Hacker News Board Hacker News, browsed like a classic message board
Live data from Hacker News

The American Healthcare Conundrum

github.com

Post reply on HN
Print view View original

611–620 of 690 posts

Re: The American Healthcare Conundrum

#611

Post by LorenPechtel »

joe_mamba wrote: post #469
cycomanic wrote: post #332

Earlier quoted context omitted.

This reminds of a debate in the German parliament 30 years back or so, about the cost for the Eurofighter project (IIRC). Essentially one speaker had argued against the staggering cost, and a second speaker from the government defended the project by saying how many jobs it created. Someone shouted that building a pyramid in honor of Helmut Kohl and it would create a lot of jobs as well, that didn't mean it's a good…

The Kohl pyramid vs Eurofighter is a funny but very poor example that isn't remotely comparable. Useless defence projects have the advantage that it keeps institutional know-how from being lost and ready for the time when war actually comes for you. That's why Europe has been left unprepared by the war in Ukraine and why the US is the defense powerhouse.

Yup. It's one of those industries where an important part of the mission is reasonably level spending over extended periods. Much of the real cost is the cost of being able to produce it, this can end up being more than the actual cost to produce one item.

(Even more extreme: drug pricing. It can take a billion dollars to bring a drug to market, something has to pay for that. Unfortunately, the reality is that it's basically the US market that covers the world's drug R&D.)

Re: The American Healthcare Conundrum

#612

Post by LorenPechtel »

dv_dt wrote: post #296
nine_k wrote: post #238

Earlier quoted context omitted.

Mostly not marketing (still large), but the R&D costs and clinical trial costs. The latter are in hundreds of millions to billions range for the entire journey from a promising discovery to an FDA-approved medicine.

Every time Ive looked into it marketing is more than half of the costs of US pharma companies - and I would suspect even more as don't know if there has much work to unmask even more of that spending via channels that can occur in ways not obviously marked as marketing or at least are really not core to research and manufacturing. e.g. is all the "discount coupon" pharmacy rigamarole considered marketing or administr…

No. Marketing is an issue but it's not the main driver.

Everybody else uses price controls to keep prices "reasonable"--the drug companies tolerate this so long as selling to the country exceeds their marginal cost of production. They count on the US market to recoup the $1B R&D costs.

Simply mandate that a drug company can't charge more in the US than they do in any other first world country. Major earthquake in drug costs.

The "discount card" bit is basically a reduction in revenue, it's neither marketing nor administration.

Re: The American Healthcare Conundrum

#613

Post by elgertam »

randusername wrote: post #475
elgertam wrote: post #329

I see a lot of the comments operating from an empirical framing. This is valid analysis and is good; we should want to understand the waste in the system as it stands. However, that isn't enough. US healthcare is wildly inefficient because the paying customer is different than the serves customer. This has been known for sixty years, since Arrow published his paper (he identified four reasons, three of which are not…

I am less interested in the quantitative analysis, but the qualitative analysis. Why, culturally, has the US shot itself in the foot in this way? > And I think part of the answer is that in most cases, individuals and families themselves must allocate resources they control to make this happen. Assuming uniquely American selfishness got us in this mess, I don't buy that rugged individualism is the route out. You'll j…

> Assuming uniquely American selfishness got us in this mess, I don't buy that rugged individualism is the route out. You'll just get that classic pattern of those with enough resources to manage criticizing the resource management of those with too few resources to learn to manage. That just further corrodes solidarity.

I chose my words carefully so as not to imply "rugged individualism" was the solution. I mean I even explicitly invoked "families" as an institution greater than the individual. And I used the word "control" rather than "earned" or something.

Weirdly, "rugged individualism" is kind of why American healthcare is so bad: we tie it to employment for those under age 65. Before the ACA, this was simply because healthcare is exempt from income tax; with the ACA, it's literally mandated. In order to get health insurance, you need to pull yourself up by the bootstraps and get a job OR pull yourself up by the bootstraps and pay extremely high premiums.

Disentangling healthcare from employment and allowing for other institutions like churches or schools to play a part in helping fund it would do a lot. And for the truly catastrophic conditions like cancer, we should just have a universal policy that kicks in.

Re: The American Healthcare Conundrum

#614

Post by LorenPechtel »

sethammons wrote: post #309
dzink wrote: post #262

Huge chunk of the costs come from the fact that Doctors pay astronomical malpractice insurance rates in some states with no tort reform. Some have to spend more than 100k on insurance - 1/3 of their total pay. Since some states allows multi-million dollar judgments from juries that raises insurance everywhere, which raises not only prices for everyone but also dramatically contributes to more procedures and tests bei…

The doctor that delivered my middle child said he had to deliver three babies a week just to cover insurance, and he had never had a case against him in his decades of practice.

Yup, obstetrics is a really nasty one. The problem is in many cases it's impossible for the doctor to prove he didn't harm the baby, the jury sees a baby that needs a lot of care and they see deep pockets.

And then you get stuff like the local case the lawyers were using as a poster boy for supposedly blaming the insurance companies. Baby had serious problems. Trial #1, 90% fault to the mother, IIRC 10% to the birthing center (which was no longer in existence.) By state law she couldn't collect because she was more than 50% at fault. Trial #2, same case, refiled in the name of the baby. 90%/5%/5% to one doctor who saw her once several hours before delivery. The whole $6 million judgment landed on him and last I heard that was being litigated over sticking him with the whole bill.

Hey, both juries agreed she was the problem. But there's no way to prove the others were blameless.

I've also seen this more directly: mock jury. Their screening questions weren't adequate--I knew how things would actually play out. Claim for IIRC ~150k, defense presents a smoking gun, but I don't think they went far enough on arguing the implications of it. We "settled" (didn't have to be unanimous) on ~30k, giving her a fifth of what she was asking for--except that doesn't make the medical bills for running up the tab go away. Lawyer is going to get his percent, docs will get the rest, she will see nothing. I kept quiet about this part as I knew it was information their screening questions missed.

Re: The American Healthcare Conundrum

#615

Post by elgertam »

bluGill wrote: post #340
elgertam wrote: post #329

I see a lot of the comments operating from an empirical framing. This is valid analysis and is good; we should want to understand the waste in the system as it stands. However, that isn't enough. US healthcare is wildly inefficient because the paying customer is different than the serves customer. This has been known for sixty years, since Arrow published his paper (he identified four reasons, three of which are not…

The reason you tell several different people why you are there is because that is important. if a system doesn't they need to start! people often remember things when asked latter. this gives more opportunity to ask about everything you care about even if you forget the first time. people sonetimes grab the wrong chart. This helps ensure that they check for things that matter to you and not someone else - your histor…

I mean isn't that why they ask for name and DoB each time? I get that they want to ensure they're working with the correct patient. I just don't love trying to recall on command the litany of symptoms I've experienced and remedies I've tried before seeing a physician.

Re: The American Healthcare Conundrum

#616

Post by elgertam »

speefers wrote: post #354
elgertam wrote: post #329

I see a lot of the comments operating from an empirical framing. This is valid analysis and is good; we should want to understand the waste in the system as it stands. However, that isn't enough. US healthcare is wildly inefficient because the paying customer is different than the serves customer. This has been known for sixty years, since Arrow published his paper (he identified four reasons, three of which are not…

> The question we ought to ask is how we can buy better health outcomes for people spend more money. you DO live in the greatest country on the planet, surely if an american citizen cannot raise the funds for healthcare, in what country can you expect to?

We spend a ton of money per capita and get bad outcomes.

Re: The American Healthcare Conundrum

#617

Post by LorenPechtel »

CGMthrowaway wrote: post #396
tptacek wrote: post #188

Earlier quoted context omitted.

What does that mean?

Before ACA, insurance had a more traditional "insurancey" role by excluding pre-existing conditions (aka managing moral hazard) in order to make money via premiums. In the "guaranteed issue" world post-ACA, insurance companies have pivoted instead to extracting as much money as they can from an increasingly vertically integrated ecosystem (PBMs etc)

The problem here is that pre-ACA you didn't have insurance, either.

Yes, they would (maybe--some plans saw huge sticker shock because the original didn't actually pay much of anything) sell you "insurance". They would offer a plan for a few years, then close it, offer something new. The old plan would see patients getting sick, costs would rise. Premiums were based on costs *for that plan*. Soon the healthy jump ship for something else, now the old plan is only the sick and the premiums go into a death spiral.

Thus the reality was that any ongoing problem soon you were uninsured.

Re: The American Healthcare Conundrum

#618

Post by dragonwriter »

CGMthrowaway wrote: post #396
tptacek wrote: post #188

Earlier quoted context omitted.

What does that mean?

Before ACA, insurance had a more traditional "insurancey" role by excluding pre-existing conditions (aka managing moral hazard) in order to make money via premiums. In the "guaranteed issue" world post-ACA, insurance companies have pivoted instead to extracting as much money as they can from an increasingly vertically integrated ecosystem (PBMs etc)

Before ACA, insurance had a more traditional "dump you when you were in need" role that leveraged pre-existing conditions rules by, if you fell ill in a way which was likely to be sufficiently expensive to make this profitable, looking for any minimally tenable evidence of an undisclosed pre-existing condition (just to have something to cite as a pretext, it didn't need to be convincing), using it to justify cancelling your insurance, and avoiding any legal remedy by refunding your entire lifetime of premium payments.

Of course, whether or not you actually had a pre-existing condition when you had signed up for the original insurance, you now have one that prevents you from getting new insurance,

Re: The American Healthcare Conundrum

#619

Post by dyauspitr »

sneak wrote: post #275
dyauspitr wrote: post #273

Earlier quoted context omitted.

It’s what all of Asia does and it’s very effective. Make people’s weight their primary problem until they resolve it. It’s not like it is some unchangeable attribute that can’t be fixed through self control and discipline. The shaming is just unsolicited motivation that works. I feel sad if people are made fun of for attributes they can’t change.

If everyone could control their weight via simply willing themselves to have more self-control, then nobody would be fat. Self-control is, ironically, not usually within one’s self control. Most people don’t contemplate very deeply about the gap between their will and their behavior. I’m extremely focused on self-determination and it’s absolutely astounding (and irritating) to me how little control I have over my act…

That’s exactly what I’m referring to. You’re made to feel so bad that it’s no longer a matter of “self-control” but social acceptance. People will do a lot to fit in.

Re: The American Healthcare Conundrum

#620

Post by LorenPechtel »

twoodfin wrote: post #137
ipsento606 wrote: post #85

Earlier quoted context omitted.

> ACA enshrined the worst parts of the American healthcare system for years to come before the ACA, insurers could deny coverage for pre-existing conditions people have forgotten how bad things used to be

Why is that inherently bad? Should I be able to buy fire insurance on pre-existing embers?

Because my pre-existing condition happened either at conception or sometime before adulthood. I wasn't in a position to buy insurance before then.
Post reply on HN