What I learned from reading a thousand emergency room bills • Hacker News Board

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

#541

Post by bluGill » Thu, Dec 20, 2018, 6:49 PM UTC

vkou wrote: post #538

bluGill wrote: post #495

Earlier quoted context omitted.

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?

NO, the problem is medical billing was allowed to become too complicated, and it is very hard to unwind that situation.

I'll contend (though of course there is no way to prove this) that if we hadn't had the advantage to company provided insurance the complex billing wouldn't have developed in the first place.

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

#542

Post by vec » Thu, Dec 20, 2018, 6:54 PM UTC

pitaj wrote: post #540

vec wrote: post #536

Earlier quoted context omitted.

> 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.

"Compared to these, the effects you described are negligible" is also a positive claim, and I did at least as much work sketching out why I believe my claim as you did sketching out why you believe yours.

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

#543

Post by vec » Thu, Dec 20, 2018, 7:14 PM UTC

isoskeles wrote: post #401

vec wrote: 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…

> quite rationally and of their own free will Is this the magic phrase that means "free market" to you? Because the word "free" is in it? We could say that the USSR, quite rationally and of its own free will , sent millions to the gulags and forced labor camps to create widgets. Cute, right? Hey, they did it quite rationally (after all, the labor is way cheaper when you're using prison camps) and of their own free wi…

We can't say the prisoners chose to enter the gulags of their own free will, though. Since freedom of contract requires all parties to enter into the agreement consentually, that means that the market for gulag laborers is not free.

The US governent does create incentives which change the optimal behavior of rational actors in the health insurance market, but those actors still have very broad latitude to respond to those incentives as they see fit. That's not perfect economic freedom, but it's a lot closer to it than the systems most other countries use. It also gets noticeably worse results on a broad variety of metrics than the systems most other countries use. Make of that what you will.

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

#544

Post by pitaj » Thu, Dec 20, 2018, 7:39 PM UTC

vec wrote: post #542

pitaj wrote: post #540

Earlier quoted context omitted.

> 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.

"Compared to these, the effects you described are negligible" is also a positive claim, and I did at least as much work sketching out why I believe my claim as you did sketching out why you believe yours.

My claim is not positive. My claim is that employer provided insurance is unlikely without government involvement. That is a negative claim.

Your claim is the opposite. You can prove it by showing that employer provided insurance started growing before the given government involvement.

I doubt that evidence exists.

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

#545

Post by UnpossibleJim » Thu, Dec 20, 2018, 8:08 PM UTC

kupiakos wrote: post #243

UnpossibleJim wrote: post #26

Earlier quoted context omitted.

Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it…

> If it's cosmetic, then I could see the argument. Then there's another problem: who defines what is considered "cosmetic"? Most insurance companies currently don't cover e.g. facial feminization surgeries for transgender women, even though they're considered medically necessary by WPATH, a document drafted largely by insurance companies [0]. [0]: https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_... , p. 5…

I said I could see the argument, not necessarily agree with it. I mean, in this day and age insurance companies also consider a severe cleft palate a cosmetic surgery and not a necessity. I certainly would not leave it up to them. I think it should be left up to the consult doctor, to be honest. If you don't agree, consult another =/

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

#546

Post by UnpossibleJim » Thu, Dec 20, 2018, 8:11 PM UTC

FireBeyond wrote: post #280

UnpossibleJim wrote: post #26

Earlier quoted context omitted.

Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it…

> privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride What state? In Washington (and many, though definitely not all), ambulance prices are regulated, for this reason. When I worked private ambulance a couple of years ago it was $680 + $8/mi.

Seattle, but I guess I had some perks. I didn't itemize it. That was for everything. They did not take me to the closest hospital, either, for some reason.

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

#547

Post by Verdex_3 » Thu, Dec 20, 2018, 8:20 PM UTC

setr wrote: post #244

tcoff91 wrote: post #195

Earlier quoted context omitted.

Usually coinsurance is limited by an 'out of pocket maximum'. So even if something happens where you end up with like 600k in medical bills the most you will pay will be like 8-20k (depending on in-network vs out of network). Which is still insane but not as scary as six-figure medical bills despite being insured.

One issue with describing figures like 600k is that I think the medical industry has a lot of funny money running around. The doctor somewhat arbitrarily charges 10k to the insurance company, insurance disputes, the doctor hires a lawyer who takes 30% of the negotiated outcome, and negotiation finally ends up at $2k. The patient sees a $10k bill, pays a $300 deductible, and only $2k ever actually materializes in the…

Yeah, some of the explanation of benefits I've received are insane. Insurance is apparently able to negotiate ~50% bill reductions for multi 10K bills.

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

#548

Post by nybble41 » Thu, Dec 20, 2018, 8:25 PM UTC

edanm wrote: post #441

xenadu02 wrote: post #396

Earlier quoted context omitted.

> Socialized healthcare has its own "immoral" trade-offs. We essentially reduce per capita quality in favor of all-inclusive coverage That's a false dichotomy; there are many mixed systems where the government provides a baseline level of care with private insurance providing additional services or benefits (eg: government covers a shared hospital room, private insurance covers a private room). >Libertarians would ar…

> True libertarians also argue that all taxation is theft (if they're purists anyway), making road construction immoral. No, it doesn't make road construction immoral in the eyes of libertarians. It makes taking money from other people , by force , in order to build a road, immoral. People are totally free to build roads privately and pay for it themselves, and even band together to build these roads. (Part of where…

> Part of where the standard libertarian argument falls apart, in my eyes, is that government in many ways really is just a scaled up version of "people banding together to build a road".

There is a significant qualitative difference in that "people banding together to build a road" is an entirely voluntary activity, whereas government is nothing of the kind. It's not merely a matter of "opt-in vs. opt-out". Even in an opt-out system one can choose not to participate without penalty, but if you inform a government that you're choosing to "opt out" they won't just leave you alone to live as you please. They draw their arbitrary lines on a map and consider everything within those lines to fall under their control. Even if you move halfway around the world and renounce your citizenship, and in doing so cut off all ties to everyone and everything you once knew, you may find that they still claim a share of your income to pay for that road you'll never be able to use.

The "scaled-up" version of "people banding together to build a road" is a co-op or corporation. Such an organization does not have the power to tax or to impose regulations on anyone who doesn't explicitly and voluntarily agree to them.

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

#549

Post by vec » Thu, Dec 20, 2018, 8:33 PM UTC

pitaj wrote: post #544

vec wrote: post #542

Earlier quoted context omitted.

"Compared to these, the effects you described are negligible" is also a positive claim, and I did at least as much work sketching out why I believe my claim as you did sketching out why you believe yours.

My claim is not positive. My claim is that employer provided insurance is unlikely without government involvement. That is a negative claim. Your claim is the opposite. You can prove it by showing that employer provided insurance started growing before the given government involvement. I doubt that evidence exists.

I don't dispute that the current status quo emerged as a direct result of government intervention. Again, I agree with you that it can be traced back to WWII era wage controls.

My claim is that, once established, the resulting equilibrium is economically stable. Your claim, as I understand it, is that it's not.

Given that the price controls that we agree created the current status quo were replaced by significantly less coercive tax incentives decades ago and to the best of my knowledge the industry hasn't attempted to realign away from employer-provided insurance since then, I don't see a reason to privilege your hypothesis over mine.

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

#550

Post by nybble41 » Thu, Dec 20, 2018, 8:40 PM UTC

WalterBright wrote: post #371

UnpossibleJim wrote: post #26

Earlier quoted context omitted.

Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it…

A free market police system cannot work, because the police use force against people, which is not allowed by the free market. Worse, the police aren't going to arrest people who pay them.

> A free market police system cannot work, because the police use force against people, which is not allowed by the free market.

The "free market" (in a libertarian sense) does not permit the initiation of force against people who have not resorted to force themselves. If that is a significant restriction on your police department's activities then there is something seriously wrong with your police department.

> Worse, the police aren't going to arrest people who pay them.

If they aren't willing to arrest anyone who pays them then no one will bother to pay them. Resolving disputes between two paying customers is part of their job description, and they won't retain customers if they're seen as biased or corrupt.