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The American Healthcare Conundrum

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671–680 of 690 posts

Re: The American Healthcare Conundrum

#671

Earlier quoted context omitted.

People are waking up and a lot is happening to counteract some of this. In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negoti…

TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsite...

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Re: The American Healthcare Conundrum

#672

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> 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 integ…

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Re: The American Healthcare Conundrum

#673

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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…

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Re: The American Healthcare Conundrum

#674
post #392

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'm sure there is a lot of nuance but long term healthcare outcomes are generally lower in the US compared to other countries. https://www.healthsystemtracker.org/chart-collection/quality...

The RAND Round 5.1 study (2023) puts US commercial insurer payments at 254% of Medicare rates for identical procedures. That's the mechanism behind the international gaps — it's not complexity or quality, it's that commercial insurers negotiate against chargemaster list prices rather than against cost. The HCRIS cost-to-charge analysis (3,193 hospitals, FY2023) puts median markup at 2.6x actual costs.

Re: The American Healthcare Conundrum

#675

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But you blame the contract as to why commercial pays less, when it’s because that’s what someone accepted. They’re obviously going for a low number and it’s your sides job to negotiate for yourself. I just made another comment about lazy managed care, then you prove my point here. While you didn’t ask for a definition, you should try and connect the dots.

The contract pegs reimbursement to Medicare rates. That's not laziness that's literally how most commercial payer contracts work. "You should have negotiated harder" isn't the own you think it is when the outcome of good negotiation is still a Medicare-indexed rate.

Pegging it to a Medicare rate isn't the lazy part. Allowing that rate to be less than Medicare is the lazy part. I really feel like you're not understanding how this works like you think you do. It is certainly a common way to write the contract, and the negotiation needed to agree on what amount to settle on is and can be a significant effort and can be heavily contested/negotiated. So it's not the contract design that's lazy. Accepting a rate below Medicare because you make enough on Medicare is lazy and puts business at risk if Medicare rates were to shift downward.

I'd not let my Managed Care team get away with that negotiation. If the other side wants to use Medicare as a baseline, then fine, reimburse at Medicare rates is the absolute lowest I'd ever go (Medicare +0%). Much more commonly, if we're using Medicare as a baseline it's going to be Medicare +20-50% or more above. Depends on the exact service and economics involved, very case by case. Going below 0% is a no-go for me and I can't think of a time I ever would have accepted it, so if you're job is to negotiate, then this is lazy. See what I mean by "lazy"?

Re: The American Healthcare Conundrum

#676

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You could say the same to tech workers after AI.

So what? Are you arguing that since we think we're all special that we should be accepting that other people think they're special? Meanwhile, people getting laid off (just so the jobs could be exported to countries with more poverty and lower pollution, worker's rights, and standards for working conditions) were getting berated that they should "learn to code" for decades, while we laughed and discussed our stock op…

> while we laughed and discussed our stock options.

We? Sorry, I'm one of the "newer" engineers that joined the industry right before the AI bubble.

I didn't laugh or discuss my stock options. I accepted what jobs were available post-COVID crash.

Re: The American Healthcare Conundrum

#677
post #501

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> The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible For-profit health insurance. Which imho should be illegal. A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by: 1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too) 2. Tying financial incentives and disinc…

Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?

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Re: The American Healthcare Conundrum

#678

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Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone. I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on wh…

> Having care depend on "being a successful advocate" does not sound like a good thing to me! It's not. You have to become a horrible demanding person to get a decent level of care instead of things being nice.

The data supports this. The AMA's 2024 Prior Authorization survey found 93% of physicians report PA requirements delay medically necessary care. Twenty-nine percent reported a PA delay causing a serious adverse event for a patient. Seven percent reported PA contributed to a patient death.

The requirement that patients fight for care isn't just a frustration. It's a documented cost driver: Health Affairs (2025) puts the total system-wide cost of prior authorization at $93.3B/year, including $35.8B borne directly by patients navigating the process. The persistence required to appeal a denial is unevenly distributed across income, education, and time availability. That is a structural equity problem as well as a cost problem. Issue #5 of this series covers the full mechanism.

Re: The American Healthcare Conundrum

#679

Earlier quoted context omitted.

Not at all. The majority of the cost is subsidised by the Government who acts as a central purchaser to minimise profiteering and keep prices down. Everyone pays a little bit towards it all via general taxation but if you prefer a system where individuals have to front the vast majority of their own costs, much of which is just being extracted as profit, then you are welcome to that. I prefer the option that leans a…

Ok, but that wasn’t part of the discussion was it? Just “lol drugs only cost a nickel here, silly USA” seems disingenuous

The NHS prices in the Issue #2 analysis are not subsidies. They are the generic reimbursement rates from the UK Drug Tariff after patent expiry on each molecule. Apixaban (Eliquis) costs £1.16 per 30-day supply on the Drug Tariff. That is what the open market charges for the active compound once patent protection expires. The NHS does not manufacture it or subsidize the price: that is the market rate for the molecule itself.

The $862 Medicare gross cost for the same molecule is not explained by active R&D recovery, either. The IRA's first ten negotiated prices (effective January 2026) cut Medicare gross costs 40-70% per drug, which does not happen if those gross costs were development-cost-justified.

Re: The American Healthcare Conundrum

#680
Author here. Issue #4 is now live — pharmacy benefit managers.

Three companies process 80% of US prescriptions. The FTC spent two years investigating them and documented $7.3B in specialty drug markups at PBM-owned pharmacies alone. Ohio's state auditor found $224.8M in spread pricing extracted from one state's Medicaid program in a single year.

Six mechanisms, $30B/year booked conservatively. Running total across four issues: $128.6B.

github.com/rexrodeo/american-healthcare-conundrum

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