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What I learned from reading a thousand emergency room bills

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Re: What I learned from reading a thousand emergency room bills

#531
post #208
post #109

Earlier quoted context omitted.

Hospitals are required to treat the uninsured, but the government doesn't actually compensate them for that. So they jack up everyone else's bills in the hopes that enough people will pay that they'll make a profit. Insurance companies will usually push back, so (sometimes partially) uninsured people with decent credit hit with huge charges.

For this reason, I'm beginning to think that we do in fact have "universal" healthcare in that anyone can turn up to the hospital and be treated despite their income. For those who don't pay (or don't have insurance) the hospital spreads that cost out over their other patients and likely marks up the price to insure against non-payment. So we end up with an unregulated mess where any one hospital has to insure themse…

We have universal care for emergency treatment, and only to the point of stabilization, and in a manner that basically combines all the worst aspects of various systems.

You can't get months worth of chemo or physical therapy or dermatological consults or whatnot at an ER.

Re: What I learned from reading a thousand emergency room bills

#532

Earlier quoted context omitted.

There was a story about an Indian guy - he flew all the way from California, spent two weeks in India, took a bunch of MRI etc scans and went back. The entire of the trip, including airfare, hotel, scans etc was less than the cost of a scan in the U.S. Not sure how much of this is true (and yes, I do realize I shouldn't be comparing US with a developing country like India, cost wise), but it is definitely believable.

medical tourism is a booming industry in places where US doctors tend to originate :)

Given Theil's penchant for SnowCrash style Rafts, I'm surprised he hasn't parked an old oil tanker in international waters just off LA, retrofitted it for outpatient procedures and a helipad.

Re: What I learned from reading a thousand emergency room bills

#533
post #523

Earlier quoted context omitted.

Life expectancy is a weird stat by which to measure healthcare outcomes. For starters, it responds rather strongly to demographics. E.g. having more males reduces life expectancy holding all else equal. There are many things like this. Age-adjusted all-cause death rate is the better stat for measuring life-saving outcomes. Child mortality is certainly a useful stat for its purpose, though.

> Age-adjusted all-cause death rate is the better stat for measuring life-saving outcomes. Are there sources of that stat over time and between nations that you would recommend?

WHO is the best source I know of for most things like this. I was unable to find the exact stat I was looking for, but here is e.g. data on all-cause mortality rate between ages 18 and 60:

http://apps.who.int/gho/data/view.main.1360?lang=en

It probably still supports the point you are trying to make, I just get grumpy about statistic selection.

Re: What I learned from reading a thousand emergency room bills

#534

Earlier quoted context omitted.

Price discovery is indeed difficult in the current market. However, the current healthcare market is no where close to a free market. For example, suppose you wanted to start a hospital that offered price transparency, like the Surgery Center of Oklahoma does. (1) In thirty-five states and the District of Columbia, you'd first have to acquire a certificate-of-need (CON) from the state healthcare regulators. In order…

Price discovery requires pricing some people out of the market. Period. There is no "free market" healthcare system that can or ever will deliver required health services to everyone. Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow. That is both a massive distortion and non-optimal for the economy as a whole. The…

> Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow

Someone is morbidly obese. They will die and are already debilitated. The cost of having their life back is eating less. Many are not willing to pay that price.

Re: What I learned from reading a thousand emergency room bills

#535

Earlier quoted context omitted.

Depending which side you want to believe, NHS waiting times are a direct result of Conservative government austerity, or excessive immigration.

To really hammer home the point here, that Conservative government, in an effort to make immigration numbers go down set immigration rules to impose a minimum income for jobs that could recruit outside the EU. That minimum was lower than the government austerity cut maximum pay for nurses. Result: can't hire non-EU nurses, shortage worsens. Waiting times increase. Eventually, as this started to be more widely known t…

Ugh. Should say the minimum income for immigration was set "higher" not "lower" than nurses are paid.

Sorry wasn't awake enough when I first wrote this.

Re: What I learned from reading a thousand emergency room bills

#536
post #215
post #181

Earlier quoted context omitted.

> We do not have a free market. Most people get their health insurance from their employer - you cannot reasonably get insurance elsewhere What you are describing are in fact the freest parts of the health insurance market. Employers, quite rationally and of their own free will, choose to offer health insurance as a benefit because it attracts and retains talent better than other similarly priced incentives. The fact…

> Employers, quite rationally and of their own free will, choose to offer health insurance as a benefit because it attracts and retains talent better than other similarly priced incentives. The fact that you're hesitant to take a leave reveals that it's working. This is false. Offering insurance as compensation started during WWII when wages were frozen by the government. Employers found other ways of attracting work…

> Offering insurance as compensation started during WWII when wages were frozen by the government.

Absolutely true, and those regulations haven't been in effect for the better part of a century now.

If you want to argue that long-discontinued government programs can entrench systems that continue to produce market distortions today then I'm happy to agree with you, but that's the exact stated rationale for the broad suite of civil rights regulations that in my experience most libertarians oppose on economic freedom grounds. I don't think you get to have it both ways.

> There is also the fact that employer-provided insurance is almost entirely untaxed.

Again, true. But I think you're drastically underestimating how beneficial it is to an insurer to cover groups of mostly healthy people (i.e. a company's entire labor force) instead of groups of mostly sick people (i.e. those most motivated to acquire private health insurance).

In order for the market for healthcare to be truly free, in the sense you're describing, medical professionals would need to be willing to consistently refuse service to people who can't pay, which is frequently in violation of their professional ethics. Since that (entirely private and voluntary) market distortion isn't going away any time soon, insurers who can find other mechanisms to incentivize relatively healthy people to contribute to the risk pool can provide the same coverage at a lower cost per person.

That means that, tax incentive or no, insuring a broad cross section of mostly healthy people as a group is always going to be cheaper than insuring them individually. And the more healthy people can be incentivized to sign up, the cheaper it becomes for all participants, which gives whoever is making decisions on behalf of the group an incentive to encourage as much of their potential pool to participate as they can. The taxes reinforce this system, but it would still be self-perpetuating without them.

Re: What I learned from reading a thousand emergency room bills

#537

Earlier quoted context omitted.

In California the cheapest plan is about $450/month from the Obamacare marketplace, so I'm not sure $1000/month is going to be that outstanding. And as I understand it, $450/month is about the minimum a plan can cost, since Obamacare outlawed the old high-deductible catastrophic insurance. Also, I doubt that the average family has $12,0000 of medical bills a year, and would be better off paying out of pocket except f…

Yep. You get a choice to be gouged on premiums or essentially gamble, hoping that life doesn't reset your savings to $0 (or lower) by getting in a car accident or something.

It's actually not quite as bad as that. My personal preference is for things with copays instead of coinsurance, but beyond that if you look at the maximum out of pocket for most of the plans there's not that much difference between Bronze, Silver and Gold. The big difference between a lot of them is whether it's frontloaded (high premium, lower deductible, higher percentage coverage, lower copay) or backloaded (lower premium, lower percentage coverage, higher deductible, higher copay). There are also big differences in the size of the provider network, so it makes sense to check your preferred physicians (if any) and hospitals.

The thing I'd be very wary of is things like "50% coinsurance after deductible" which I think translates to "this is catastrophic coverage, you're responsible for all 'regular' medical expenses and we'll cover things like hospitalization."

None of the selection is easy, even for professionals (https://armandalegshow.com/4-why-you-and-i-will-likely-pick-... but all of the shows are interesting). Still, if you're in one of the states that allows a little longer to get on an Exchange plan and you need one, do so.

Edit: another worthwhile read about the decision tree for selecting a plan if you're in a state that runs its own Exchange (like California where you have until mid-January): https://www.balloon-juice.com/2018/10/18/going-through-my-ch...

Re: What I learned from reading a thousand emergency room bills

#538
post #413

Earlier quoted context omitted.

A constant 30% discount on employer insurance via tax breaks does not explain the ludicrous growth in hospital bills over the last 4 decades. Your vision benefits enjoy similar tax breaks, but I've yet to see an optometrist try to bill someone without benefits $800 for a vision exam, or $4,000 for a pair of glasses. Its not the tax break. It's something else.

Insurance companies benefit from all those tricks: medical care billing is too complex to understand unless you have a full time team of people to understand it. Insurance companies have this team and you don't. Vision doesn't work that way because enough people don't have basic vision care that they won't stand for the complexity.

So, the problem is that medical billing can be made too complicated for the free market to work - not the flat ~30% tax break?

Re: What I learned from reading a thousand emergency room bills

#539
post #505
post #465

Earlier quoted context omitted.

If no one is priced out and you are operating in the free market then you need to raise your prices. Repeat until you maximize profits.

Does it have an end goal of maximizing profits, though? Couldn't the goal of price discovery be to find the point where supply = demand, without necessarily maximizing profit? Granted, this ignores the human trait to increase consumption when removed from directly paying all associated costs (e.g., my behavior at Golden Corral)

If maximizing profits (or, more precisely, maximizing expected value) isn't a terminal goal for all involved parties then it isn't a free market.

Re: What I learned from reading a thousand emergency room bills

#540
post #536
post #215

Earlier quoted context omitted.

> Employers, quite rationally and of their own free will, choose to offer health insurance as a benefit because it attracts and retains talent better than other similarly priced incentives. The fact that you're hesitant to take a leave reveals that it's working. This is false. Offering insurance as compensation started during WWII when wages were frozen by the government. Employers found other ways of attracting work…

> Offering insurance as compensation started during WWII when wages were frozen by the government. Absolutely true, and those regulations haven't been in effect for the better part of a century now. If you want to argue that long-discontinued government programs can entrench systems that continue to produce market distortions today then I'm happy to agree with you, but that's the exact stated rationale for the broad…

> The taxes reinforce this system, but it would still be self-perpetuating without them.

Prove it. You are making the positive claim. You have the burden of proof.

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