We really need to switch to a National Health Service style of administration of health costs. Right now we have Medicare which makes unilateral cost determinations, and doctors and hospitals end up accepting below-cost reimbursement that because how could they turn away all the retired people, but they end up subsidizing these unilateral decisions with money from private insurance payors (namely everybody who's working).
Medicare might not technically be a monopsony, but it acts like one, and all the rest of us working folks end up paying the gap that rounds out the rest of the costs.
We have a few generations that have had easy lives, where they had easy access to homes, to higher education, to wealth building, and decided to cut off access to the same as soon as they got it, while still living off the labor of current working people that are not even allowed to build new apartments next to these wealthy people while they pay for all their health care.
The economy is a massive multiple player rpg with a point system economy that's fixed by federal and state laws, and it's been rigged both at the health care level and at every level to extract wealth for those that had it easy in the past.
The dirty little not-so-secret is that we pay doctors too much in the US. To the tune of several times as much as other large developed countries, like Germany, France and England. Medical care in the US will never ever be as cheap as those countries as long as the providers here earn 2x or 3x.
That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Another part of the problem is the bloated administrative bureaucracy of hospitals in the US, we well as the fact that you aren't allowed to build a new hospital (and yes, this is actually true) unless you can prove that a hospital is needed in a particular community.
With no competitive market for healthcare providers, nor a competitive market for places where they work, why shouldn't they extract as much as they can from the rest of us?
They get away with it, too, because "medical doctor" is one of the highest trusted and most reputable professions. It's badthink to discuss these things in polite company.
Until we fix those things, it simply doesn't matter how the insurance/payment system works. Every time I hear that we need to get rid of private insurers, nobody can seem to explain how doing that will save more than 10-15% despite the fact that insurance companies have a statutorily-limited profit margin.
The shortage of physicians has nothing to do with medical schools. The immediate bottleneck is a shortage of residency slots. Every year, students graduate from medical schools but are unable to practice medicine because they don't get matched to a residency program. (Some do get matched the following year.) This is primarily due to limited funding from Medicare, although some residency slots are funded from other sources.
https://savegme.org/
I agree that certificate of need laws should be repealed to increase competition between healthcare facilities. That only impacts some states, not the whole country.
https://nashp.org/state-tracker/50-state-scan-of-state-certi...
That's not true. You can look at the residency match for 2025 here:
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
While many specialties are fully filled, we need pediatricians, family medicine, and internal medicine docs. They're generalists and where the largest shortage is. There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
> There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
You lost me...from your cite[1]:
I'm curious what conditions merit a "match".Aren't a lot of these shortages scattered around rural areas where young doctors really don't want to move to? I understand from a buddy who is currently in med school that there are all sorts of incentive carrots being deployed to attract doctors to these underserved communities.
[1] https://www.nrmp.org/wp-content/uploads/2025/05/Main_Match_R...
There's a video as to how the match works here:
https://www.nrmp.org/intro-to-the-match/how-matching-algorit...
Basically, you interview at a bunch of programs and then rank them. The programs (hospitals) rank applicants and then the algorithm does its magic to "match" applicants to programs. Now, if one doesn't match with any of them, there's something called the scramble where a med student works with their program to match into a program somewhere in some specialty that has room. This is non-ideal, but can work out.
Generally speaking, the match algorithm is setup to guarantee all U.S. medical school graduates a match somewhere in something. In may not be what you want, but you will have a job. Then, preference is given to things like the island schools (affiliated medical schools in the Carribean, which are very expensive, but somewhat easier to get into), and then to other international medical schools. Somewhere in there are also foreign physicians who want to work in the U.S., but are forced to redo residency.
I don't know everything about how it works, but that's the general idea. To that end, I don't fully understand the stats you pulled from the reference. That doesn't mean they're not valid, but I don't know.
And, yes, often times, there are open slots at some program in the middle of nowhere. As much as there can be incentives such some debt relief by working in rural hospitals, the jobs are not a good fit for a lot (most) people. I mean, someone just worked extremely hard for 10 years or more and you want them to go live in a town of 10k people. It's not that it's not important, but you can't force people to do it and it takes a particular personality to be happy there. A lot of highly educated people want to live in urban centers with amenities. Not all, but probably most.
Places like Canada use their foreign docs to fill this rural gap. A not small number of the rural docs are foreign born and trained and they essentially work this crappy jobs until they have permanent residency and then they move to more desirable markets. It's a trade, I guess, but there's not a small amount of resentment about it.
Appreciate the perspective.
> A not small number of the rural docs are foreign born and trained and they essentially work this crappy jobs until they have permanent residency and then they move to more desirable markets.
Not sure that I follow how "rural" necessarily begets "crappy" though. Is the working quality of life somehow that much worse, or is it the relative social isolation and/or lack of recreational options while off duty, or is it really just a case of urbanite out of their accustomed habitat?
It's a combination of factors. Rural hospitals and clinics tend to be under-resourced with lack of equipment in buildings that aren't particularly nice. As far as small town, if you like it, great. However, people who are highly educated tend to like to be around others who are similarly educated and that's difficult to find in a rural town unless it's also a university town. There tends to be a lack of school options for their children and given how much they spent on their own education, they tend to prioritize this highly. There tends to be a lack of town infrastructure like good grocery stores, or theater, or museums, or other amenities. Docs also have their own medical needs and understand that those can't be met at small clinics, so they like to have access to good hospitals. Imagine intimately knowing all the ways something like childbirth can kill you and also knowing that there's not an appropriately trained surgeon in town. By the time one finishes their training, they're probably in their 30s and may want to find a partner. Options tend to be limited in small towns. On the darker side of things, foreign people are often not particularly welcomed in rural towns and this can be a particularly bitter experience for the foreign docs that are essentially forced to work there.
So, no, it's not just an urbanite out of their comfort zone. There's a whole host of issues. And, to be clear, we need people to work these jobs, but it's not particularly pleasant for a lot of them.
Ahh, grokked. Thanks for helping me better empathize with such a nuanced situation.
That's largely a separate problem. Most teaching hospitals aren't located in rural areas.
My statement above was correct. There are students who graduate from accredited medical schools with MD/DO degrees but don't get matched. Part of that is because some of them simply don't apply to programs that have extra openings. Medicare / Medicaid pay primary care physicians below market rates so students are naturally reluctant to pursue those specialties.
If they don't match, they're allowed to scramble and move into one of those programs with open positions. If they don't choose to, that's on them, but it's still not a problem with number of residency slots.
I very much agree that pay is a barrier to entering specialties like family medicine. Though it depends on the market, I normally see family medicine at around $200k/year and that's not great if one needs to take something like $750k debt to get there along with eight years of training after a bachelors. If we want to fix that, then we need to make the value proposition better and reduce the medical school debt, improve working conditions, and/or increase pay.
So, yes, if one wants to maximize their earning potential, then they need to enter one of the specialty residencies and fellowships. Those are currently filled. However, that's not where the biggest need is and I contend that's not why there's a physician shortage.
But aren’t the specialities where the highest salaries are? So to reduce costs, shouldn’t those have more slots?
Doctor salaries alone do not account for the hundreds of billions in profit that health insurance companies extract from us. You are right there is not a competitive market place because the US government cannot provide a universal plan for anyone. We all know the insurance companies would fold overnight as government welfare programs are extremely popular (just look at how much corporations love government welfare).
Odd how the most popular programs in the US, social security + medicare, are the ones with zero means testing.
Maybe let's not blame one of the few only noble professions left in our greed fueled world.
Blame the hospital administrators or pharmaceutical reps before you start blaming doctors.
It’s a red flag whenever someone talks about healthcare and they focus on health insurance companies and hospital administrators. It’s a sign that they’re working backwards from some ideological beef rather than looking at where the costs actually are.
Health insurance companies have profit margins around 5% or less. Hospitals are half that. A Subway franchise has a higher profit margin. That’s just not where your healthcare dollars are going.
Hmm...sniff test sampling:
- HCA[1]: FY25 profit margin = 9.0%
- UHS[2]: FY25 profit margin = 8.6%
- THC[3]: FY25 profit margin = 6.6%
Yeah, a bit of disaggregation is likely needed here, but in these companies, labor expense as a percentage of revenue is on a declining YoY trend while revenue continues to grow.
What's the prevailing ballpark ratio of doctors to all other hospital staff again? And what details are buried in that ever so opaque and increasing "other operating expenses" line item?
[1] https://www.sec.gov/Archives/edgar/data/860730/0001193125260...
[2] https://www.sec.gov/Archives/edgar/data/352915/0001193125260...
[3] https://www.sec.gov/Archives/edgar/data/70318/00000703182600...
If you have a fixed profit margin, the way to make more absolute money is to allow your costs to increase. Insurance companies have zero reason to negotiate prices down.
Well not quite. Health insurance is still a competitive business. Customers — both individuals and group buyers — are very price sensitive and while switching plans is a hassle they will change from Aetna to Humana or whatever if the difference is large enough. And many of the largest carriers are non-profit corporations so there's literally no "profit", although some of the employees are very well compensated.
All the highest compensated non executive level employees I know are doctors, who would be highly compensated at every business. Same for all the executives, whose pay does not seem outsize compared to executives at other similar sized organizations. If anything, health insurance companies are known to be pretty stingy with pay unless you're in high demand, e.g. doctors.
The issue is not that health insurance companies make too much money (ok, it's not the only issue)They, along with the system they put in place introduce immense amounts of friction into every medical interaction and prevent doctors from practicing good medicine.
You're giving doctors a little too much credit. While most of them have good intentions and try to act in the best interests of their patients, something like a third of the care they deliver is considered "low value" in that it's not evidence based and isn't likely to benefit patients. While some of the friction caused by health plans is just pointless waste, the utilization management processes can actually nudge doctors towards practicing better medicine.
https://www.bloomsbury.com/us/price-we-pay-9781635574128/
The insurance companies are not stopping the government from paying for everyone's healthcare. It's the other way around, governments are using insurance companies (better referred to as managed care organizations since they don't really sell insurance) to add the friction so that some people get more healthcare and some people get less.
Who gets more and who gets less depends on who has political power (that's why the old and non working get subsidized by the young and working), and in a democracy, this question ultimately comes back to the voters.
Bottom line is due to demographics and restrictions in the credentialing process (including for medicine itself, one of the costliest components of healthcare), there is nowhere near enough supply of healthcare relative to demand, AND due to the enormous damages awarded in lawsuits in the US, the cost of liability protection is sky-high and increases prices for every step of the healthcare chain.
We need way more healthcare providers, and tort reform, and publicly funded medicinal trials, and without that we will continue to limp on with this bureaucratic maze to essentially reduce demand to manageable levels.
That is no longer true. What we have historically referred to as “health insurance” companies responded to ACA margin limits by becoming sprawling behemoths whose rampant self-dealing makes such profit margin calculations meaningless.
The problem is that health insurance companies squander immense amounts of money on adjudicating claims. Huge amounts of GDP are spent on fights between insurers and providers over what is covered.
You can deduce that cannot be true using the medical loss ratios, which is money flowing out to healthcare providers. At roughly 85% or so, that means 15% is left for the entirety of the rest of the business, including adjudication.
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
That is not to say the adjudication process is done well. In fact, it is hugely wasteful, either intentionally or unintentionally, and the problem is that the government does not audit the insurance companies often enough, nor does it levy penalties sufficient to incentivize proper and efficient adjudication.
The government should be doing constant random checks on claims to see if they were processed and adjudicated in a timely and efficient manner with a sufficiently low error rate on behalf of the adjudicators, and the government is basically doing none of that.
Show us the data. You want to make the claim, bring the evidence.
shimman claimed
>hundreds of billions in profit that health insurance companies extract
yet no request for evidence?
Here's data for medical loss ratios:
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
Here are the sub 5% profit margins for the publicly listed insurers. On the same website, clicking on the "Revenue & Profit" tab will show you that all of the health insurers, combined, earn less than $50B of profit per year, and most of that is probably not even insurance related since a large portion comes from UNH's enormous healthcare provider business.
https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...
https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...
https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro...
https://www.macrotrends.net/stocks/charts/ELV/elevance-healt...
https://www.macrotrends.net/stocks/charts/HUM/humana/profit-...
https://www.macrotrends.net/stocks/charts/CNC/centene/profit...
https://www.macrotrends.net/stocks/charts/MOH/molina-healthc...
The above obviously does not include the many millions of Americans covered by non profit insurers, such as Kaiser Permanence, Providence, Cambia, and the various Blue Cross plans.
Here are the 5 year returns for the above businesses compared to SP500:
https://i.imgur.com/S8bNSM2.png
Suffice to say, you would not want to be a shareholder of a health insurer.
> The dirty little not-so-secret is that we pay doctors too much in the US.
Doubt.
> That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Now explain this trend[1].
[1] https://fred.stlouisfed.org/graph/?g=1T22Y
No, they are not paid too much. There's a lot of incorrect assertions here, so it'll take a lot to work through them.
Physician pay depends on specialty, but it can range from the low $100kish mark for pediatricians to $500-750k for certain kinds of surgeons. Family medicine tends to be around $200k. However, this amount ranges vastly by market and top pay often goes to those willing to work in more rural hospitals because no one wants to. For example, pay in NYC for physicians is appalling low compared to the rest of the U.S. market. In addition, certain systems have hard caps. For example, the VA hospitals cap physician pay inclusive of bonus at $400k. This is documented and you can in fact just look up a random doc at the VA with one of the many federal pay search tools.
While some doctors can make more, it typically because they own a practice and that increased pay comes from good old fashioned capitalism. Meaning, they tax the amount their nurses, NPs, medical assistants, etc. make just like all businesses make money per head on their employees. Whether you believe this is right or wrong is up to you. However, this is not any different that someone who runs, for example, a yard care business. More accurate pay can be found by those who work directly for large hospitals.
Next, the cost of medical education in the United States is vastly higher than other countries. Right now, medical school will cost you somewhere from $400-600k. This is in addition to whatever debt accrued during undergraduate. Further, medical school applications are highly competitive, so students often accrue additional debt by completing a masters in something like public health prior to entry to medical school. This means that someone may have upwards of $750k of debt when they finish medical school, but they still have somewhere between 3-10 years of residency and fellowship before they make attending money. During this time, the debt accrues interest and balloons.
Now, once you become an attending, you're still not good and expenses are vast. Shift work can vary from something like 7 12-hour shifts in a row for intensivists to 14 shifts in a row for hospitalists. Note, just because it says its a 12-hour shift doesn't mean you work 12 hours. They still need to chart and bill and if it's busy, that may be another few hours after the shift is over. In some remote clinics, an ER physican may work 7 24-hour shifts in a row. That may sound absurd and unsafe and it likely is, but it's the reality of the work. If someone is working that schedule, they have increased expenses to just, frankly, live. On the low end, it's very difficult to cook in that environment, so you have to buy a lot of premade food. On a more expensive end, having children on this schedule is extremely difficult. You either require a spouse that doesn't work or you need something like a night nanny. If you're working 12 hour shifts, you must sleep at night and you can't be up to take care of a baby otherwise you run the risk of killing someone the next day. Unless you're paying someone under the table, current nanny rates in large markets are about $20-25/hour. Insurance rates are also high. I don't mean malpractice either. Generally speaking, one needs to carry disability insurance because if one gets into a car accident and breaks their magic hands, there's no way to pay back that debt otherwise. These policies are thousands a year. That's just the start. They pay a large amount of money to buy their time back because they don't have it.
Next, there's a myth about limiting residency slots in order to increase pay, at least recently. I will not defend the AMA and some of they took, especially in the 1990s. Here's the 2025 residency match data:
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
The number of offered and filled slots is on page 2 (or 13 depending on how you count). Some specialties filled all of their slots. Where the U.S. vastly lacks is pediatricians, family medicine, internal medicine (who can work like family medicine if need be.) Pediatricians had 147 unfilled slots. Family medicine had 805 unfilled spots. Internal medicine had 357 unfilled spots. These spots can be filled by people who graduated from U.S. medical schools, island medical schools, Mexican medical schools, or a vast array of other foreign medical schools. However, they're not filled because they don't have the applicants. That's not medical school collusion. That's the hard reality that medical school is extremely expensive and the training is extremely long.
Now, how do other countries handle things? One, their medical school is not as crushingly expensive. Two, places like Europe cap the number of hours a physican can work. If you want to pay American physicians less, you'd need to blow out their medical school debt, reduce their hours, and offer better benefits. Until then, no, really, they're not overpaid.
If you want to start pointing fingers, try the vertical integration of insurance companies, pharmacy benefit managers, and hospitals. I don't have the numbers readily available, so I'll stop here. But, really, it's not the docs.
Potentially. The issue is how do you manage solvency.
State Medicaid and Workers Compensation funds were already insolvent before the 2024 election, and as such most states lack the fiscal overhead needed to fully support a fully funded single payer program today.
It would end up the same way the NHS has in the UK.
Vast swathes of the US are deeply fiscally troubled due to the impact of the COVID pandemic, and if that is not solved then we cannot even start to contemplate single payer.
This should not be used to justify austerity which is not the answer and does more harm than good, but points out that a reckoning is needed. From my personal experience dealing with the current crop of state and local politicos, it's looking dicey in portions of the US.
Edit: can't reply
> Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever
Yes. But you need capital to build an insurance fund. And a large portion of that is going to service existing liabilities.
Going single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever.
The core issue is it suddenly destroys a large number of companies and removes millions of unnecessary jobs from the economy. That’s a great deal of wealth and a great number of voters who don’t want you to save hundreds per month by making them redundant.
Yes, and that national administration has to include national standards of care. The government should set cost-effective standards of care for various scenarios. Then doctors should have immunity to lawsuits as long as they followed the standard of care. You shouldn’t be able to sue a doctor and get some expert up there saying he should have run these additional tests or tried this additional treatment.
You can sue anyone for anything. That doesn't mean you're going to win. It's already extremely rare that a physician who actually followed an established standard of care to be found liable in a malpractice case. We should be hesitant to prevent anyone from seeking redress through the courts.
I'm also skeptical about putting the federal government in charge of establishing standards of care. We already see that some medical conditions have been heavily politicized by certain patient interest groups. And while evidence-based medicine is great, we still have nowhere near enough data to establish clear clinical practice guidelines for medically complex patients.