The American Healthcare Conundrum • Hacker News Board

Re: The American Healthcare Conundrum

#531

Post by realo » Tue, Mar 17, 2026, 5:18 PM UTC

cmiles8 wrote: post #337

TuringNYC wrote: post #327

The problems are so vast it is difficult to even describe to outsiders. For example, if I purchase a particular medication at a local pharmacy, it costs $25. However, my insurer mandates that I purchase it via their Pharmacy Benefit Managers (PBM) Optum, which charges $125. Easy enough right, you price shop? Well then it doesnt count towards your deductible. The whole thing is an elaborate trap to not pay. Sometimes…

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers. When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, the…

"... quality of care in the US is far better ..."

Care starts when you need it, at the ambulance level.

Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later.

So no. Quuality of care in the US is not that good.

Re: The American Healthcare Conundrum

#532

Post by tmountain » Tue, Mar 17, 2026, 5:18 PM UTC

SoftTalker wrote: post #521

TuringNYC wrote: post #327

The problems are so vast it is difficult to even describe to outsiders. For example, if I purchase a particular medication at a local pharmacy, it costs $25. However, my insurer mandates that I purchase it via their Pharmacy Benefit Managers (PBM) Optum, which charges $125. Easy enough right, you price shop? Well then it doesnt count towards your deductible. The whole thing is an elaborate trap to not pay. Sometimes…

If you can pay cash without insurance, then you don't need the insurance. Insurance is (should be) addressing the risk of unexpected expenses that you cannot afford. Not predictable, small expenses that everyone has.

This ignores catastrophic scenarios.

Re: The American Healthcare Conundrum

#533

Post by simojo » Tue, Mar 17, 2026, 5:19 PM UTC

thegrim33 wrote: post #491

Am I completely tripping out or does rexroad's profile use a template where they were supposed to fill in a blank but forgot? "Former [your background if relevant]". Really opens my eyes to all the other politics posting accounts that have a similarly constructed profile description .. But of course, they'll never be banned and instead they get front page of HN and hundreds of upvotes.

What do you see as the bad part of this? That the user is trying to farm points by copying patterns of upvote-winning users, or that there's a flood of inauthentic new users? Genuinely asking.

Re: The American Healthcare Conundrum

#534

Post by triceratops » Tue, Mar 17, 2026, 5:22 PM UTC

estearum wrote: post #504

triceratops wrote: post #481

Earlier quoted context omitted.

> Because it makes pretty much no economic sense for anyone else to do it I think other funding models simply haven't been explored. I'll pull one out of my ass. The hospital does it themselves. In exchange the doctor works at the hospital for the next N years, or pays a contract break penalty. The hospital can pay the doctor somewhat less than market rate and doesn't have to deal with staff turnover. It should be ob…

Residency training costs like $750,000 to $1.5MM per physician Primary care doctors would have to work 12-15 years while giving up 25% of their gross salary just to pay for the residency program. They'd also have to pay x% of their salary to pay for their debt from med school training before the residency. People just wouldn't go into the field, which is already happening even in a world where the residency is funded…

> Residency training costs like $750,000 to $1.5MM per physician

And how much do residents generate in billings?

Your numbers may also be off by a lot. It'd be great to see some sources. https://news.ycombinator.com/item?id=45507076

Re: The American Healthcare Conundrum

#535

Post by FireBeyond » Tue, Mar 17, 2026, 5:26 PM UTC

anon7000 wrote: post #373

cmiles8 wrote: post #337

Earlier quoted context omitted.

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers. When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, the…

> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-b…

And pharmacy vertical integration is an easy way for them to get around regulated profit margins. While if your profits are capped at 15%, the only way to increase them is to increase premiums as a result of increasing providers costs (which the insurers can and absolutely are doing, of course), if you own the pharmacy supply chain, you have freer reign to increase those prices.

Healthcare is one where vertical integration can be really profitable, even at the smaller scale. I used to work as a paramedic, both local agencies and private. The private ambulance company I worked for started when a man who owned a nursing home realized how much money the facility was paying for ambulance transports, so he started an ambulance company. He realized how much his ambulance company was paying to industrial/medical gas companies for oxygen, so he started a medical gas company. And so on. And went from his one small nursing home to his daughter having a $100M empire by the time he died 30 years later.

Re: The American Healthcare Conundrum

#536

Post by eitally » Tue, Mar 17, 2026, 5:27 PM UTC

nicoburns wrote: post #372

youknownothing wrote: post #368

Earlier quoted context omitted.

As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK. Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the s…

I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for les…

I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.

Re: The American Healthcare Conundrum

#537

Post by pnutjam » Tue, Mar 17, 2026, 5:28 PM UTC

youknownothing wrote: post #368

Turskarama wrote: post #353

Earlier quoted context omitted.

> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.

As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK. Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the s…

"And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you."

This happened to us with private healthcare. There is basically one specialty group for the procedure my family member needed so any 2nd opinion request just got routed back to the same doctor, "Oh, your Dr X's patient". Also, we could barely afford the procedure so we missed out on some follow up testing that would have verified things worked properly and basically got blacklisted from that practice so hopefully it's resolved...

Re: The American Healthcare Conundrum

#538

Post by mbbutler » Tue, Mar 17, 2026, 5:29 PM UTC

Jensson wrote: post #285

legitster wrote: post #82

If you ever want to "sanewash" healthcare spending in the US, this random guy stood up an entire website to argue that per-capita healthcare spending in the US is more or less in line with expectations based on per-capita income: https://randomcriticalanalysis.com/why-conventional-wisdom-o... TL;DR: As people/countries get richer, a larger share of their money goes towards consumption. It's not just that Americans pa…

But USA isn't the richest country on earth yet why do they spend the most? Edit: I recognize that post now, he uses a special metric "actual individual consumption", which adds healthcare consumed by people as income. So the more expensive healthcare is, the more "actual individual consumption" you will have in the country. That is not the normal GDP metric, but using that special metric USA is on top since healthcar…

I especially love the quadratic fit, chosen with no justification, that brings the US within the uncertainty envelope in the second plot. Also notice how much work the Mexico and USA data points are doing to the previous linear model fit. Oh, my high leverage data point can't be an outlier because it's within uncertainty when I fit the data with the potential outlier included. This is basic linear model validation stuff.

Re: The American Healthcare Conundrum

#539

Post by nickff » Tue, Mar 17, 2026, 5:29 PM UTC

nsvd2 wrote: post #509

anon7000 wrote: post #373

Earlier quoted context omitted.

> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-b…

In no way shape or form is the medical industry in the US a free market, it's one of the most heavily regulated sectors in the economy. Remember when the government wanted to make purchasing health insurance mandatory? Forcing employers to pay for their employees health insurance greatly distorts the market. And many other things... By the way, as much as people complain about the profit seeking motives of insurers,…

Just to tack on, dentistry is an example of a somewhat freer market than 'healthcare', and veterinary care is an example of an even freer (though somewhat different) medical service.

Re: The American Healthcare Conundrum

#540

Post by 46493168 » Tue, Mar 17, 2026, 5:31 PM UTC

onlyrealcuzzo wrote: post #519

46493168 wrote: post #380

Earlier quoted context omitted.

The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people. See, for example, “Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland” by Jonathan Metzl

> The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people. This subset does exist, but is smaller than the percentage of people who think the system is broken - and the solution is not to just open up the floodgates and make it ev…

>You FIRST have to fix the system before you open up the floodgates.

I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out. There's things that the top 5 US states for healthcare have in common, and there's things that the bottom 5 US states have in common [0]. They know how to talk to each other if they want to know more.

[0]https://www.commonwealthfund.org/publications/scorecard/2025...