A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
It doesn't matter what they charge if the patient doesn't pay it; which is what often happens with uninsured people showing up at the ER.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
It often happens with insured people showing up at the ER as well. Many patients don't pay their bills, either because they can't afford it or are just deadbeats. As overall healthcare costs have increased, insurers and employers have shifted more costs to plan members through higher deductibles / co-pays / co-insurance. So hospitals end up with a lot more bad debt, and this in turn causes further price inflation.
Carriers and providers don't make this easy, either.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
> All insurance should be non-profit.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
> Aren't their profits regulated regardless?
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
> One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the profit ratio that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed]. Over the long term, investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve dynamic doesn't magically change, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
Maybe the only solution to rising healthcare costs is to slow down the pace of medical advancements. People love to point out how cheap care is elsewhere, but the most advanced and costly treatments usually become available in the US first, taking years or even decades to spread. (Note, higher prices on pre-existing tech subsidize the cost of bleeding edge treatments, so comparing MRI prices isn't very helpful.) Moreover, people elsewhere don't really know about them so it doesn't detract from their perception of the quality of care they receive. If you're dying and the doctor says there's nothing he can offer you, then that's that and no ill feelings toward the medical establishment. If he says there is something but it's gonna be crazy expensive or there's a shortage/waiting list, now your pissed.
The bigger factor in the American system is taxes. If everyone in the healthcare industry stack, from suppliers to nurses, is exempt from federal and state taxes, healthcare costs could come down by 70%+.
No. Under EMTALA, hospitals are required to treat anyone who shows up to the ER regardless of ability to pay; this is an unfunded mandate.
I'm not necessarily opposed to making all health plans non-profit, but that's kind of a red herring. Many of the largest insurers, like most Blue Cross Blue Shield Association members and EmblemHealth, are already non-profit. They generally don't charge plan members any less than their for-profit peers.
"Insurance is a scam that lets the rich get richer. All insurance should be non-profit." Such empty platitudes never made for a good argument.
> They are not taking any losses;
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
No, this absolutely does not explain the US's wildly off-base per-capita expenditure because uninsured people still go in the denominator of the per-capita figure! I'm sure the per-insured-capita figure is worse but that's not what we are comparing!
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
The fun part is when you break those numbers down between government and non-government expenditure. You’ll find that US governmental spending on health care per capita is higher than every other country’s entire (gov and non-gov) spending per capita.
https://www.oecd.org/en/publications/health-at-a-glance-2025...
Could this be because US gov healthcare spending takes place mostly via Medicare, which is specifically for people 65+?
Per capita stats are computed based on population, not per treatment or per person eligible for treatment. The US spends more per head on giving only a fraction of them subsidised healthcare than other nations manage on universal health, [more years of] education, [more generous] welfare payments etc. Some of that is down to medical professional salary discrepancies, but some of it is down to a terrible system...
>"Per capita stats are computed based on population, not per treatment or per person eligible for treatment. "
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
The spending per capita, unless I’m mistaken, is just “per person in the country” not “per person insured by the government”.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
Close to the same percent that doesn’t have employer coverage, they’re saying, those too old or ill to work fulltime.
I say convert SSA to UBI, set a floor, and let the price of things find a new level with more people in the marketplace:
That number seems hard to believe? Specifically that non government spending would be this low. Presumably "compulsory" includes way more than direct government spending.
https://data.worldbank.org/indicator/SH.XPD.GHED.PP.CD?locat...
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
In that link, government/compulsory for the United States seems to indicate times when an insurance company covered it. Voluntary/Out of Pocket is when insurance company wasn't required to cover and did or person paid out of pocket.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
That interpretation would require me to believe that a Canadian pays, on average, only 12% less out of pocket than an American. $2483/yr vs $2186/yr.
That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
So what's the solution? Some states have already limited malpractice liability but that hasn't done much to hold down costs. When patients are harmed by preventable medical errors they should be compensated.
The solution is NOT to decide on one problem at a time to all agree on solving by incremental compromise, or trust free market competition driving what is in reality a non-free market.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
That's a non answer. The medical profession is already embracing evidence-based medicine as well as specific tools such as checklists and EHRs to reduce preventable errors. But there will always be some providers who are simply sloppy or incompetent or even malicious. Nothing else you proposed is actionable, just vague complaints and hand waving.
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When patients are harmed by quacks, it is a true problem and those quacks should be incarcerated and never allowed near medicine again. If there are too many quacks, then this is a systemic problem that needs to be addressed completely separately from malpractice and professional insurance.
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
That's a silly comment. There's a huge difference between establishing civil liability versus a criminal conviction, and rightly so. The quacks aren't going to be incarcerated.
I think instead of my comment being silly, it's just difficult for you to understand because your Overton window only allows people who agree with you but differ on how much compensation should be allowed and the particulars of how that compensation is decided and doled out.
I'm used to this though.
Uncompensated care attributable from uninsured patients is ~2–3% of operating revenue/costs. So it's there but not massive.
It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
Here's what happens in my locale. If you show up in an ER, they quickly decide whether you need emergency care, or regular urgent care, delivered in the same facility. And medicine is anything if not statistical, so they know the amount of each kind of service that they need to plan for.
Usually tied to employer coverage contracts, and with strictly limited menu of offerings for patient health needs.