Comment by mindslight
3 days ago
In many ways, the problem is that we do treat health care different. What other industry will actively reject attempts to ask about prices? What other industry just sends out bills with no contractual basis and exaggerated fraudulent amounts made up after the fact? What other industry do you need to buy "insurance" to even be able to financially communicate with service providers? What other industry does the government provision social services by telling businesses that they must serve some of the most expensive customers for free, and then ensures monopolies so those large losses can be made back from every other customer? What other industry is it impossible to obtain services until a professional declares that you "need" them, at which point it's supposed to be close to free?
These massive profits are because of the so-called "regulation" that has continued to keep market dynamics away, new entrants out, and the industry supremely entitled (from doctors to billing departments). The political debate continues to be sidetracked by doubling down on this mistaken idea of thinking constructive outcomes can simply be declared in law. What needs to happen is to focus on making healthcare a competitive market where patients have agency, while also providing direct financial subsidies when people need them.
The problem is that it is different. What other industry sells a product that you might need in order to survive or to not be disabled which requires the dedicated efforts of multiple professionals with a decade of post-secondary education? What other industry sells a product that you might suddenly need at a moment’s notice that is the only way you’ll survive the day, that requires sophisticated equipment, dedicated facilities, and a team of the aforementioned highly educated professionals?
Most industries are either optional things you want to have but can live without, or necessities you need on an ongoing basis that need more than a few minutes of individual attention.
There’s a lot more to medicine than emergencies and lifesaving treatments. But I think those are the original sin from which the rest flows.
The basic question is this: should people be left to die if they have a sudden life-threatening event (heart attack, hit by a bus, shot) and they can’t demonstrate an ability to pay for treatment? (Note, not the same as not being able to pay for treatment. This would potentially apply to a rich person who got mugged and left for dead, for example.)
Few will answer “yes.” And everything else flows from the “no.” The US’s universal health care system is built around it. We pretend we don’t have universal health care, but we do. It’s just tremendously shoddy and weird. The one place with universal care is the hospital emergency room. Those have been required to treat everyone regardless of ability to pay since 1986. Once you start doing that, the rest flows from there. People start saying, what if it’s not critical to survival but they’ll be crippled without it? What if it’s life critical but there’s time to verify payment?
Can we do better without removing that? No doubt. But we’ll have a hard time getting to a proper competitive market.
Other industries with these characteristics (police, firefighting, rescue, ambulance if you count that separately from medicine) are usually handled by the government or at least contracted by them.
> Few will answer “yes.” And everything else flows from the "no."
Everything else has flowed from the "no", but I do not think it needs to have. Imagine the government being a definitive payer of last resort, instead of this unfunded mandate where hospitals have to provide emergency service for free but then receive a bunch of regulatory capture to make up for it.
That still leaves an avenue for hospitals to defraud the government about how much providing that care cost, and emergency care has that dynamic intrinsically regardless of who is paying. But that's still leaps ahead of basing the entire industry on a foundation of billing fraud shakedowns. And it would be a lot harder for emergency departments to claim exaggerated fraudulent costs when the rest of the hospital is charging much less.
The vast majority of care is not life saving emergency treatment, and this is where the brokenness of the current system gets really galling. For example I just had a specialist declare that the proper course of treatment is to follow up in 12 months. I nudged them that 12 months seemed like an awful long time, but they held fast. I would happily pay for another check in 6 months if the system would let me. But instead, the concept of patient agency has been completely scrapped in favor of top down "necessary" and "not necessary".
I think there are two paths. Having the government be a payer of last resort for emergency services starts you down the road of paying for more and more things. You’ll start asking questions like, why are we paying massive amounts to stabilize a poor, terminal cancer patient who collapsed when we could have paid 10x less on screening and early treatment? Why aren’t we paying for procedures that allow people to work and bring in more taxes than the procedure costs? Why are we ok with paying to save someone’s life when they’re hours away from death but not when it’s weeks away?
Eventually you’ll get something like the systems you see in most wealthy countries.
Or you can go the way we did, which is enact universal care in the dumbest way and pretend we didn’t.
2 replies →