend last year when my wife’s mom was hospitalized (and later passed away a few weeks afterward). Multimodal ChatGPT had just become available on mobile, so being able to feed it photos of her vital sign monitors to figure out what was going on, have it translate what the doctors were telling us in real time, and explain things clearly made an incredible difference. I even used it to interpret legal documents and compare them with what the attorneys were telling us — again, super helpful.

And when the bills started coming in, it helped there too. Hard to say if we actually saved anything — but it certainly didn’t hurt.

Doubters say it's not as accurate or could hallucinate. But the thing about hiring professionals is that you have to blindly trust them because you'd need to have a professional level of knowledge to qualify who is competent.

LLMs are a good way to double check if the service you're getting is about right or steer them onto the right hypothesis when they have some confirmation bias. This assumes that you know how to prompt it with plenty of information and open questions that don't contain leading presuppositions.

An LLM read my wife's blood lab results and found something the doctor was ignoring.

All these things are language parsing and transforming. That's the kind of thing llms are good at.

Having lived in Europe 10 years (I am from south America), it is crazy that the rest of the world doesn't follow Europe's health coverage: everybody is covered, all the time, you can be covered either by public insurance (was my case) or private. There are no preconditions. Kids get covered for almost everything up until they are 18 or 21 (don't remember), drugs for adults is only 5 euro each. No matter the cost. And it just works.

By the way, Private is cheaper when you are younger, gets more expensive when you are older. So if you choose private, under very phew circumstances you can switch to Public.

In the other side, you have the US health care which is probably one of the worst in the world. Crazy.

European healthcare in my experience has capacity issues.

Typically hospitals are overwhelmed by the sheer amount of patients. Waiting times for procedures are incredibly long.

Where the system kind of shines is emergency care and long term illnesses, you go in and they save your life for free.

For any other kind of treatment you are generally better off turning to the private sector in Europe. You are going to have to pay depending on the country the cost might be outrageous but typically you will get access to procedures in days vs months.

Capacity issues are dependent on country. In my country (Netherlands) is it not that bad and you can easily switch Hospitals if there are queues for certain operations (that are not urgent).

> US health care which is probably one of the worst in the world

Not really. If you have money, the US system is one of the best. It just really, really sucks if you don't have money.

US health care outcomes are really not great, even if you are rich. Yes, you live longer than poor people in the US, but still do worse than Europeans, even those with lower incomes [0]. All while spending much more [1]. It's a system designed to siphon money from wherever it can (individuals, governments, companies, etc.), not to provide the best health care.

[0] "in some cases, the wealthiest Americans have survival rates on par with the poorest Europeans in western parts of Europe such as Germany, France and the Netherlands." https://www.brown.edu/news/2025-04-02/wealth-mortality-gap

[1] https://ourworldindata.org/us-life-expectancy-low

Isn't it universally true that if you're rich your life can be much easier? With enough wealth the actual health care system does not matter much. Neither does the country in which health care services are rendered. You just pay and get things done, and maybe even take some vacation while at it. However, given that not every one of us is rich, the point is to optimize the whole thing such that the little folk can still survive and get their health issues addressed.

No that isn't universally true. There's plenty of countries (eg Cuba) with entirely state-run healthcare systems where more money won't get you better care.

What % of the US population would you think have to pay to get that "best" care?

Would a household making $250,000 have enough to pay for that best care? That would mean 2% [1] of US household. Other comment in the thread mentioned earning "6 figures" and not being able to pay.

A health system that is affordable to 2% of the population is definitely not working.

[1] https://www.factcheck.org/2008/04/americans-making-more-than...

Well, everything is great if you have money. I was talking about the health care as a system.

If, as someone with money, you look across systems, the US is one of the best. That's the point I'm making. There's plenty of places where all the money in the world won't buy you the quality of care you can get in the US.

Quality of care available to wealthy people is an important factor in evaluating a system. In the US, there are many millions of wealthy people who the system is great for.

I have money and it still sucks. Perhaps you're thinking of billionaire money?