This is a really important goal, but whether simple mandates can solve it, I'm not sure. The real problem is that consumers don't care about the prices, which is how all the various layers of providers and middlemen are able to jack up all the prices without limit.
High deductibles are one way that consumers can be made to care, but obviously that has its own problems. Single-payer would not fix the problem by itself, either... although using monopsony power could certainly help, if executed competently.
Merging a single-payer approach with a high deductible approach could work, and the deductibles could actually be paid via a government-filled HSA account that one could rollover into a retirement or college savings account, if unspent.
> The real problem is that consumers don't care about the prices
I think this is a trope in multiple areas trying to pose personal accountability as a solution where one actually needs systematic solutions. You see it with the climate crisis (make sure to buy only 100% organic recycled meat), or student loans (make sure to choose a major that has a 20 year postivive ROI), and medical expenses (make sure to price out and choose the most cost performant cancer chemo cocktail).
Really we need working institutions and controls those institutions can impose because the markets for industrial processes, or educational funding, or heathcare are vastly complex products with large capital, time, knowledge commitments needed to adequately check misperformance. The investments needed far exceed most time or money resources that make sense for any one person can put into single transaction. That's why collective institutions are needed to focus on developing the specialized information and policy needed to manage the poorly performing systems.
The economy is the sum of individual actions, which are all guided by incentives. Set up poor incentives, and each individual poor decision might not matter too much, but the collective result can be awful.
The idea that we ought to throw our trust in with bureaucrats is kind of ridiculous, particularly in the age of Trump.
But even if this were Scandinavia, incentives would still matter.
I’m not sure it’s a lack of “care” and more a lack of ability to take action.
If I have a broken arm I’m not going to price comparison shop amongst hospitals.
Anecdote: I attempted to comparison shop for an mri to diagnosis a potential rotator cuff injury. While I could get the actual scan fees I couldn’t get the fully burdened cost and during the visit it’s entirely opaque what things will be new line items on the bill.
And if you're taken in to the ER, you're possibly not even ABLE to consent to charges. You're at the whim of the hospital staff!
Did you know they charge for 'chaplain time' for having a chaplain stop by and say hi (you don't get to say yes or no, and this is obviously not medically necessary)?
Emergency care accounts for about 2% of total healthcare expenses. The issue you bring up about consent during an emergency is a real one, but it's not where all the money is going.
Note that your article cites at least 1 other study that says 5-6% or even as high as 10%. It would be interesting to see a breakdown here - does this include prescription medication? It seems like if you're talking about provider regulation, you shouldn't include that.
Unfortunately the article doesn't make it easy to figure this out.
Even assuming that the 10% number is the right one, it still seems good enough in my book if, in the beginning, only 90% of the expenses get addressed successfully.
While urgent care is a significant part of total medical expenses, it's not that large part - the vast majority of really expensive procedures are scheduled well in advance, and doing price comparison would be quite feasible if the institutions would allow that.
That's the "if institutions would allow that" part. Or, more accurately, if institutions would get legally forced to allow that. We didn't get price transparency and limits for ridiculously lying advertising in other consumer markets just by sheer goodwill of merchants, it required legal mandate and enforcement of it.
> If I have a broken arm I’m not going to price comparison shop amongst hospitals.
This gets mentioned in every healthcare thread. With transparent pricing we'll soon know which hospital costs 3x of the other, so we (or beforehand or family) can decide which one to go to for treatment.
This is a very urban/suburban mindset. There is a not insignificant portion of the population that has no choice and the one place they can get medical care is already over an hour away.
Most folks are moving to cities, the portion you mention is small and getting smaller.
Don't let perfect be the enemy of the good. People can make their own decisions. There is no ethical position for keeping pricing information secret. Just because one can imagine a rare scenario where it wouldn't be useful is hardly a reason to continue hiding it.
While true, 20% of a large number is still a large number. It's easy to disregard these people, but they should not be disregarded. They have suffered directly due to the privatization of hospitals and the requirement to satisfy stockholders.
Also, I'm not against price transparency, but I'm highly skeptical that it will improve anything. The reasons should be quite apparent but price setters will settle on or near the highest prices since everyone in the system is incentivized to do so. It also doesn't solve the problem that many people pay a $N copay noatter what the price is due to insurance. And the third issue is the in and out of network problem.
When you consider all these, along with the lack of choice for pretty much everyone, it isn't going to change anything.
Nobody wants to "disregard" rural patients. Rural patients would also like to know the price they'll be charged after driving 1.5 hours. Often we have a choice among several faraway towns to which we could drive. We've made our peace with the fact that living in the sticks requires driving further.
This argument is too dumb to qualify as sophistry.
From your anecdote you indicate that people will comparison shop among hospitals but are unable to do so. I have a similar story about a broken ankle where I couldn't even get an estimate for an X-ray and a cast.
According to DHS head (as heard on NPR this morning), something like 70% of hospital visits are non-emergency, meaning that people can at least exercise more cost comparison on those bases. But I think people already largely do that, by way of ensuring the provider they use is part of their insurance's network; after coverage, cost differences are pretty small (what's the difference between 10% of $5000 and 10% of $6000?).
The real issue is when people don't have coverage or when their insurance denies it. The latter is hopefully mitigated by Obamacare's "no pre-existing condition" exclusion. The former happening is pretty obvious: people can't afford it and their employers don't provide it (single-payer would help with this). Alternatively, some people just need _a lot_ of health care, and 10% of a million dollars is still a lot of fucking money.
But if you need the health care, what are you supposed to do? That's what we mean when we say "people don't care about prices". The prices aren't going to change that much because of this legislation. The real issues are 1) not everyone is paying into the insurance pool 2) there's a needless layer of gamesmanship between insurance and providers and 3) providers and insurance are working on a profit motive.
To fix healthcare: 1) Put everyone in the pool via taxation (aka single-payer), 2) Move healthcare to public or non-profit with lots of oversight to prevent fraud.
>People complain about 20U$S copays on doctor visits that bill 400U$S to insurance.
Well if that’s the case...it’s because the $400 bill isn’t the real cost for the service and insurance actually pays $0 of the bilked $400.
What happens is the patient pays $20 copay gets billed ~20% of the $400, or $80...then everyone but the patient is happy, Dr. gets his $100 for the visit and gets a $300 tax deduction, the insurance gets its premiums from the patient and gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books.
Unless there's a weird provision I'm not aware of, you could be over representing the value of the deduction.
The best thing for the doctor is to get paid (and pay taxes on) $400. The $300 deduction is of no value to them because they never recognized the $300 as income. The deduction is basically "Hey, sorry you couldn't collect your billed amount. You don't need to pay taxes on money you didn't earn".
Sorry if you fully understand this already. The lack of understanding of basic taxes is a pet peeve of mine. People make statements like "Johnny was looking for one more tax deduction, so he donated to my charity". Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.
>The best thing for the doctor is to get paid (and pay taxes on) $400.
No...the best thing is for the doctor to not upset the insurance company and get dropped from their network and lose all their patients.
Remember the famous line if you like your insurance/doctor you can keep your insurance/doctor. Turns out the president has no control over whether insurance will outright drop doctors from their networks.
As to your point on accounting, it simply depends on the doctors/hospitals accounting practices. It’s possible there is no deduction as you say (no big deal to the doctor, they got paid their fee anyway) or they can use an actual method of accounting and carry the loss forward.
In fact you may be understating it a bit. If the doctor uses cash accounting, then it's not that the $300 deduction is of no value, there is no $300 tax deduction.
As you point out, a cash basis taxpayer pays taxes on actual income received. Money you may have hoped to receive but didn't isn't income, so there is no tax and no deduction related to it.
If the doctor filed taxes using the accrual accounting method it would be different.
As I mention to a number of other comments...it simply depends on the accounting method.
It can be waived (not treated as income at all as you say) or it can be treated as income (taxes paid) and the loss carried forward for future deduction.
> Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.
You are assuming that Johnny isn't the one that doesn't understand tax deductions.
The only way the doctor would get a $300 deduction is if they use accrual accounting and had already reported the $400 as taxable income. It's isn't a free deduction that comes out of nowhere.
With accrual, you report income when you bill for it, not when you receive it. Suppose you treat a patient on December 31 and bill the insurance $400 on same day. You report the $400 as income and pay taxes for the entire $400 in that year.
The next year, insurance only pays $100, so now you have a $300 loss to report in the new year. But you only have this loss because you've already reported the $300 as income.
If the doctor uses cash accounting, there would not be a $400 income entry on December. There wouldn't be any income to report until they are actually paid, and then the income is the actual amount they are paid, $100.
There is no opportunity cost deduction. Unless the doctor can show that he is losing money (amortized cost of office/staff overhead etc) on that $100 service, there is no deduction. They can't arbitrarily say they sell their services for a certain amount and deduct when they don't reach that amount.
If you have a widget that cost $50 to make/market/sell and you sell it for $100, then have a "sale" or "friends and family" discount to $60, you don't get to write $40 off your taxes. If you sold it for $40 you could write the $10 loss off of your taxes.
Just to add one more note to this lengthy thread... :-)
> Dr. gets his $100 for the visit and gets a $300 tax deduction
I think that is the phrase all of us have been jumping on. What you wrote there is simply not true. There is no scenario, regardless of whether the doctor uses cash or accrual accounting, where they get $100 for the visit and a $300 tax deduction.
There are three possible situations here:
1. Doctor uses cash accounting. The $400 invoice is not a taxable transaction. Doctor gets paid $100, reports it as income in the year it is paid, and that's that. There is no $300 deduction.
2. Doctor uses accrual accounting and is paid the same year. They report $400 of income along with a $300 loss in that year. Net income is $100, and doctor pays taxes on the $100 income. Their tax for this transaction is exactly the same as if they had used cash accounting.
3. Doctor uses accrual accounting and is paid in a subsequent year. They report $400 of income in the first year and pay taxes on the entire $400. Then, in the year they get paid, they report a $300 loss, because they were only paid $100 out of the $400 they previously declared as income. The only reason this $300 loss exists is that they already reported the entire $400 as income in the previous year and paid taxes on it. They aren't getting $100 income and a $300 deduction, they got $400 income in one year and a $300 deduction in a subsequent year.
As you mentioned in another comment, there may be reasons why a doctor would want to do this. Perhaps they just started their practice and are in a lower income bracket this year but expect to be in a higher bracket next year. In that situation the accrual method may help balance their income across those two years: they can pay taxes on the accrued (billed) income in the year that their tax rate is lower, and then take the loss in the next year at a higher tax bracket.
There may be other reasons to do this as well, but none of them change the fact that accrual accounting would mean they reported $400 in income along with the $300 loss, whichever years those happen to be.
It's not $100 in income combined with a $300 deduction, whichever way you account for it.
There is certainly a difference between a list price and a negotiated rate, but there isn't some sort of secret "we'll tell the patient in writing we're paying $400, but actually we'll pay you nothing" rate.
That’s insurance based healthcare in a nutshell. Insurance doesn’t negotiate just rates but the actual reimbursements.
The real fraud is the fact that insurance companies have been buying up health care practices/hospital systems and dropping all other providers from their networks and forcing the patients to go to the insurance owned providers (often times unbeknownst to the patients). Although there have been a couple successful large class actions by both doctors (who got dropped) and patients as well, but this hasn’t changed anything in practice just provided a little hush money.
I dont think that deduction idea makes sense. You would have had to actually report the income of the 400, pay taxes on that, and then deduct the next year. Unless there is trickery involved I'm not savvy of.
That’s exactly how it’s done under accrued accounting. And in health care paying taxes on uncollected Billings and carrying the loses forward can make a lot of financial sense.
> gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books
On a macro scale, healthcare prices are a huge issue. On a micro scale, healthcare prices are a non-issue.
Perhaps the latter is part of what leads to the former, and perhaps full disclosure will change things, but generally there has been no point in even trying to shop around based on price, since there are no good options and very little information about prices.
What is the “micro scale” you’re referring to where healthcare prices are a non-issue? Medical bankruptcies are a pretty conspicuous problem in the United States.
I'm sick, I need to go to the doctor. In the USA, good luck figuring out how the price of anything in any way should affect the choices one makes at that moment.
Is there a difference between going to the CareNow clinic near my house or the Code3ER near my house? I have no idea. Should I go to a hospital instead? Is that cheaper or more expensive? I have no idea. Once I get there, are things going to cost me more or less depending on which arbitrary doctor I end up with? I have no idea. If they order further tests or a consult with someone else or some medicine I've never heard of, do I have the ability there to ask questions about price? No, I've tried. Doctors genuinely seem to have no idea whatsoever what things cost, by and large.
So at that scale, not the big picture but the individual scale, prices don't matter because if they did, I'd just stay home and hope I live through whatever ails me. Which is often what I do, in fact.
I hope forcing publication of prices makes a difference. I'm suspicious that companies will find a way to do so that protects their profits, but hey, I'm hopeful.
As for the physicians and pricing - I have some sympathy there. First, I'm happy that they are not making medical decisions based on overall price but instead based on risk. This seems to be the best way to treat me the patient and not me the line item.
That said, they also have to deal with liability (especially in an ER) so they have to treat any POSSIBLE thing that you might have before you leave since people often arrive with zero medical history and they have to rule out side effect things that may not be an issue. Further, the fact that their physicians often deal with advanced specialities and/or emergency medicine means you're paying for a specialty for something that could be simple. I try to stay out of ERs unless I'm worried about my life and instead use urgent care / clinic visits when my GP is not available. Their billing seems to be much more consistent, anyway, and there's less risk a physician won't be covered by your insurance just happening to stop by.
They are there but you more than likely don’t know anyone personally that has done it. Most people have insurance via group plans and don’t get that sick, it is the outliers that have huge problems. That is what makes the problem so hard to get people fired up about.
I have done that and seen all of those. I'm thinking at the systemic level. If everyone had to care about prices, then there would be more demand for transparency, and more competition in pricing, which would help even those who are unable or unwilling to price shop.
I also bring up single-payer in a related way because the need to find in-network providers within reasonable distance often is such a limiting factor that price shopping isn't possible.
With single-payer, one could actually choose between all of the providers... in addition to other benefits.
There are websites like ZocDoc which are like yelp for doctors, but they can only do so much because of the lack of price transparency, and lack of ability of consumers to choose doctors out of network.
There are some markets where price shopping is possible and does happen. For instance, LASIK prices plummeted as a result of competition and price shopping.
There could be many more, if not for various policies that impede this.
I think LASIK is probably closer to cosmetic surgery than "healthcare", at least as far as most of this discussion is concerned. If your arm is broken you can't really shop around.
It takes like 5 minutes, max, to shop around for a pizza. You can easily pull up prices, reviews, and so on.
If price transparency and quality comparison were made easily accessible, and one could actually choose options regardless of considerations like "in-network," then it would be entirely conceivable that the majority of medical procedures would involve price shopping.
And such shopping around based on price and quality would improve things even for those who do not price shop. Feeling the pressure of market discipline would force providers to compete on quality and price.
There are sites that try to be like yelp for healthcare, but you ultimately don't have any price transparency, not every doctor is listed, and you have to navigate a maze of insurance categories. In a saner world, we would have better transparency in healthcare than pizza delivery.
My employer’s healthcare plan includes Castlight. It’s a mobile app that shows nearby in-network providers. If I need a procedure, I can search for that and get average prices.
Dentistry is also like this. Lots of people have some dental insurance, but it doesn't cover enough of the really costly procedures to make most patients ignore costs.
I think this is it. Imho, you essentially have two populations of patients: those with good enough jobs to have good enough insurance that their fairly price insensitive in most cases, and those who are under-employed and/or under-insured who know going in they can't afford to pay for service regardless. Neither of these groups are particularly invested in effecting change to the status quo. On the flip side, though, there is a large population in the middle where price matters a lot ... but imho these voters are overwhelmed in their PR efforts by the big spenders at the top, and the under-insured are effectively disenfranchised anyway, so their voice doesn't matter much (Medicare/Medicaid & VA services are the exception here).
This order is about disclosing the prices that consumer pay (co-pays/co-insurance), not the total price with insurance reimbursement. Essentially it would force every clinic to be like Kaiser and MinuteClinic who tell you upfront how much you need to pay for the visit so there's no hidden fees.
HDHPs are rampant now. I have a $6500 deductible. It's absolutely miserable. I dump all the money I can into my HSA every year and inevitably I spend it all. The magic benefits of HSA as an investment vehicle for retirement or college are vastly overstated. Yes, if you basically never go to the doctor, it might work. Go to the ER or urgent care once a year and you're done. (Further, your investment options and the fees thereof are controlled by your employer's HSA servicer, and tend to suck.) Whenever I have a medical issue, I personally try to just suck it up and wait it out, because just to see a nurse practitioner to see is $150, let alone if they have to do anything. Every time my kids get sick I also have to make the same type of decision: is it worth it? This is an absolutely miserable place to be in, but this is exactly what HDHP proponents think is a great idea.
Meanwhile, my total annual premium cost is still > 20k.
I absolutely do care about prices (which doesn't matter right now, nobody will tell you what they are), and so does everyone I know, most of whom are on these same plans. The only people I know who aren't are unionized. But I have no way of finding out what they are beforehand. I don't even think this mandate will help. Yeah, sure, now the hospital posts the price - but what about the other dozen providers that involve themselves in a single procedure?
For example, my wife underwent a routine procedure a few months ago. I am still receiving bills from different providers. So far I'm at 7. Never mind trying to even audit them to see if they really did anything!
At the same time, do we really want health care to be under intense price pressures? I'm not so sure. I imagine the medical bureaucracy will continue to expand unimpeded while actual quality of care will go down. That's what I already see happening as a result of cost-cutting.
Some cruel reality: you need to ration healthcare to reduce spending significantly. The iron triangle of healthcare: Quality, Access, Cost.
That said, there are definite things that increase the cost disproportionately, and the way the government subsidizes insurance through an employer makes a major disconnect between patients and providers. If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.
The cruel reality appears to be that you ration health care without reducing spending, because medical administration and bureaucratic costs eat the savings and more.
Untying insurance from employment is a great idea, but it won't solve this. With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing. Neither will single payer fix the underlying problem, although at least individuals will be better off.
At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
There are no effective market forces you can 'unleash' in the case of health care. It wouldn't matter if you removed all government regulation and subsidies tomorrow. Even in a world where it all somehow works out, do you want medical providers in a race to the bottom? In the absence of meaningful quality of care information (impossible), consumers are incredibly sensitive to one thing: price. What you will end up with is cheap(ish) providers providing incredibly substandard care by cutting corners and killing people.
I seem to remember a comment on here complaining about $30 pacifiers. Why do pacifiers cost $30 when they’re post paid from a hospital and not when they’re bought literally anywhere else if not for the presence of market forces? I can assure you this effect is not just limited to pacifiers.
> With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing.
Long way to go for HDHP to take over the market. But its definitely the way to go. It will however attack mostly the primary care market, not the hospitals which are 40% of the national health spending.
> At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off. I do think that cost is the single most important thing to attack, and the policies to do so are very easy to enact. They are just very unpopular, because the democratic party wants to increase the state, not make healthcare cheaper, and because republicas have their head up their ass on this topic for reasons I dont understand.
According to Kaiser, HDHPs are the second most common health insurance plan and account for 28% of all insurance plans.
> Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off.
Yes, if the problem is skyrocketing demand. But it isn't. Yes, if we waved a magic wand and provided unlimited free access to medical care, demand would rise somewhat. But demand is not the reason for the current high prices, and it's not the reason costs are outpacing inflation. Medical care in the US is much more expensive than in comparable countries, but demand is not appreciably different.
As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved. The fundamental problem isn't that demand is too high. The problem is cost disease, the root of which consists of dozens of different factors. This is a decent article, albeit one that barely scratches the surface.
Look at those graphs! It's mindblowing! Medical costs have increased ten times more than inflation, while doctor and nurse salaries were flat (actually worse, since now their salary goes to paying off educational debt) over the same time period. If there's a demand problem, why aren't salaries of medical professionals rising faster than inflation?
Lastly, I think most people would disagree that cutting costs is the most important thing. Going bankrupt is better than dying of pneumonia because you were worried about wasting money on a doctor visit.
> As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved
There is definitely a sort of impasse on both ideological positions. The forces that be for some reason have not agreed to test out their ideas: a public option and deregulation simultaneously. But neither policy is popular in neither party.
I disagree with your diagnosis, but I'm willing to do a policy that satisfies both your ideas and mine. Support a public option that will not have the issues you mention, and let me have my unlicensed, foreign, cash-pay, non-subsidized doctors, non-FDA meds and malpractice waivers.
Medicare for All will solve a lot of these issues. Look at the healthcare prices in Japan, which has a single payer system. Insanely cheap, high quality, and more doctors per capita than the USA.
The other part that someone like Sanders is pushing is tuition-free colleges. If doctors aren't burdened with half a million in student debt, maybe we can get cheaper care.
Medicare for All would help individuals, but does too little to stop rising costs - you get the benefit of government negotiation and annihilate insurance overhead, but it’s not enough. You help people in the short term, but ultimately you only delay the day of reckoning.
I already posted a link showing doctor and nurse compensation have been flat in the same time period that medical costs increased 10x faster than inflation. While free university might be a good idea for other reasons, this isn’t it.
> In the absence of meaningful quality of care information
Except that quality information gets provided quite satisfactorily in plenty of industries, even ones that might appear otherwise quite opaque. Sure, sometimes it is done in distorted and counterintuitive ways (many marketing practices, including many kinds of advertising, are ultimately reputational games that are designed to signal quality), but meaningful info is far from "absent"!
I'd be all in favor of that, but it's not quite as easy as it sounds. A lot of labor relations has resulted in health care being used as part of the total compensation package, a carefully negotiated, hard-fought conclusion. To wipe that benefit away would be a step backwards for a lot of people.
It should be possible to reopen those negotiations and reach a fair conclusion, but there's going to be a lot of fighting on a case-by-case basis (with a lot of cases). I believe it would ultimately work out better for everybody, but the "ultimate" would be years -- if not decades -- away.
> To wipe that benefit away would be a step backwards for a lot of people.
Welcome to vested interests.
> It should be possible to reopen those negotiations and reach a fair conclusion
As much as Uber can negotiate with taxis. The solution here is to cut all the bs out and dereg. Import free doctors from all the world for cheap, by allowing them to practice medicine and to apply to a Doctor visa. US can triple its doctoral staff in 5 years with no educational cost by simply doing less things.
> If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.
That's exactly how things were in the 1930s. Healthcare was unaffordable to the degree of public outcry, which is why universal healthcare legislation was introduced repeatedly and stifled by the AMA every time. In fact, early health insurance programs were designed to bypass pay-as-you-go medical fees because they weren't meeting the needs of the hospital or patients. It wasn't a tenable system.
In 1930's the national spending of healthcare was like 4% of GDP, while now it is like 17%. If we could go back to the 1930's on that I'd take it.
The problem is not that the AMA was able to attack socialized healthcare, but that the AMA was able to dictate who would be able to practice medicine, what their education should be, how much they should charge and how they would organize.
Any american could go abroad to a country like say, Argentina, get free medical education and come back and treat patients without half a million dollars debt. But its illegal.
We live in an aging society, so the GDP metric is misleading.
Although, we certainly do spend irrational amounts on healthcare, partly because consumers don't bear consequences for going with the pricey procedures.
There's also numerous layers of regulatory capture, artificial scarcity, and rent-seeking in order to protect various industry-wide or regional cartels. The combination of that with consumers who have no reason to care about price is a potent recipe for price gouging.
The AMA is one of those. Hospital associations, medical device associations, phamaceutical associations, electronic medical record companies, and so on all take their cut.
The idea that debt is limiting the number of doctors is laughable.
I think public investment in educating medical providers is too small (it shouldn't be profitable to wrap a provider in like 5 people...), but doctors that aren't total fuck-ups are doing great by the time they are 45. We are likely in a supply constrained situation right now, prices would be nicer if there was excess supply.
Are you sure it's illegal? Like 80+ percent of the doctors in my metro area got their degrees in India (where they immigrated from). There is some form of reciprocity going on.
Foreign doctors still need a US residency. The number of slots for residencies is capped. I could imagine a world where the US signs reciprocal agreements with EU countries to honor their medical professional training without a residency. I cannot imagine the same for India or Argentina.
It isn't just unionized people that don't care about prices. Most people on Medicare or Medicaid do not care... that's like 1/3rd of the country right there. And among the highest per-capita consumers of healthcare.
There's plenty of people on Obamacare who are getting heavily subsidized low deductible policies, and paying very little.
The government is the largest employer, and most government employees do not care about prices.
Throw in those who are unionized or at cushy stable jobs with low deductible plans, which is innumerable millions more.
I'm thinking at least 75% of the country has little reason to care about prices, and even if they did the system is so byzantine that there isn't much they could do if they did. This is all an interlocking and self-reinforcing problem, which rewards the various layers of the healthcare industry with windfall gains irrespective of their own quality.
And all the staff at every specialist’s office dedicated to navigating the insurance & provider bureaucracy. Or every party having their own crappy payment & client portal - often created from scratch!
I think everyone here recognizes the insane inefficiencies of US healthcare. Maybe single payer could help streamline things. Or what if this price disclosure requirement could be wrapped into a more comprehensive system that allows all parties choice and visibility and interoperability?
FWIW, HDHP+HSA has worked great for me. Low premiums and I’ve built up a significant nest egg in the HSA over the 8 or so years I’ve had plans that used them.
I know it doesn’t work great for everyone though and I’ve seen some discussion that it doesn’t bring down costs because of the lack of transparency in pricing preventing comparison shopping (which is also my experience).
High deductibles are one way that consumers can be made to care, but obviously that has its own problems. Single-payer would not fix the problem by itself, either... although using monopsony power could certainly help, if executed competently.
Merging a single-payer approach with a high deductible approach could work, and the deductibles could actually be paid via a government-filled HSA account that one could rollover into a retirement or college savings account, if unspent.