ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.
I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.
10 days post denial, I was able to get the procedure approved from these efforts.
21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.
This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.
Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.
They got billed exactly zero.
Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.
Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.
You can be fine for years, but a single, major medical event can zero out those salary gains and lead directly to bankruptcy. It's a systemic flaw that isn't obvious until it's your turn to deal with it.
Then all of a sudden fall ill, lose everything and return back to India.
People keep forgetting the US society is a giant stack/pyramid ranking system, the structure keeps getting narrow as you move upwards. You get pushed off the sides, in the ever narrowing funnel, and you need increasing levels of luck at every level to survive.
BTW, this is not just with regards to health care. You could lose your job, suffer from ageism. Lose your home, run out of money. A million different things can happen, that can cause the above said phenomenon.
Its shortsighted and plain stupid and properly selfish move. It works rather well short term if one simply doesn't give a fuck about suffering of others, but even thats shortsighted and stupid long term - we live in hyper-interconnected society and not some prepper wet dream, what goes around always comes around.
Another similar is public education, literally defining future of society. How dumb is to not have it in stellar shape, shitting on one's own kids and mankind future.
But hell will freeze sooner than majority of americans will realize and accept that. Till then, if its important enough for you, you can vote with your feet, its easier than ever.
More importantly, it doesn't solve the real problem. You're still subject to the same system. Fighting for prior authorizations, staying in-network, and navigating all the other administrative friction.
More than likely they'd find a way to make you go bankrupt rather than pay up. That or deny till you die.
I’m on the cheapest plan my company negotiated and my premiums are basically zero, because I’m young enough that most years I don’t spend more than a thousand bucks on health care (for me and my kids). Couple years ago I did hit the out of pocket max, though, and they did indeed cover everything from that point at 100%. I would never have gone bankrupt.
You can pay a lot of money in premiums, have a $0 deductible, and now OoP maximum, and still end up having claims denied.
I realize some people are stuck with UHC. I’d turn down a job unless it was perfect in every other way and paid extremely well if they only had UHC plans.
Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?
Yes. Everything that they are trained and able to do here, is covered by the national insurance, at least where I live.
We never even have to explicitly ask them to approve anything, it's all automatic. You don't see the bill.
You might have to pay the difference for "nonessential upgrades", like a plastic cast instead of a normal one when you break your arm. Had to pay 5.00 EUR for that and it was the only time I had to pay out of pocket in my entire life.
This is exactly what happens in the US. It's just that in your case the nonessential upgrade is a $5 cast. Sometimes the nonessential upgrade is an expensive surgery. My grandfather had heart surgery at 86 shortly before he died. My relatives went to 3 surgeons who all refused to perform surgery on the grounds that he was too old and frail for the procedure. Then they went to a fourth who agreed to perform it. The first three doctors were right, and he died a few months later. The insurance company quite correctly denied the claim and my family ended up fighting them over a bill for open heart surgery north of $50,000.
Your government wouldn't (and shouldn't) have paid for that surgery either. I think the real difference is that since you have a government system, that in your country that unnecessary surgery just never would have happened in the first place. I will admit this is a more efficient system, but it is no different in that there is a cost benefit analysis being done over what gets paid for and what doesn't whether you see it happening or not.
Diagnostics aren't free, either: many (most?) countries do not have anything remotely resembling the private offerings that Quest Diagnostics and Labcorp provide (breadth of tests, 3+ different methodologies for some tests, etc.)
I had an MRI denied for a partial pectoral rupture. Which was a routine diagnostic as a precursor to open shoulder surgery to determine the extent and location of the rupture to figure out if surgery was absolutely necessary and to prep a viable surgical plan.
I had to fight the insurance company with the assistance of both my surgical and non-surgical sports medicine doctors.
The good news though appears to be that I imagined the entire thing, because denials for routine things never happen.
And from my personal experience with narcolepsy, AI is a much better doctor than most human doctors.
To give an example, about 60 to 80% of the time, when I visit the dentist for a regular cleaning the charge is denied and I have to submit additional paperwork to convince them to pay it. I can't think of any more simple and basic procedure than that.
I have no idea why your experience with healthcare in the US is so much better, but I can assure you that there are many people whose experience is more like mine.
Yes, if that's an indicated and effective treatment.
Do you think people should just be left to die if they can't pony up the dough in the hospital? Oh, your card's declined, no oncology ward for you?
What if they have a 99% likelihood of death, are unlimited funds expended in this case?
What if there's a shortage on drugs - who should get the limited supply available?
Which country with public health options pays for biologic medications or similar patient-tailored solutions?
It depends on what would be an effective and indicated treatment.
> What if they have a 99% likelihood of death, are unlimited funds expended in this case?
Then treatment would neither be effective nor indicated. But if it was your parent, your child, your granny, wouldn't you rather they at least try?
> What if there's a shortage on drugs - who should get the limited supply available?
The people for whom treatment is most likely to be effective
> Which country with public health options pays for biologic medications or similar patient-tailored solutions?
The UK, for a start.
We're not the customers of healthcare, insurance, mortgages, etc. The planet's wealthiest pensioners are. No difference in comp is going to make that work out best for you.
Also, the existence of Cadillac plans implies that someone in our government doesn't believe the population at large should be receiving world-class care. It's like when Senator Biden had two cranial aneurysms, had top surgeons flown in on taxpayer dime, then fought against universal healthcare.
We're all already paying for the best healthcare in the world, just not for us.
We can say whether those maximums are still too high (some really are), but the mechanism is there.
The real issue is that most people don't have a rainy day fund to deal with such emergencies. And that they are too expensive anyway.
There are 2 concepts you should always keep in mind.
1. Always avoid the hospital unless you are literally dying. Surgery centers are owned by doctors who will negotiate a fixed fee, because there's someone to negotiate with (unlike Hospitals which run on the CYA principle). Also, most doctors can do procedures in office, if they have the right one.
2. Medical debt will never lead to collections. Hospitals may sue you, depending on the state, but that carriers reputational risk. A good PR push and a decent lawyer to threaten discovery will be enough to fend off even the most aggressive hospitals - this allow you to setle at a very reasonable price vs what insurance would normally pay.
"Always avoid the hospital" isn't a choice either. You don't "negotiate" with a surgery center for a heart attack, a stroke, or a major car accident, which are some of the common events that cause this. And the claim that "medical debt will never lead to collections" is factually incorrect.
It is the number one cause of collections in the United States. The idea that every citizen can just "hire a decent lawyer" or "run a good PR push" to settle debt isn't a functional or scalable mechanism, nor is it reality.
I'm sorry but if I need a hospital, my first thought isnt, "well how is their reputation".
I don't understand why people defend the insurance system in the US when you're already paying taxes. If it's not the responsibility of the government who you pay to take care of their people in an emergency then what are taxes for. It's like people just accept it because that's how it's always been.
What we have is all-you-can-eat ferrari care
Insurance is what i have when i drive my car , or get water damage insurance for my house.
The monster we have today is not insurance. Instead, it is the frankenstein born out of the womb of bureaucrats and politicians influenced by money. Decades of tinkering politicians without a clue, messing around with the relationship between the doctor and patient, responding to voting patterns of the electorate, led us to today.
Unless you blow it up, (and it will blow up, just like it happened in sweden) there's no solution, except paying more for ferrari all-you-can eat.
I asked one of their counsellors once if they ever have any ultra wealthy people who don’t have insurance and also don’t qualify for any assistance. (This was at a children’s hospital with a Level IV NICU.) She said she was unaware of that ever happening, other than very wealthy foreigners who would prepare in advance, arrange payment in advance, fly in, and have a special procedure done.
Overall, in many states, it is logistically impossible to have an unaffordable bill and also not qualify for assistance. The worst situation actually is the person who has insurance but has high deductibles and copays.
If you do not have insurance, you tell them you don’t. They’ll give you a bill lower than what you’d pay as deductible if you had insurance. Or you just don’t pay…
This raises insurance premiums and reduces the quality of healthcare in a dystopian AF feedback loop.
Norway has only 50k births a year. The US has 3.6 Million, and >40% of those are 100% free to Medicaid recipients. So 1.4 million each year, meaning a story like this is about 28 times more likely to be told from someone in the US than Norway.
When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.
That would be up to their job if they had one of course, but Medicaid does have some cash benefits and if you have a baby on Medicaid you typically get auto-qualified for TANF so that covers a lot of bills.
>When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.
This would only be true if the parents received long-term care or something. And this happens to TONS of people who have otherwise been financially well off, they have to exhaust their assets before Medicaid starts paying for a nursing home. It's got nothing to do with pregnancy benefits.
All I know is a family member would get the Medicaid warnings about their estate each month in the mail.
You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).
I've found that people often forget to call their state senator or assemblyperson. It has consistently amazed me how quickly a large company that's sitting on their butts about a topic will move lickety-split once their Government Affairs and/or PR teams are on the thread...
Another tip from having worked at a regulated entity: a physical letter to the CEO mailed to HQ creates a mandatory-response paper trail that will produce a very, very different (better) outcome than e.g. asking to talk to a supervisor while on a call that's not going well.
That's awful but I'm glad you were able to figure this out. I've had my own problems with insurance companies, but nothing to this level. I can't imagine the frustration, especially with YOUR CHILD'S HEALTH on the line.
Five years back I ended up getting surgery for a herniated disc. I was in immense and crippling pain. Before having the surgery, we decided to go through a round epidural shots. I had done that 20 years previously and it resolved the problem, so why wouldn't I?
Turns out my insurance company (who I will name: BCBSIL) delegated the approval for the epidurals through some kind of extra bureaucratic process with a 3rd party. It took days and additional effort on our end to get approved.
I remind you, I was in crippling pain at the time.
The delays getting this approved lead to me taking more Ibuprofen than I would otherwise have taken, which in turn lead to signs of internal bleeding. I had to ease off the Ibuprofen and significantly increase the amount of codeine (a drug which does not sit well with me) just to get by. Now not only did I have to wait for the approval, but I then had to wait for the signs of internal bleeding to go away before the doctor would give me the shot (which was the right call, even though it sucked).
Delays, compounding delays, compounding delays, all while I was absolutely miserable.
Anyway, I finally got approved and got the shot and it kinda helped, but didn't fix the issue. I had a second shot, got worse, and then decided we had no choice but to schedule the surgery.
The most frustrating thing (but something I am glad for) is that the surgery was approved immediately.
It's so maddening how inconsistent the whole thing is.
Don't forget about the individuals responsible. Both the ones that made the denial decision, and the ones that instituted the internal system that incentivizes such denials.
You know, it is one thing if it is you or I as terrible as that is.
But this was a 6-year-old.
Calling 100's of people Ofc the find one poor guy never heard of such a sum denies this kind of line of questioning. Then the insurance company uses this to deny all claims made by the pharmacy for ALL their patients for that given drug/medication.
The pharmacist told me the mountain of documentary evidence they have to collect to rebut these denials is very large. Once a customer at their pharmacy said he did not want to sign off on a paper that he got a medication, the pharmacist got the customer's ok though to video record his consent, just so he does not have to deal with this mess.
He also mentioned to me that a pharmacist should NEVER pay any kind of reimbursement to an insurance company on a claim that was denied cause that somehow legally can let the insurance company deny future claims. Not entirely sure what exact legal procedure allows them to do that.
Without getting into details, the moment I realized that he was being intentionally obtuse I started looking into options.
First contacted an attorney who essentially said, “Yes, I can do it but I’m going to cost a lot and the insurance company won’t reimburse you for my time.”
Kept looking and discovered public adjusters were a thing. Did some research, found one who was reputable and he took me on for free. Pretty sure we used net, about 2-4 hours of his time.
He told me exactly what was going to happen, how the insurance company was going to react and it played out exactly as he said.
1. He requested a process to take the valuation of everything damaged in the fire to a 3rd party arbiter.
2. Insurance company will send you a letter saying it’s not time for that yet. We will proceed anyway. And we did.
3. He will nominate 3 arbiters and the insurance company will nominate 3 arbiters. Neither will select either of the others nominees and an independent 3rd party will select one instead.
4. The moment the insurance company realizes the valuation of your things will be outside of their control, they will become extremely agreeable. And they did.
And honestly the only thing I really wanted was another week in a hotel for my family because the company cleaning my house of smoke was short staffed over the holidays. Would have cost them likely $1,000 but instead he escalated the situation dramatically.
But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.
I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.
Yes, in USA you get much more money, like you said 2x~5x, but then:
University is expensive as fck. Health care is expensive as fck. You have 5 days of paid sick leave per year in most companies. You have 10 days of paid holidays per year in most companies.
In contrast, in Europe: University was cheap or free. Healthcare is cheap and universal. If you are sick you are sick, either the company or the health insurance pay. You have between 20 and 30 days of paid holidays.
This is why quality of life in Europe, is so superior. And again, I am saying this as a non-European.
One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $60K/year tuition prices. US universities charge on a sliding scale based on the applicants' families' ability to pay.
For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.
For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.
That said, it's entirely possible or someone to go out and sign up for bad investment private university with no aid and rack up $300K of debt by graduation if they're not paying attention to anything, but it's a myth to think that everyone does this.
The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.
As someone from a country (Sweden) that to a larger extent has decreased people’s reliance on their families, and grown the welfare state instead, it’s weird to think that your parents wealth or income should have any impact on things like tuition, once you’ve reached the age of majority
Once I finished high school, my parents had nothing to do with my business as far as any institutions were concerned, and vice versa. But uni was tax-funded and free at the point of use. And when they get too old to care for themselves, it will likely be the government supporting them financially, not me (unless I strike it rich first, in which case I suppose they’ll spend their sunset years in style)
I'm not saying the European system is bad. Certainly there's a lot to complain about with a system that asks 18 year olds to make life-defining decisions about both their career and their financial prospects. But the differences do go beyond whether or not you're on the hook for your tuition.
Also talking about Germany, unless things changed dramatically in the last few years, most natural sciences and engineering degrees don't require a grade point average.
It seems like these are unrelated issues.
Does the wider freedom of choice in US education somehow cause college to cost more? Because more people want to go?? I don’t get it.
> Europeans solve these problems just by caring more about human values
Sweden has higher gross enrolment in tertiary education than the US, and a larger proportion of older students (people who go back later in life to progress their education or change paths)
I’ve heard that in countries like Germany people are often ”locked in” by choices they’ve made at an early age. There’s an element of that in Sweden too (more vocationally-focused high school programs may not give you all the courses that you need to enter all university programs), but that is not too onerous to overcome if you change your mind later (you can do ”foundational studies” to bridge the gap, or just sit exams to prove that you’re qualified)
Edit: but it’s maybe also to your point that universities have limited seats, just like everywhere. Maybe your high school grades or score at the equivalent of the SAT aren’t high enough to study mathematics at the top-rated institution even if you’re qualified, because there are too many people ahead of you. But you will be able to go to uni somewhere to study something
Personally I think the government should get out of the business of these loans, fully fund state schools to make them all free, and let the private schools and the private banking market deal with the rest of it. We were going down that path in CA until Reagan killed it when he was governor. [1]
[1] https://newuniversity.org/2023/02/13/ronald-reagans-legacy-t...
https://en.wikipedia.org/wiki/Public_Service_Loan_Forgivenes...
IIUC, there was a bit of a scandal where the companies the DoE where paying to manage those 10 year forgiveness plans where giving incorrect advice and so a lot of people aren't going to qualify.
https://oag.ca.gov/news/press-releases/attorney-general-bece...
Of course we can blame them for taking $60k out for studying something that will never get them a good paying job, but these are 18 year olds. I was lucky in that my parents are immigrants and were like "absolutely not, this is crazy, go to the flagship state school and study science". I paid off my $24k in loans in a couple years. Many didn't take that path.
[1] Bloomberg archive link: https://archive.ph/IBuzw
This is an extremely important point that keeps getting ignored. People keep comparing _public_ schools in Europe to _private_ schools in America.
To further your point, just about every place has a community college where you can do the first two years of your education for about half the price of the state school. The total tuition for this route (2 years at community college, 2 years at a state school) is going to average just under $30,000 for 4 years. Which is definitely in the "work your way through college" range.
And this is before any financial assistance, which the majority of students receive.
Foreigners talking about how crazy expensive college is in the U.S., but they're likely mislead by people who took out large loans to go to extremely expensive private colleges. There's an easy way to stop this kind of debt - don't allow federal loans for private institutions. But no one is really interested in stopping it.
Not necessarily the case. In Sweden private schools are paid for by the government, assuming they have been approved by the CSN (central agency for study-support(rough translation))
I don't know how that works in the rest of Europe, because I've never studied outside of Sweden. But in Sweden it doesn't really matter if the school is private or public. The only instance you have to pay yourself is if the school isn't sufficiently good to pass muster.
Also, again in Sweden at least, but possibly other parts of Europe as well, the tuition isn't effectively $0. The government will pay any student enrolled in higher education a monthly support. Back in my day it was 10k SEK per month (roughly 1000usd), no strings attached. Not sure how it currently stands but I imagine it hasn't changed much.
This money is meant to ease the burden on students, so that they can put more focus on studies.
"Working your way through collage" over here means you'll have a 20% job to pay for your cost of living minus the 10k SEK mentioned above.
The difference in cost of study is quite real, even taking your comment into account
(I don’t mean to belittle your comment about universities which is factual and helpful. I’m just pointing out that US education system is just as fucked up as the US healthcare system the OP is talking about.)
Even people in the US don't understand why those $200K hospital bills aren't real.
Insurance providers (including government programs) have a fixed limit for what they pay for procedures. They pay min(billed_amount, allowed_amount) so providers don't want to risk leaving money on the table by having billed_amount < allowed_amount. To ensure this doesn't happen, they bill an arbitrarily high number with the expectation that insurance will lower it down to some much smaller number.
So every time you see posts on the internet where people talk about their "$200K hospital bill" they're always talking about that arbitrarily high value. If you have to pay cash for some reason, they will reduce the value to the cash pay amount which is in line with the insurance paid numbers.
Nobody ever pays those high hospital bill amounts.
An FSA really has nothing to do with an HSA.
More or less all high income earners who do not have a chronic health issue are better off choosing a HDHP paired with a HSA - especially if the company provides any sort of matching benefit. Keep that account as an additional retirement account and pay out of pocket for most healthcare needs.
Think of it also as actual insurance vs. a pre-paid health plan.
The math of course changes for folks who are not highly paid, or have expensive chronic health conditions that would result in maxing out the deductible each year.
You are likely thinking of a FSA which is use it or lose it.
If you have a FSA I strongly suggest that you get an HSA instead.
https://www.fidelity.com/learning-center/smart-money/hsa-vs-...
I have the paranoid idea that they designed FSAs in such a goofy way for budget scoring and it drives me nuts.
Which should be illegal. It should be only HSA across the board. Its nonsensical that this is a thing.
I'd love an HSA, but I can't due to my plan (can't do a high deductible plan for $reasons).
I think there may be some loophole in setting up an independent HSA but I haven't looked into it enough, only recently heard of such a scheme
Heck my (prescription) meta ray bans were paid for in part with FSA funds.
Doesn't read that way to me.
My post does seem a bit weird after their edit but at least one person learned something.
So, yeah. Little bit.
"If you have a FSA I strongly suggest that you get an HSA instead."
Did you mean to reply to them?
Why do 41% of Americans have some form of medical debt?
https://www.kff.org/health-costs/kff-health-care-debt-survey...
In the medical context, the only contract in the picture is possibly between the medical provider and the healthcare management organization. It would be fine if providers only sent the fake bills to them as they're both willingly playing this perverse game.
But the problem is when they send their fake numbers to patients as if they're some kind of legitimate bill. Medical bills to patients are presented on a "cost reimbursement" basis - helping you cost them this much, so you are responsible for reimbursing them. By inflating the numbers 3-5x they are straight up lying about the costs they incurred. That's fraud.
This is such a weird excuse for bad policy. Making more money[0][1] somehow means its okay to saddle students with an average debt of $30-40 thousand dollars. A downpayment on a first home would be a much better use of that money, for example.
Really, the average US citizen is nickel and dimed to death with this sort of thing, from health insurance, to dental, to lots of other required but not accounted for as required costs (like cars and associated car insurance).
Not to mention, we have little safety net in the US, you're really going to hurt if you have a bad run of luck after job loss. No qualms in allowing people to become homeless as a matter of policy.
If someone were to ask me, I would say that we in the US have it completely backwards in respect to how the average citizenry is expected to live. Its not thriving, its constantly having some kind of lingering potential disaster to plan for.
[0]: which I sincerely wonder about the true veracity of this statistic
[1]: Don't forget too, that more and more struggle to pay their student loans each year and the trend has generally been that its getting worse, not better.
The implicit policy that student loans are an acceptable and benign form of debt for the average citizen. Everything said after is predicated on this idea.
I don't think thats good policy.
Granted, none of the top universities in my country even makes it to the top 500 in the world, so maybe this isn't a completely fair comparison? Actually, it's expensive by some other EU country standards - public schools in France and Germany, including PSL (ranked 28th in the world) and TUM (ranked 22nd), are free for all EEA applicants, with some nominal yearly registration fees (amounting to $1k in total for a 4-year degree). A more expensive school, like ETH Zurich (rank 7 in the world), is $4500 total for a 4-year degree if you're a Swiss citizen or EEA citizen with a Swiss work permit; it's triple that for an international student.
So yeah, when we say "university is crazy expensive in the USA (and probably UK too)", we're actually talking about the $30-40k numbers you're looking at. $200k and so are almost inconceivable to us.
That's the cost over 4 years. Most people will be able to get financial assistance to help pay for that and you easily manage to make 30k (or less with grants) in 4 years to pay for school. People making below 35k per year are going to pay practically zero taxes. You can work about 15 hours a week making $10 per or full time over the summer to pay for that.
There's no need to take on any debt.
People in the US make considerably more money than those in the EU and, generally pay less taxes so there's a lot more disposable income available. I think people here prefer to be able to just get what they can pay for rather than hope the government will let them pursue the education they want (there are aptitude tests and quotas in some EU countries).
It's not really better ir worse, it's just different.
Sure, if you're a brilliant young mind and can get into Harvard and qualify for assistance with your tuition, you're set for life, basically, in a way no EU university can match. But for the vast majority of the population, the outcomes are significantly better with the EU system.
Also note that the gigantic tuitions at US universities are actually a relatively recent phenomenon (and a similar thing happened in the UK). Even in the 50s and 60s, tuitions were much closer to the current EU norm.
Of course, there is some room between these extremes, especially for unpopular subjects where you hardly even get enough students to fill up a professor's time. And in those cases, you'll also see that EU systems will essentially accept anyone. Typically, for uncompetitive universities and subjects (majors), the only condition is to have passed (gotten at least 50%) for the local equivalent of the SATs - a very low bar.
This is not true at all.()
You quote tuition at the school with the highest endowment in the country. The college cost situation is absolutely still high at the less endowed second tier, and “ordinary” (non-generational wealth, two full time earner) families are paying full price.
() Except in the sense that “almost nobody” goes to any of these schools, comparing to the 50k enrollment at large public institutions.
I went to a 2nd tier in-state school 20 years ago and even that cost 10k a year by the time housing, food, and books, were paid for.
Plenty of people who can barely avoid it end up paying a large chunk of $.
I wouldn't be surprised if this changes in the future, I am talking about the period of my life to date.
> > In Spanish, the Diccionario panhispánico de dudas (English: Pan-Hispanic Dictionary of Doubts), published by the Royal Spanish Academy and the Association of Academies of the Spanish Language, recommends the genderless term estadounidense (literally United Statesian)
https://en.wikipedia.org/wiki/Demonyms_for_the_United_States
> , but to clarify what I mean
You’re restating your point while not responding to the point that OP brought up.
And what they're saying is that this isn't just an indication of how awesome the US is compared to other places, but also of how averse Americans are to learning other languages compared to other people.
Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
No. Yours is uncharitable because it has got nothing to do with how many languages you speak. This is not a multiglot competition. The only point being made is that someone with a fair amount of American exposure will have a head start emigrating to America compared to say an American to Latvia. Or France. Or Germany. Just on the language front in isolation/alone.
> Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. Or maybe they were really just embarrassed to have insufficient command of the Master Language, I don’t know, maybe your version is correct.
> If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg.
I was referring to this specific part of the comment I replied to: "Americans are averse to learning languages as opposed to other people". My response is a very accurate explanation of the reasons why this is a) an unfair way of looking at things, and b) not unique to Americans. What aspect of my response is uncharitable? I'm not saying things should be one way or another, just explaining how they are.
"Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. "
The situation I described has occurred to me more then once, even after I tried to communicate in the local language. English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
"For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg"
Lmao, why are you so angry? I grew up in Australia and south east asia.
Okay that’s fair. I glossed over that part.
> The situation I described has occurred to me more then once, even after I tried to communicate in the local language.
Your interpretation of the chain of events perhaps.
One person goes to a country and meets kind strangers. “Wow, these people are nice to strangers”. Another person has the same experience. “Wow, these people must love me or X attribute.”
> English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
I’m very upset that I speak English fluently. It really inconveniences me. > Lmao, why are you so angry? I grew up in Australia and south east asia.
Do you know what a comparison is? I did not call you an American. There’s no reason to take offense.
If you go to a place that views western culture through a looking glass and is trying to learn English to progress to a better point in life, English is cool, speaking English is cool. Not saying that is a good way for things to be (or that literally every person you will meet will have this mindset), but that is how it is for a significant portion of people.
"Do you know what a comparison is? I did not call you an American. There’s no reason to take offense"
I'm not offended, but your remark was a) clearly intended as an insult and b) demonstrated that you were likely stereotyping me on a very particular way, which runs completely contrary to my actual experience with these matters.
The reverse is not true. European nations aren't very immigration friendly by comparison. On top of that, the US government, assuming you keep your citizenship, does not make it easy to live abroad. US government tax policy for citizens who live overseas is much more aggressive than any other western country, from what I understand.
Combined with the fact its alot harder to go the other way, and the US government does a fair amount to discourage it, I'm not shocked more US citizens aren't moving to Europe.
[0]: At least before Trump returned to office, I'm unsure how much of this has changed.
> The US has for a western country, relaxed standards for immigration
First, let's start with the "Anglo-American sphere" (my term): US/UK/CA/AU/NZ. Of those five, US is the hardest to get a working visa for skilled individuals. The rest are "points-based" system where you can apply for a working visa even before you have a job (95% sure about this -- pls correct if wrong). They are much more friendly. Also, the rules are simpler, clearer, and applied more consistently.
I know much less about other OECD-level (and G7-level) nations, but anecdotally, overall, the process is much more straight forward compared to the US. What the rules say, the rules do. Not so much in the US where they randomly delay or reject applicants without good reason. (Also: Google to find horror stories of what happens when you lose your job in US as a foreigner who does not have PR. Fucking nitemare.) You hear this much less in (to name a few): Ireland, UK, France, Germany, Belgium, Netherlands, Denmark, Norway, Sweden, Finland. (I don't hear as much about Portugal, Spain, and Italy, but quality of life looks awesome!) All of those countries are wealthy, highly developed and have excellent quality of life. All of them welcome skilled migration and have clear programmes (you can Google about them) to get a working visa. Again, strictly anecdotal: The US immigration system is much more adversarial compared to all of the other countries that I mentioned. Oh, and I forgot to add Japan: After PM Abe changed the rules, it is way easier these days to get a skilled worker visa in Japan.
Last point:
> European nations
This circumvents the original predicate, which did not have such a limitation. I know many countries have priority / helpful pathways for STEM career individuals as well as capital investors, but that wouldn't apply to everyone.
Even the US has very different pathways to citizenship depending on various factors. Last time I looked into it as research in depth, there alot of common limiting factors across Europe. Their policies are much more strict once you dive into the nuance.
That said, the US immigration landscape is extremely lopsided, thats a fair point.
>Europe is enormous -- like continent-sized -- with ~50 countries.
I realize, though as a US citizen I also realize that when most US citizens say this, they mean a much smaller contingent of countries, rightly or wrongly. I'm sure Europeans dislike how loose we use the term, but as a US citizen, it usually means cold war boundary countries, so Germany and what was considered western Europe before the iron curtain fell. Thats been my experience. People also generally forget about Portugal and a few island nations. Its a safe bet most people mean the Nordics, France, Germany, the UK, Netherlands and Denmark most of the time, conceptually.
However to be specific, France, Germany, Switzerland, the Nordics, all have strict general requirements to have a path to citizenship. I don't think the average US citizen would be able to meet them.
That alone is enough to put most people out of grasp of doing this, for a multitude of reasons, of which not having the capital is only part of the equation, as you would also need to have a suitable investment on the other side to put said money, not a promise. I'm sure there are other nuances involved too.
Thats before the fact that the cost of a house in California would price most people out of the equation to begin with.
People only live in one unvarnished (more or less) reality at a time. Americans live in America and get told stuff about “Europe”; Europeans live in Europe (or their respective countries if we want to get anal about it) and get told stuff about America. Only a very very small number of people get to live in multiple places and for long enough stretches of time to be able to compare them pretty fairly.
In what kind of dream reality do people come to have such perfect (I’m being hyperbolic) information about other places that they then are able to base their move-or-not decisions on? This is just not reality. People know what their own place is like. They “know” other places through propaganda, mostly.
But Americans are so propagandized that you have to teach them about their own propaganda.
In software the money difference you still end up ahead of where you would be on an equivalent salary in the EU. Also last time I was considering a move to the EU job market was weaker than the US. Also you still need to get all the necessary work visas which aren’t automatic. Even as a dual citizen I can’t just show up to work at a company in the EU.
If 50% of Americans spoke Polish by the shake of a wand, I bet there’d be more Americans in Poland than Poles in Poland.
I could see that the appeal of Ireland can be increasing and Poland sounds cool. I'm not saying that the USA is great, it has tons of problems.
UK numbers yes, though maybe gloomy weather plays a role? Just kidding. That said, Brits are slightly more likely to move to Spain than US despite it being a tiny country in comparison and not necessarily easier to move to after Brexit.
Spain, not sure. It’s tricky to compare since non immigrant Spanish speaking population in US is probably significantly lower than Spaniards speaking English. But yeah, you probably have a point on that one.
Spain’s entire population is 48 million.
I have never met an American that migrated to Spain.
What language do you think Germans and Spaniards use to do commerce with each other? There needs to be a common language, there’s no bandwidth to learn all languages, so due to historical and modern reasons, English prevailed.
Re Australia, Australians have highly preferential options to move to US which is not reciprocated.
That's very subjective, and I would rather have my freedoms instead of your/their liberties, thanks!
While healthcare is brought up all the time this is usually ignored. The idea of parents saving a 'college fund' for their child is something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).
Like most things learned from movies, you're not getting the full picture. Most US universities charge on a sliding scale based on family earnings. For larger universities, tuition can actually be free depending on parental earnings. At the extreme end, some Ivy League universities like Harvard have $0 tuition for families earning less than $200K/year.
We also have community colleges and state-run universities with subsidized in-state tuition. It's still more expensive than free, but the tuition is in the range where as long as you're smart with your degree selection the ROI of getting the degree will more than make up for any loans you have to take on. That said, you can get yourself into trouble if you take out loans to study for a degree that doesn't translate to a job.
(By way of policy bona fides: I'd strongly support forgiving student debt for all for-profit schools, but would oppose forgiveness for degree-holders from universities, which would be a sharply regressive policy).
https://www.admissions.illinois.edu/invest/tuition
This claims $21k per semester:
https://cost.illinois.edu/Home/Cost/R/U/10KP0112BS/15/120258...
Directly from the page:
> Illinois Resident
> Tuition & Fees: $18,046-$23,426
> Food & Housing: $15,184
> Books & Supplies: $1,200
> Other Expenses: $2,500
> Total: $36,930-$42,310
I literally looked at the exact school you used in your example and you are just wrong
Shortly later
I also think you might have to ask around to find a student paying full price for books.
And which today must be read via internet archive
https://web.archive.org/web/20200404172130/https://likewise....
Basically explaining to Armenians at home why their relatives who moved to America don’t send better remittances back home despite their $X pay rate. Here’s why …
University isn't near as big of a problem. That's not something the blindsides you like health care expenses. Nobody is making you spend $300k on university. Got my engineering degree at a public university for ~$100k in total and had it paid off 5 years after graduation. But a $195k hospital bill is something I'd never be prepared for. Nobody chooses to go to a hospital.
There are still reasons why high university costs can be a problem. Teachers, for example, don't get paid near enough to be able to cover university costs in a few years like I was able to. But becoming a teacher requires just as much investment.
But even then, the cost of college loans is far more manageable for even teachers than an unexpected $195k visit to the hospital. University cost is a problem in the US, but I don't think it's comparable to the problem we have with health care costs.
Not to mention, I also gave the example of the tuitions for a Swiss university, and Swiss salaries are typically at least comparable to US salaries, even in CS.
The full time tuition rate at the university I got my engineering degree from is currently $11k /yr. I can't imagine that's even 10x a typical EU university - let alone 100x.
My local community college's full time tuition is currently $5.8k /yr. Either way it's a lot of money, but lets not exaggerate things too far. We're worried about affordable access to education here - not getting everyone into Harvard.
Let's say that's unfair, since the state pays your tuition (though this is the common experience for most French students!). In Amsterdam, one of the best universities in the world, TU Delft, charges €2k/year tuition. Your tuition was less than 10x this, true, but not that far from that. Also, for a common 4 year bachelor's degree, that's €8k in total - your $100k total is more than 10x this.
Again, it's too much. But it's not comparable to emergency medical bills without insurance.
Ha! I wish. It's not free. You will pay the same that Americans pay for Uni over your life many times over since tax rates in the EU are really high. Healthcare isn't exactly cheap either.
And everything you wrote is just the result of decades of prosperity that are now coming to an end. This will be a shock for many.
Is it? I pay 13.5% of my income as healthcare 'tax' for public healthcare. Overall, it is cheaper than US healthcare (as a percentage of GDP), but individually it is still a significant expense.
Many (most?) European countries have private healthcare systems. Switzerland has it and offers some of the best healthcare in Europe and in the world. Similar systems work great in many other European countries as well. The problems with American healthcare are not because it's market-based, it's because how that market is managed.
Some other countries have public universal healthcare. It can work well, but it requires a high-income country with both wealth in abundance and significant government efficiency. It only truly works well in Scandinavia so far. This is not "socialist healthcare" as some will dubiously claim, it's sort of the opposite, which is why it works.
Ok but to be fair most people in the US aren't making "extra $1-200k / year" over a person in Europe. They aren't even making $100k / year to begin with.
He was saying "Most people in the US" don't make 100-200k more, and that they probably don't even make 100k. This was in response to the generalization that "people from other countries ... underestimate how well paid people in the US often are".
Now there was talk of getting the political motivation to change things, so I guess everyone is assuming Medicaid/Medicare/VA recipients don't want to change the system, but that wasn't really established, nor was that really being refuted.
I could have made this comment at the level where it went off the rails, but I thought making it at the leaf level would help everyone involved see the deviation between what was said and what was being argued.
Although I have to say the rosy picture some paint here about the high incomes is counter to anything I ever heard - and saw, although I left the US in the early 2000s, after having lived there for almost a decade (still mostly paid from Germany, never ready to make a complete move).
"Medical Bankruptcies by Country 2025"
https://worldpopulationreview.com/country-rankings/medical-b...
"Healthcare Insights: How Medical Debt Is Crushing 100 Million Americans"
https://www.ilr.cornell.edu/scheinman-institute/blog/john-au...
By the way, Europeans don't quite all have a "nationalized healthcare system". Germany, for example, has "Krankenkassen" but also private insurance, and the "Krankenkassen" are private organizations.
We pay health insurance and get to choose the provider, those with higher incomes can switch to complete private insurance. We also have lots of our own problems and increasing costs because of immigration but more so aging population.
However, I personally know several people who had severe illnesses for a long time, and their normal "Krankenkassen" insurance never made any problems. One person with plenty of money, whose wife was dying, even asked US medical experts if he should come to the US with her, and those US experts said he should stay where he is, the German univ3ersity hospital right next door had some of the leading therapies in the field. She lived five more years instead of dying after less than half a year with the standard therapy, every single expense paid for with the standard insurance, additional private insurance unnecessary. Similar with my stepfather, who had soooo many severe conditions, and yet every single item down to the special medical bed brought into our house so that he could finally die at home was paid without question.
The problems are with more mundane expenses, e.g. glasses, or the dentist, where only some of the treatments are covered. The really expensive illnesses seem to be better covered than the more common and much simpler problems.
The costs DID increase.
I did not try to make a political statement, what happened here, anyway???
I have no idea what there is to defend - even if you assume they will all get high-paying jobs some ay, for the first few years costs will increase while they either learn the language, are not allowed to work (status pending), or get minimum wage jobs (food delivery and parcel services at least in my city now is dominated by immigrants).
Even with your most positive outlook, initially there will be lots more people and the same system (number of doctors), and the numbers of payers increases slowly.
I even wrote "but more so aging population", conveniently overlooked in this strange politicized discussion.
I am NOT against immigration!!! Don't make stuff up people.
You wrote, incorrectly:
> We also have lots of our own problems and increasing costs because of immigration
As the NZZ article explained, health care / Krankenkassen are the area where it is the clearest that immigration is an economic benefit. Look at statements like the section title "Krankenkassen profitieren", followed by "Ein grosser Profiteur der Zuwanderung sind dagegen wohl die Krankenkassen." and the ending paragraph of said section:
> Laut dieser Analyse gab es in diesen sieben Jahren einen Wanderungssaldo aus dem Ausland in Höhe von 4,7 Millionen Menschen in das System der GKV. Für das Jahr 2019 ergab sich daraus eine Entlastung der GKV über etwa 8 Milliarden Euro (umgerechnet 0,6 Beitragssatzpunkte). Seit 2019 hätten sich die Rahmenbedingungen aber deutlich geändert, heisst es dazu von der TK.
So the numbers we have do not support that part of your statements. And I'm not aware of newer numbers that say the contrary - the recent cost increase sees completely different reasons for example, as in https://www.mdr.de/nachrichten/deutschland/panorama/krankenk..., the "but more so aging population" part of your comment fits there.
our blocs aren't that different
except in the US middle class and upper middle class
I'm from the eu and earn far less than these American techbros do, but far more than my American friends who work normal jobs. They work at the DMV, a supermarket, or general office work. You know, normal people. The vast majority.
In fact it's quite low, somehow people are expected to survive on several thousand a year, after the rent, utilities, transport costs are all paid.
https://www.fool.com/money/research/average-us-income/
These are official stats, but unofficial employment puts the number lower:
https://investorshangout.com/carlyle-group-unveils-alarming-...
Can we really say this is true about individuals in the US?
I think it's pretty clear the propaganda machine has successfully privatized health care to the great detriment of the populace and have the clamps on it.
After all, if you told everyone you had a solution where insurance rates would be cheaper, their healthcare system would cost less overall, and the health outcomes would be superior, they would all be like "sounds great". Then, when you reveal this solution is the complete destruction of the insurance "industry", insurance payments are "tax", and the health provider is the government, they would balk, scream about socialized healthcare, and say how they don't trust the government.
That's a trained response, not a real thought.
So when you're talking about how bad the American system is, you're really talking about a minority of its users. That doesn't make everything OK, but does highlight the political difficulty of enacting seemingly-popular changes.
It sure seems that way if a wealth family with top level insurance can still get bankrupt by medical bills. Examples of that are right here in comments.
https://www.npr.org/sections/health-shots/2022/06/16/1104969...
https://rooseveltinstitute.org/publications/medical-debt/
https://www.marketplace.org/story/2024/03/27/health-and-weal...
As for income distribution
https://worldpopulationreview.com/country-rankings/gini-coef...
State GDP figures are skewed by high earners. The US is massively and systemically unequal, with far less economic mobility than the EU.
If you had said the median tech worker? I might have believed you, but the median family? No way.
* Excludes everybody on Medicaid
* Excludes fixed-income seniors on Medicare
* Makes it overwhelmingly likely you have subsidized employer-covered health insurance.
Figure your employer "covers" half the gross cost of your $24k/yr health insurance (they aren't, really: that's money they'd be paying you directly without the distortion of employer-provided health care). Do the take-home pay math. Put them in, like, Ohio, or Iowa, or Colorado; just not SFBA or NYC.
Now move that same family to Manchester, take the wage hit for moving to the UK labor market, and work out the take-home pay. They'll of course pay $0 for the NHS.
Are they better off or worse off?
I'm not valorizing the arrangement, I'm making a point about how political tractable changing it is.
And it would be exactly the kind of political engineering minmax scheme large corps in the US are great at: petition legislators to cut regulations so you can cut costs and maximize profits, but keep juuuust enough of the right perks in the right places so that a slim majority of people in Wisconsin, Michigan and Georgia oppose shaking things up.
That doesn't make M4A bad policy (I think it's bad policy for other reasons), but it does take "people are being irrational" off the table in a discussion like this.
It's that time of year again - enroll for 2026 benefits. My employer raised employee premiums by 10%, raised the deductible, added more administrative burden such as "step therapy" (the insurance company denies your claim for a drug until you've tried a cheaper but less effective drug, even if you've already done "step therapy" while on another health plan!) Your employer will change the plan premiums and structure every single year. They can lay you off, exclude expensive drugs, exclude doctors, etc. Some specialties like anesthesiology and psychiatry are usually not in network. In extreme cases an employer can change health administrators mid-year and your deductible will reset.
https://www.pwc.com/us/en/industries/health-industries/libra... https://kffhealthnews.org/news/article/workplace-health-insu...
(1) You'd eliminate the system of advantages and supports that cause employers to offer private insurance, which is where most people get their insurance from.
(2) You'd create a huge adverse selection problem --- the more effective/useful Medicare is, the fewer families will want to spent $24k/yr on private insurance, meaning the families left on private insurance have a reason to want it, meaning the composition of the risk pool would shift dramatically.
Like, if we ever did M4A, we'd probably end up with a widespread system of supplemental insurance; we already have it with Medicare! But that's not the same thing as keeping your existing plan.
If M4A plus supplemental insurance gives me about the same coverage I have now for a reduced total cost that sounds like a win to me. Even if it ends up costing me the same amount the net improvement from everyone having access to basic health care would still be a win.
The US spends nearly as much in taxpayer funds as a share of GDP as other developed countries (and vastly more on a per capita basis), with even more in private costs on top of it. It is simply dishonest to say that the "wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays", because neither the US wage premium nor any lower tax burden are attributable to differences in healthcare systems, but rather are in spite of the far greater burden of the US healthcare system.
OTOH, it is true that a major challenge is that people respond with this line to any proposed major structural changes to the US system.
I'd appreciate if you'd avoid using language like "simply dishonest" with me in the future. It's easy to tell me I'm wrong about something without accusing me of commenting in bad faith. This is in the guidelines. Thanks in advance!
It's a bit out of date now but the book The Healing of America found that Germany, France, and Japan had world-leading healthcare results, measured by things like survival time after major disease diagnosis, but spent much less of a percentage of their GDP on healthcare. None of them had single-payer. Their systems were pretty close to the ACA, with private insurance companies and a mandate.
They were also different than the US in certain ways. Probably the biggest was a national price list for services. A lot of healthcare isn't really a functioning market; in many cases you're in no position to comparison shop. A result of the price lists was that doctors made a lot less money, but this didn't seem to affect quality.
Other differences included: no claim denials allowed for anything on the price list (which saves a lot of administrative staff), effective national digital records systems (ditto), and the insurance companies had to be nonprofits.
All three countries actually got better bang for the buck than Canada's single-payer system. Japan was the cheapest, spending only 5% of their GDP on healthcare, despite an aging population of heavy smokers. Germany was the most expensive at 13% (compared to US 18%) but covered things like week-long visits to the spa for stress relief.
The author did a spot check on the user experience by seeing a doctor in each country for a shoulder problem, and those three countries worked out really well for him. In Japan the doctor offered surgery the next day, at a very modest cost. They did make do with simpler equipment; the MRI machines were bare-bones but they got the job done and a scan cost $100.
Yes, you can just do the math, and changing nothing about the US except transition to a European style universal system, the median family would face lower aggregate tax, out-of-paycheck, and out-of-pocket costs than they do now, with less health insecurity around unexpected events (either health or employment), unless the tax increases necessary were deliberately and perversely targeted to avoid that.
That’s a direct consequence of the difference in the macro-level costs: they aren’t separate, orthogonal concerns. People just have a hard time accepting that the US health care system is structurally constructed right now to waste vast hordes of money preventing people from accessing health care, but that’s exactly what it does.
I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
Not tax penalizing non-capital income is sort of an essential reform in the era of increasing automation anyway; I'm not sure what point you are trying to make there. The average middle income family isn't making a substantial share of their income in forms taxed as long-term capital gains, so that seems...unrelated to the focus of your argument.
> I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
It does both (particularly, in the “actual care” angle, as regards low-benefit, high-cost measures near the end of life.) We have a system based on denying and economically incentivizing younger people to avoid and defer care, but then doing much less of that with (most of) the elderly.
But taxing capital gains at the level of ordinary income would be an immense change our tax code. All sorts of things the broader economy would change as a result. If you accept Sanders plan, you're not holding to your original constraint of changing only the health financing system.
I want to be clear that I'm not stipulating that families would be better off under M4A if you didn't do this: I still think your argument has the fuzzy end of this lollipop. I think it's unlikely that you will come up with a set of numbers for any proposed single-payer health system that leaves the median family with private health insurance better off on a take-home basis. I'm making a strong claim, so you should be able to knock it down straightforwardly if I'm wrong, and I'm interested to see if you can.
Other countries have healthcare systems that don't generate medical bankruptcies, and don't put a slaver's chain around the necks of employees who risk financial destruction if they have to give up an employer-funded plan.
You're essentially arguing that 500k medical bankruptcies every single year, out of a population of 340 million, is a small price to pay for an imaginary financial benefit that you're convinced exists, for some loosely defined demographic, but which you've failed to quantify.
This is, very specifically, the problem that destroys your argument.
Some people in the US are better off until they aren't.
One serious medical crisis - like an extended bout with cancer - is enough to wipe out the benefits, and leave people who used to be prosperous out on the streets.
Literally. Not as an exaggeration, not as rhetoric, but as a cold, hard reality that affects half a million people every year.
* Free tele psycho-therapy. Not sure what the limit is but it's >= 2 hours per week. I even cancelled same-day once with no fee. The quality of the care was also very high.
* I developed wrist pain from typing, holding a Steam Deck, starting pull ups. I was able to see a physical therapist at the Google office (through an embedded One Medical) after 1 week. No referral needed. Saw them once per week for 5 weeks paying $20 co-pay each time. They fixed my issues permanently.
* I also occasionally used the Google One Medical locations (and public ones) for injuries from a low speed bike crash, vaccines, etc. Don't think I ever paid more than $20 for anything. On a Google income that amount is completely inconsequential.
But the bottom 90% do badly. Society is very divided, and most people lack social mobility, they lack a voice on the national and international stage, they lack the security that either a social safety net or high pay would give them.
The UK is similar, although much less pronounced. I moved to Australia about 18 months ago and society here is much flatter, the difference between the top 10% and bottom 10% is much less. There are still problems here, it's not a utopia, but it's very noticeable how most people are struggling less, and how the top 10% of earners aren't living that different a life.
In both systems, the upper X% can afford it. But it makes no sense to focus on that. What matters is how many don’t have access.
That number is much larger percentage-wise here than in Europe. And it will only increase the way things are going.
The propaganda spin on the health care system in the US has been on overdrive ever since Hillary Clinton wanted to implement some reforms in the 1990s, leading to absolutely massive resistance to any change whatsoever. Even the changes implemented by Obama, which were a HUGE improvement in access, barely made it across the legislative line, and dismantling that access to the health care system has been a huge rallying cry for one of the major political parties. I won't say which one because mentioning that fact results in people turning off their brains and downvoting.
The US healthcare has optimized for availability and higher access to the most treatment options. This does not mean evenly distributed treatment options, but that people have the chance to get access to things more quickly.
And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.
The insurance death panels already existed at the time. It didn't even happen after.
That's what made the whole thing so ridiculous in the first place.
As an individual who has lived in multiple countries in three continents, I dispute that “the care most people get is better than adequate”. Perhaps better than the world average, but certainly not better than in most first-world countries. And that’s not even counting the impact of delayed decisions and denied care, and the stress of dealing with the system overall.
And if you’re looking for more than anecdotes, there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
> there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
Americans aren't dying earlier of diseases that are solvable with a doctor visit, surgeries, pills, or other easy medical interventions. The medically related early deaths are primarily because of overnutrition and lack of exercise leading to pre-diabetes, diabetes, high blood pressure, and heart disease. That comes from public policy mandating car dependence throughout society and huge subsidization of empty calories in the food system. Overeating and lack of exercise are problems that have been stubbornly resistant to the medical system's efforts to change behavior. There's also other heightened early death risks like car crashes, drug overdoses, and suicide, but few of these deaths could be prevented by increased access to the medical system.
This ignores the outsized influence of lobbyists, especially post Citizens United.
The majority (depending on which polls you cite, seems to range anywhere from 57% to over 70%) favor a universal healthcare solution for all citizens. Yet like many other majority opinions, this doesn't translate into legislative action in that direction, in large part thanks to lobbyists and dysfunctional partisanship. None the less policy is not reflecting the majority.
It seems to instead be merely a wedge issue in culture war. Republicans firmly oppose it, Democratic politicians fight for it, and apparently voters don't care enough to advocate for what they say they want in polls.
- The Partnership for America's Health Care Future
- American Hospital Association
- U.S. Chamber of Commerce
- Various lobbying organizations related to private insurance and adjacent systems, like pharmacy benefit management organizations
Politico has a great article about the Medicare For All fight[0]
The opposition spent hundreds of millions of dollars fighting it.
[0]: https://www.politico.com/news/agenda/2019/11/25/medicare-for...
But the largest inefficiencies are all on the providers side. We simply pay practitioners too much, enforce artificial scarcity of practitioners, and prescribe too many services.
So if we're talking about "The American System" as a whole --- which is what the thread is about --- it behooves us first to consider the question "how much better would things be if we simply zeroed this category of expense out". The answer is, to a first approximation, we would get a 6.5% price break. I would not drive even a couple blocks out of my way to get a 6.5% price break on a pack of chicken breasts.
I agree. The complex insurance billing system enables his by obfuscating prices and limiting ability to comparison shop.
Large employers (e.g. Google) are also generally "self-insured" meaning that the "insurance" component is offloaded to the purchaser, the employer of the insured individuals. In those cases, the health care insurer processes the claims from health care providers, determines if they were justified, or if the treatment/diagnostic/drug is justified by coverage determinations of the provider, etc, but the employer (e.g. Google) just pays the claims in the end too.
Oddly enough, all the plots I have seen of cost increases don't show a massive skyrocketing of costs since the profit caps were introduced. If anything, they have been somewhat reduced.
However a reckoning must happen at some point, health care can not consume the entire economy's efforts.
That is the definition of not worth it.
I don’t know if this a case of ideological delusion to go along with political impotence or just the usual upper middle class playing their part in obfuscating the on-the-ground realities. Structurally the latter is more likely.
What is there to disagree with? Are there any option other than introduction of universal healthcare?
Obamacare attempted to make the US healthcare system into a universal system by mandating that people purchase coverage, heavily subsidized to become affordable to every income level, in addition to massive expansion of Medicaid to those with the lowest levels of income or no income at all. Automatic enrollment in health insurance exchanges, even if people did not make their own choices on the health insurance exchanges, is what would make the US system universal health care.
Universal means that everyone has coverage, that the question to the patient is "what insurance plan are you on," rather than "do you have insurance." And making coverage universal has no connection to lowering costs. We need larger structural changes in the logistics of how care is delivered and how the money flows.
Single payer is another choice to be made, but that doesn't necessarily mean that health insurance is cheap, that all the care gets delivered that people want delivered, etc. Medicare is often cited as one direction for this, but most don't realize that private health insurance costs are partially high because they help subsidize the care of those who are covered by Medicare, because Medicare reimbursement rates are far lower than any of the private insurers have been able to negotiate.
Other routes are full decoupling of insurance from employment, full price controls that normalize Medicare and private insurance rates, which either make health care more free market or less free market depending on how you define those terms.
However every year that passes makes any of these reforms more difficult because administration of the costs and billing is getting more complex each year. ICD codes, PLA codes, all that stuff grows in complexity.
HMOs, like Kaiser, may provide a route towards greater simplicity of administration of health and costs.
But implementing any large change will require political buy-in of people, and when we have our current low-trust, high-misinformation political system there's been no way to make any political traction for changing anything. Until we regain a functional democracy or turn to full dictatorship, it seems unlikely that we will see structural changes that improve anything. Hell, we had Republican states actively trying to prevent poor people from receiving coverage from federal dollars. How can we ever come to terms with a change unless that sort of attitude no longer has traction?
I really don't understand this sentiment. It's not like the current state of the US insurance market were based on the principles of a free market. On the other hand, not coupling your health insurance to an employment contract that can be cancelled at will has nothing to do with socialism.
You can probably see where the problem comes in. Take, for example, a politician who campaigns on Medicare for All or universal healthcare. To win an election, they often need massive campaign funding—much of which comes from wealthy donors, including those in the medical or pharmaceutical industries. And once in office, they’re targeted by powerful lobbying efforts worth billions of dollars from those same industries.
In the end, the issue is that politicians can legally receive millions in donations and support from industries whose interests might directly conflict with the needs of the people they’re supposed to represent.
Ultimately though, it is known by most people irrespective of party affiliation that medical costs are out of control. One recent example of this collective understanding was when the united healthcare exec was killed. Before there was even a suspect, people generally knew why he was assassinated. Most people in the U.S. have either been directly affected by the insanity that is our healthcare system, or one of their loved ones has. Those that haven’t yet, it’s just a matter of time. It’s just so pervasive.
As your following explanation makes clear, it's actually an unrepresentative democracy.
For further reading, I recommend learning about the Citizens United vs FEC case that vastly increased the amount of money going to politicians, far over individual donation limits.
Even if we magically fixed the electoral system tomorrow, the results would be superficial. Sure, we might see more Democrats in office—but if they’re still beholden to massive, uncapped donations, how can we expect them to enact real, meaningful change?
This problem with money in politics is not something that only affects one party. It's a systematic issue that needs regulation. Without real regulation on money in politics, everything else is a band-aid on an open and festering wound.
Both of which are infinitely better than what we have now, which is bastardized worst elements of both.
But because both sides will never agree we'll get neither, only the current hellscape.
The way our government is designed right now, the populace doesn't really have elected representatives. More accurately, they have a corporate bought-and-paid for stooge that managed to be more likeable in a political race than their opponent, so we don't actually have anyone representing our interests _as a country_ at the federal level.
Trust busting and multiple supply lines really need to be established in order to have a chance at restoring normalcy. Which is all but impossible as Pharma alone is the single biggest spender of advertising alone, let alone policy influence over politicians.
So why would they deny coverage? All they have to do to earn more money is keep paying for more and more healthcare.
Not to mention, if they can delay payment for a month, that's a month worth of interest on the money in an interest bearing account.
(Net cost of health insurance, all expenses, is around 6.5% of total US spending, as against 51.5% of direct provider costs for doctors, nurses, and procedures, not counting prescriptions.)
Even if they only get to keep up to 20%, doesn't mean they will pay a dime of what they can get away with not paying.
Here's a fun story: my sister was living with an exchange student from the US. Some day the student was complaining about intense intestinal pain she's had for the past few days. My sister told her to go the hospital. The student asked her if she was crazy. My sister then had to explain her that hospitals are free and won't bancrupt her...
Also, if healthcare wasn’t tied to having a job, then the inherent laziness and moral degeneracy of people without jobs would be encouraged by letting them not be sick. (BTW, being self-employed does not count as “having a job” in this mindset.)
The French system is more predictable (because any vaguely sane healthcare system has a price for a code instead of negotiated rates, negotiated rates is the most inefficient way to run this market) & you can get cost estimates though. And in both countries, if you live in a small town in both systems, the healthcare you will receive will suck.
I know doctors probably take their jobs more seriously, but I'd be surprised if it doesn't bleed over into healthcare quality.
1. Americans are not displeased with the situation. Ironically, I think this is one place most Americans agree there is a problem. The solution is the hard part because:
2. This presumes a drop-in solution where no one loses. This is where the fight is.
3. This presumes that democracies do what is logical or beneficial for the vast majority, which is a very naive view of democracy.
https://www.techdirt.com/2025/10/22/more-than-170-u-s-citize...
It is a sad state and I have almost given up on the hope that someday it will change. I m lucky enough to afford healthcare and feel for those who can't.
Up to a point, I guess? Correct me if I'm wrong.
And don't get me started on the inefficiencies and waste of time that you have to go through to fight a "claim" that is incorrect.
Almost no one gets a bill from the hospital and just pays it, and in most cases if you do it's totally financially illiterate.
Countries with “free” also healthcare ration it and don’t cover everything.
Socialized insurance is still insurance, and at least in Canada it’s the only game in town, so if you have a procedure that is denied or not available your choice is basically to go to the US and pay for it and be in the same position as an uninsured American.
It is certainly not a direct democracy where each individual policy is resolved by separate independent voting, no.
> So then insurance-based healthcare is what American people truly want?
Pretty consistently, no, but there is not any single alternative that a majority of the American people prefer recently (for a while, as far back as the 1990s, there was a clear popular majority for universal single-payer), and more importantly, it is not the only issue that factors into people’s voting decisions.
The patient ends up just as dead, but there is nothing to get furious about like when the doctors could fix it, but only if someone pays for it.
Also, this works for every people, not just American.
"In contrast to their largely negative assessments of the quality and coverage of healthcare in the U.S., broad majorities of Americans continue to rate their own healthcare’s quality and coverage positively. Currently, 71% of U.S. adults consider the quality of healthcare they receive to be excellent or good, and 65% say the same of their own coverage. There has been little deviation in these readings since 2001.
Compared with their counterparts, older adults and those with higher incomes register more positive ratings of the quality and coverage of their own healthcare."
https://news.gallup.com/poll/654044/view-healthcare-quality-...
It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins"). It's a constitutional republic where basically you have 50 mini countries each with different weight in the house of representatives and in the electoral college and a bazillion checks and balances that make repealing existing laws and enacting new ones very difficult. I think the majority of Americans do not like the current healthcare status quo, but getting changes that everyone is on board with through the political machinery is very difficult and Americans are polarized and tend to distrust change plans proposed by the opposite party (since parties tend to propose legislation that favors their own first).
But it's worth remembering that, if it were, Trump would still have won. He won the popular vote. So, assuming that enough votes were legitimate, a majority of Americans actually do want the current health situation in the US, in fact arguably they want even less coverage.
Maybe, maybe not. But 2024 surely would have looked very different.
It's because our politicians are largely owned by our corporations and spend a ridiculous amount of money protecting their interests [1]. We almost had a public option with the original "Obamacare", but it was forced out of the bill [2].
Also, just turn on Fox News for an evening and realize it's been the number one news channel in the US for 20-something years. They've been a right wing corporate propaganda machine for a long time, all while brilliantly portraying themselves as the "underdog" fighting the mainstream media. Americans aren't very educated and take pride in their ignorance, unfortunately. [3]
[1] https://en.wikipedia.org/wiki/Citizens_United_v._FEC
[2] https://en.wikipedia.org/wiki/Public_health_insurance_option
Not Twitter and the Internet? As a non-boomer that's been the majority of the activity I've seen from people around my age.
I have insurance through my employer as do most Americans. And most are happy with their insurance. I can go to the doctor often same day, I can see a specialist and pay just a co-pay of between $25-50.
I had some bills but my out of pocket max is something like $5k, which I have saved up. The benefits of living in the US is that the same kind of work (engineer) pays about 3x as much here and you pay a lot less taxes (save many multiples of my out of pocket max).
So I prefer to live in a vibrant economy and take care of my own insurance.
https://edition.cnn.com/2024/03/13/uk/england-nhs-puberty-bl...
The NHS and its bizarre political agenda is an example of what can happen when a government controls access to health care.
There's comparable examples from other places; Ireland has come a long way in getting the church out of reproductive health, but there are still problems. And of course it doesn't matter whether it's public or private, abortion care is at risk in many US states.
The UK does allow you to go private, remember.
Moving our system to 340 million people + letting our corporations out of paying would put the US into an economic death spiral. US corporations would love this plan. But at 340 million... I don't see doctor visits but once every 2 years -- many would just die waiting for appointments.
Presidential elections are even worse because they're determined by electoral college vote rather than popular vote. Even ignoring the potential for "faithless electors", all but two states allocate the entirety of their electoral votes to the candidate who wins the majority of their vote, which means that if you live in a state with a majority who reliably vote for a specific party's candidate every four years, your vote for president is effectively meaningless.
The only obvious way to fix these issues with how elections work would be to elect people who make different decisions about how to run them, which is hard to do because of the issues themselves. The system is self-reinforcing in a way that makes it extremely difficult for the average person to do anything about it, and any desire to do so gets weighed against the concerns about the policies that you might actually get to influence by voting for one of the two candidates who might actually win. At the end of the day, people who are concerned with the fundamental systemic flaws in things like elections and healthcare still likely end up picking pragmatism over principle (with the expected value of a vote for a candidate who is almost guaranteed not to win being lower than one who is might be less desirable than a third-party one but still has an actually realistic chance of winning and is preferable to the other major party candidate) or just check out of the system entirely (with people not bothering to vote at all already being a fairly common phenomenon in the US).
As the song goes:
"Everybody knows that the dice are loaded
Everybody rolls with their fingers crossed
Everybody knows the war is over
Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That's how it goes
Everybody knows"
Same for other kind of insurances such as issues with the house, etc..
-Currently a dictatorship
-Historically more of plutocracy
-Our history has effectively yielded the current healthcare situation especially since those who would be most vocal tend to have better coverage and thus are less invested especially since the high costs are largely obfuscated
It's the single most powerful lobbying group as a whole, and nearly every politician is bought and paid for by them. Good luck getting a majority or super majority to work against them.
Having an election day where people vote doesn't mean you live in a democracy.
Voter ID laws, voter roll purges, registration barriers, polling place accessibility, early and mail-in voting restrictions, and perhaps most importantly gerrymandering, misinformation, and intimidation all serve to reduce the power of the ballot box.
And that's before we even get to US citizens in Puerto Rico, Guam, the US Virgin Islands, and American Samoa being unable to vote in Presidential elections at all.
This is missing the point about why people don't like the past M4A proposals: It's not about cost savings, it's about losing access to their existing health care with scarce details about what would change.
The surprising reality about American health insurance is that many people's plans cover a lot of things, procedures, and medications that would be harder for them to obtain under Medicare or even in other socialized medicine systems like the NHS.
If politicians would lay out a Medicare buy-in option and let everyone opt-in to it, it would be far more popular. The past proposals that involved shutting down the private insurance industry and handing it all over to the government is resoundingly unpopular.
No, that's just the condition for one proposal for Medicare For All.
As much as Americans complain about healthcare in general, most people don't want to give up their own health insurance once they have it. This is a known political trap that the previous M4A proposals walked right into, before crashing and burning.
When you say "Medicare for All" to people without details, they assume it means a Medicare option for all. When they start reading the details and realize they have to give up their current insurance, they don't like it.
though at the moment I'm super happy DJT does not control my healthcare.
The incentive structures that have built up around US politicians simply doesn't leave any room for it to realistically happen. Until the incentives are changed I'd vote against nearly any major government program.
Edit: its worth noting that your question for whether I'd take medicare is a separate issue from my original point. If the existence of Medicare as it is today was on the ballot, I would vote to get rid or drastically change it. If the program exists regardless of my opinions of it, my choice to take benefits from it is entirely a question of means and comparative benefits of all the options.
Ironic, considering that MCA is the more 'free market' of the two. Almost as if medical care shouldn't be for profit.
1 A very high cost of drugs due to no intervention by the government as part of free market philosophy. This means that the same insulin that costs $25 in Canada can be sold for up to $1000 per month. New introduced drugs for Alzheimer's or other diseases can cost up to 50k per year - again because no price controls.
2. Insanely high prices of services due to a captive market - example a ten minute ambulance ride can cost up from $1000 to $5000. The private ambulance companies know they can charge a high base rate because they are connected to a city or municipality via contracts. Bribes as campaign funds are popular here. E.g. a new York based ambulance operator paid 45k in campaign funds to NY's governor elect and got a contract worth one billion dollars
https://www.wkbw.com/news/state-news/report-nysdoh-awards-mu...
3. Overcharging by hospitals for medicines and services again due to a captive audience. The hospitals are free to maintain various price books and you are not told what each service will cost at the time of administration of service. lately the hospitals have been forced to open up their price books but they are so convoluted that no normal human can decipher those prices.
Thus a ten cent aspirin would cost you $25 in the hospital and a MRI can run up to 15k.
4. Very high charges for doctors due to strict control on the number of MD positions and no increase in colleges or D seats over multiple years.
https://www.aamc.org/news/press-releases/new-aamc-report-sho...
5. Insurance companies have a for profit motive and need to extract their profits from premiums paid. Thus they fight tooth and nail to deny procedures and medications and set up convoluted processes for appeals.
6. Extensive fraud on Medicare and other government run health programs especially in durable medical goods and fake billing. In fact one of sitting US senators medical care company was involved in the largest Medicare fraud fines in the US and he still holds his seat.
https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....
Infact fraud billing Medicare for services not rendered is so popular that even Insurance companies do it
https://oig.hhs.gov/fraud/enforcement/united-states-interven...
Combine all the above factors and you will see why the US consumer gets so little while paying so much for his healthcare.
In the end there are more of them who want to "own the libs", or "not pay for freeloaders" than those who want to contribute to another's child surviving.
No, that's the goal. Denying coverage is how insurance companies make money. The less money they give, the more money they keep.
> The hopeful part of me is that many others can use similar techniques to win.
And the realistic part in me says that these tools will be used to deny appeals without a human ever looking into them and making sure you will never get to talk to a human or get approval for anything ever again.
Insurance companies, or the companies they pay to launder their involvement, would pay a lot more for that than the public would be able to.
The US healthcare system sounds horrific
Is this incorrect?
And the insurance still played games. Like, it's in your best interest to pay once and get this situation resolved in a scheduled/controlled manner than wait for multiple emergency hospitalizations AND have to pay for this in an emergency situation...you're probably talking at least 2x cost if not more.
yep
because "life-saving" isn't a single well-defined boolean condition that can be determined by ER staff as part of triage
> I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.
then I guess you've never dealt with major health issues like cancer, blood disease, etc. etc. because what you're describing here happens all the time
If you come in with a gaping head wound and can't pay, by law, hospitals are required to treat you.
If you come in with brain cancer, no one is compelled to give you the radiation, chemotherapy or surgeries you may require, even though it is literally life saving. You are stable, albeit slowly dying, so too bad.
Maybe I'm just too skeptical, but
a) This is a very new account with exactly 1 other posting 3 months ago, and
b) They don't refer to their child with any sort of gender. They even used slightly awkward sentence construction just to avoid gender. Few parents think of their child as an "it".
So either this is a sleeper bot, or the surgery in question was gender reassignment.
Or this poster routinely refers to their child as an "it", not a "he" or a "her".
You know, when you deal with the past 18 months where your kid has 6 hospitalizations due to illness, 2 minor surgeries, 3 major surgeries (this last one was spine related, others heart), countless appointments, multiple feeding tube feedings a day to sustain nutrition, nearly $2 million lifetime billed do insurance (as a 6 year old)...who the fuck cares about what gender I decide to write about or the reason I might not share it?
Many people nondescriptly don’t gender themselves in online discussions.
Could be, but they made only a single other posting and are effectively not even pseudo-anonymous, but completely anonymous.
The lack of data standardization in health insurance is atrocious. (In the US, CMS/Congress pushing what it can, but at a glacial pace)
The strongest argument for single payer is that a diverse marketplace has demonstrated a fundamental inability to interoperate.
Eventually, we'll just have a free (or at least much cheaper) psychiatrist in our pocket.
Sure, AI advice is workse than the advice of a competent professional, but it's very often better no advice, and that's what you get if you can't afford the professional.
That is, until someone sells them a turnkey AI service to do insurance claims... and decides to play both teams so resolutions come back at pre-AI levels, and the free market(TM) is happy because a new equilibrium has been reached.
Maybe I just need more sleep.
For example them counting on you to big hire a lawyer for collecting medical debt or mortgage debt your spouse or parent owes. As a general rule you aren't responsible for it. There are exceptions. e.g. Filial laws(children responsible for parent's debts) exist in many states, but are difficult to invoke. Community property laws https://www.irs.gov/publications/p555#en_US_202502_publink10... in 9 states that can link your income to your partner, when the state you were domiciled in with your partner in a home/condo you bought together.
So in general, adverserial use of AI cannot bring claims "back to pre-AI" levels. Much more likely is the fact is reduced debt collection activity and illegal billing will reduce to a new baseline.
This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.
The AMA (a nonprofit!) clears ~$300M/year revenue from the codes, which is the direct cost passed through to consumers, but the indirect costs are the byzantine nightmare of OP.
Does not stop people threatening you though.
This is my opinion only, not legal advice, and does not relate to my employment.
that was changed
https://www.bitlaw.com/copyright/database.html
Databases are generally protected by copyright law as compilations. Under the Copyright Act, a compilation is defined as a "collection and assembling of preexisting materials or of data that are selected in such a way that the resulting work as a whole constitutes an original work of authorship." 17. U.S.C. § 101. The preexisting materials or data may be protected by copyright, or may be unprotectable facts or ideas (see the BitLaw discussion on unprotected ideas for more information).
(I did not use AI, but this appeared at the top of my search and I think the search engine used AI to generate it):
In the European Union, databases are protected under the Database Directive, which provides legal protection based on the originality of the selection or arrangement of their contents...Some countries offer additional protections for databases that do not meet the originality requirement, often through sui generis rights.
Taking their example, if you had a collections from quotes from presidents, and I got a bunch of similar collections, then made my own ultimate definitive collection based partially on your list, then there’s very little chance I’d be liable for violating your copyright. If I copied the list and typesetting verbatim, you’d have a better case.
Also, modern rulings about LLM training (the topic of this thread) certainly mean copyrights on compilations of facts don’t survive training + inference cycles.
...then you go on to make the "sweat of the brow" argument
"typesetting" doesn't enter into it, "database" is meant to include the computerized version
Copyright is about reproduction. It does not cover uses. Once you bought it, it's yours, as long as you don't reproduce it outside of fair use.
The problem with most language models is they will often uncritically reproduce significant portions of copyrighted works.
This isn't a counter argument, just pointing out how absurd copyright is.
(IANAL)
The fundamental policy choice was to protect computer software under intellectual property law, with exclusive rights and market compensation. There were a number of ways that could have been done. Other jurisdictions toyed with new, software-specific laws. But in the end the call in the US was to bring it under existing copyright law with some tweaks to definitions and a small handful of software-specific rules.
Copyrighting software is as absurd the other things you listed.
There are examples of software code that is probably not copyrightable, but that's limited to very simple code that has only obvious implementations.
I don't really agree, and for context I think copyright in general is nonsense.
Even if it is art (I'm not convinced), the recent artificial scarcity on art is absurd. Some other thoughts to consider:
- https://drewdevault.com/2020/08/24/Alice-in-Wonderland.html
- https://drewdevault.com/2021/12/23/Sustainable-creativity-po...
Are you talking about copyright here? It sounds more like design protection.
Wouldn't the book be as copyrightable as any other non-fiction work?
There's old but more recent law from Practice Management v AMA (1997) supporting that AMA's codes can't be copyrightable as they're part of legislation.
Berne's Art 2(8), to which USA are signed, related to non-copyright of facts.
I'm afraid I'm not appraised of the full situation, however.
Fight fire with fire.
It can't pay out profits to shareholders, but it can hire its owners as employees and pay them any number of millions.
If this also helps the medical industry, it's an accidental side effect.
Doesn't change what it basically is - aka Scamming the Public, and privatising the gains.
I would expect that if (when) the AMA folds on the matter, concerns around the codes will be somehow forgotten
So you think the same Senate that is planning on gutting healthcare for millions of Americans is going to go after the AMA billing codes? Is this real life? They MIGHT demand some donations to the ballroom, but I doubt they care enough to even do that.
Ahh, here's the correct link and as I suspected, this has absolutely nothing to do with reducing healthcare costs for the average american. It is a direct attack on the AMA for advocating for supportive care for transgender citizens.
https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...
With opinions like this, you can rest assured Cassidy is concerned with healthcare costs for the average citizen:
>This comes after Cassidy denounced the AMA for defying President Trump’s Executive Order by promoting gender mutilation and castration of children.
I used to think American healthcare was in part expensive because Americans have poor health (e.g. high obesity).
Now I am beginning to think that Americans have poor health by design for the healthcare industry to be able to maximize their profits. Making some Americans healthy just seems to be a side product.
Daughter tried suicide a few weeks ago. "It was not a serious attempt," but obviously it is. We go to only local hospital; they don't have a pediatric unit, so ER basically just looks at her and aren't sure what to do because it's not like she's bleeding out. They clean the cuts and ask if I want county behavioral health involved. I'm in over my head and need help, so I say yes.
Behavioral health mobile response person comes out -- good guy, made me see something I hadn't prior -- because I've had her in therapy for half a year prior but we weren't really making much progress on anxiety/depression issues -- but he says we weren't going to get anywhere with therapy before drugs, that she was too far out, and in retrospect that was absolutely the right call. Anyway, he puts her on 72-hours mandatory hold. Here, this means the child must be transferred to a pediatric health facility with suicide watch and psychiatric services. This became a big problem.
Cincinnati Childrens Hospital had no beds (and I have ill will toward them anyway). Dayton had no beds. Charge nurse was calling people for hours and hours, and I joined in calling places (we stayed at hospital the whole time without sleeping), and it wasn't until 24 hours after admission we're finally transferred. My mom was/is a social worker for those with developmental disabilities, and spent about a decade working at long-term facilities for juveniles, where it was almost always court-ordered. I spent a fair bit of my time there for economic/childcare reasons while she was working -- awful place for the kids (not for me; I hung out in staff rooms and watched movies). Doors, by law, could not be locked, and they were terribly understaffed; violence and rape was expected. We had a second person from county behavioral come out, and once I realized the only kinds of places open to us, started pleading and insisting to have the hold lifted, but they refused. I wind up with one out-of-state option, and one in-state; both about an hour and a half away, and both the kinds of facilities I was terrified of. I later talked to other parents and was surprised to find time to find a facility, lack of beds, and travel time were all common issues between us. I went for visitation every day, and at least one adult would almost always come out of visitation crying, not realizing these places are poorly-staffed, unsafe prisons until they first visit and talk with their kid.
Anyway, so the 72-hour clock starts only once daughter's transferred to this pediatric psych facility (she wound up staying for 5 days; this is a whole other issue where they had no social worker available to provide AMA paperwork, they claimed). -And this place is a long-term juvenile psych facility, so it tends to have a lot of kids who were sentenced by courts to be there; violent offenders, but it was a mix (daughter has a story about playing Uno with a kid experiencing "weed psychosis", which'd I'd never heard of before; interesting stuff). You know, so I'm going to bed every night, and I've got some wild nightmares I could share -- BUT everything turned out mostly fine. At one point, daughter witnessed staff slam a kid against the wall hard enough for him to bleed from the head, and didn't clean the blood off the wall; the toilet in her room didn't work and the room smelled like feces; they couldn't lock doors, and the facility was severely understaffed. A recipe for disaster, but it could have been a LOT worse than it was, though trauma is there nonetheless from the experience.
Now, the reason the county insisted on sending her to this hellhole is because it's the only way to unlock county behavioral services. You must first have committed an attempt to harm yourself or someone else, or be ordered by courts. I wrote at the beginning I was able to get a counselor before all this, but this took a lot of emails and phone calls, and the place I found with help required 2 hours on the road per visit. The person I got was new in the field and didn't specialize in pediatric; he was not a licensed psychologist nor psychiatrist, but he was the only person I could get and I was grateful for any assist. There were/are no available pediatric psychiatrists or psychologists EXCEPT through county behavioral; they have them all locked away from the market, basically.
The total bill for all this, by the way (uninsured, cash, including the ambulance) was $8,709.45. I didn't negotiate; I've planned for this, I took out $20k from broker on the first day I got to go home. Money isn't the issue; it's the non-availability of service which's the real problem here, for us. I was surprised to walk into county behavioral and be told while registering at front desk they don't accept self-pay; that they aren't set up for it. I've never run into this before, and it got a morbid chuckle out of me because this's been a heck of a roll of the dice up to now, specifically to get in county services, and now I'm told they don't offer anything for us.
I ask for the people who insisted on the 72-hour hold (and btw, the facility which held daughter prescribed nothing but an antihistamine, with trauma inflicted, though minor; worthless experience except to unlock services) to speak with me, and I get one of them. She talks to supervisor, and apparently nobody knows their own policies because they do, in fact, accept self-pay. I had to fill out a Medicaid form, which we don't qualify for. Now, the strange part about this is if you have insurance (and this is why they have you apply for Medicaid), they charge you on a sliding scale, but if you don't have any insurance and get rejected by Medicaid, they really don't have any system set up to bill you, so everything's free. The psychiatrist and counselor both are free; it's crazy, so I'll kick some money to food pantries while SNAP's cut off in the state due to federal shutdown, but it's like nobody's ever really thought through the systems we have for healthcare; it's inefficient and brittle from every angle, not just the providers/insurers screwing people over for capitalism angle; like a proof-of-concept someone slapped together over a weekend where everyone's spinning their wheels without a clue what to do, except it's something we've had for centuries and are spending $trillions/year on. -And every time the government provides new weapons or issues new mandates, it somehow seems to get worse.
(Things are going well now, btw; we got a real psychologist scheduled same-day, and first appointment with psychiatrist was 2-3 days after intake. She's doing better, but the journey here was straight Hell.)
the AMA is their homie and is sponsored by them
The white coats are far from blameless here.
I seem to remember this test is why the Mozilla Foundation and the Mozilla Corporation exist, but I could be mistaken.
Edit: Seems that the AMA is a 501c6, which is a different kind of non profit.
The license is meaningless if training AI is considered fair use, and if you never agreed to the license.
They might be able to lean heavily on medical researchers and the like (who probably need a license for other uses), but when push comes to shove I suspect Google and OpenAI would win.
It would also be permissible to search existing records and prices (if an actor has them) to cross check average prices for some procedure.
I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.
It's pretty clear that even access to a potentially buggy and unreliable expert is very helpful. Whatever else AI does I hope it chips away at how institutions use lengthy standards and expertise barriers to make it difficult for people to contest unfair charges.
The discounts he negotiated left me with tons of cash & were in excess of the fee he charged me.
For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k. His response was, "lol I'm uninsured and don't give a fuck about my credit score, so, fuck you basically." The bill was revised to $500, which he paid just to not have that debt on his record.
IMHO, it's actually worse than we realize. The Medical Loss Ratio requirement is good because it requires insurance companies to spend 80% or 85% of premiums on health care. It's bad because one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums so they can get 80% of a bigger pie. It also gives them incentives to provide care themselves so they can capture some of that 80% spend.
> For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k.
I experienced this personally with my own insurance. My bill was over $20k, and it took a year to convince the insurance company that removing a few feet of my intestines was actually emergency surgery. I ended up paying $800. My roommate in the hospital had no insurance and ended up not paying anything (which I did not begrudge them at all, since the reason for no insurance was debilitating back pain that led to unemployment)
This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.
The truth is though, healthcare providers are ultimately responsible for prices.
This assumes the competitors are not all colluding to raise prices across the board
SP500 10 year annual return: 14.6%
UNH: 13.59% Elevance: 10.79% Cigna 9.42% Humana: 6.1% CVS: 0.55% Molina: 9.42% Centene: 0.9%
Or, the likelier explanation, is that health insurance prices are highly regulated and have to get their prices approved by a government official(s), and B) they don't have a lot of pricing power due to the competition and they are not colluding.
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...
https://s202.q4cdn.com/665319960/files/doc_financials/2025/a...
The executives seem to have a heavy interest in equity returns.
This sounds like a really good thing, almost everything coming in has to go back out…
What it really means is they love high “allowed” prices. They live on the 20% and want to see the pie as large as possible.
Healthcare costs go up? They raise premiums — win-win.
The road to hell is only paved with good intentions.
I had read that comcast won't go into century link territory and viceversa, and something along those lines for the major isps, in order be local monopolies and set prices as they like.
LOL. Meanwhile, in real-life America, there are only four or five major carriers that control the market, and none of them are incentivized to do this "competition" thing you speak of by engaging in damaging price wars. Why would they when continuing to be part of the problem makes them more and more profits each year? See also: military contracting. Do you see them constantly undercutting each other? No, they buy each other, reducing the number of bidders on every contract.
In real-life America, they don't even earn enough profit to earn their shareholders a better return than SP500:
https://news.ycombinator.com/item?id=45736978
And in real-life America, the only people health insurance companies engage in price wars with is the state insurance regulator who gets to deny requested price increases.
My most sincere wish is that all insurers would be nationalized, every last employee summarily fired, and their HQs all imploded and replaced with memorials to all the people whose lives they have cut short over the years. Not a thing of value would be lost IMO. Worse than paying people to dig holes and fill them in again.
Where I live, they do compete on price - prices vary by about 30% for similar coverage. They can't engage in the kind of price war you're thinking of since insurance companies, by law, have to maintain a fund able to cover costs, have to get rate changes approved by regulators and are largely banned from price discrimination.
I understand the desire to shift blame entirely onto insurance companies rather than providers. After all, one is all about money and the other is seemingly all about healing.
Heck, when a provider does bill people directly because an insurance company refused to pay, we blame insurance companies - even when the charges on those bills are highway robbery - like those in the article itself.
The fact is, the net cost of health insurance was about $279 billion in 2022. Meanwhile, $3.7 trillion went to healthcare providers, pharmacies and the like for care. The ones who stand the most to gain from higher prices are providers.
Frankly, decades of lobbying from the healthcare provider lobby to enrich themselves should have made it this obvious, but sadly, people see doctors as selfless angels and it blinds them.
I practically damn feel sorry for surgeons when I see what they get from insurance versus the hospital for providing the operating room or bed.
Wouldn't it be 20% of a bigger pile?
The fact that there seems to be a 4x markup means makes me think insurance companies are in bed with these hospitals. If you can mark up prices arbitrarily high, the insurance "discount" is fake.
Don't leave out the part where the consumer doesn't even shop (or sometimes pay) for the insurance policy either, it is determined by their place of work.
So the consumer of healthcare is doubly shielded from any price signals the market might supply.
HCSMs are membership organizations in which people with common religious or ethical beliefs share medical expenses with one another. They are not the same as traditional health insurance.
Because patients are considered "self-pay", they negotiate their own prices with providers and they are likely to get an 80% or more discount on "list price" for the service. They are reimbursed by the HCSM if the HCSM approves the reimbursement.
As of 2025, approximately 1.7 million Americans participate in Health Care Sharing Ministries (HCSMs), which amounts to about 0.5% of the U.S. population. In Colorado alone, HCSM enrollment (at least 68k) is equivalent to 30 percent of Obamacare enrollment.
Because HCSMs often exclude essential health services and are therefore more attractive to people who are relatively healthy, enrollment of this size, relative to marketplace enrollment, may increase premiums for marketplace plans.
I am not promoting HCSMs but I did research it when I lost my COBRA coverage a few years ago. I do find it an interesting alternative approach to paying for healthcare. We really do need to explore options in this country.
I can definitely see AI being applied in the HCSM context.
https://www.commonwealthfund.org/publications/fund-reports/2...
Not quite: US hospital billing is based on the idea that the insurance company does the haggling for you.
Insurance companies negotiate (cough) "the best rate that the hospital has to offer," therefore: What the insurance company pays is confidential, and the official unnegotiated price is highly inflated. That's why hospitals will always negotiate with uninsured patients, because they're deliberately inflating their fees.
---
In 2011 I had surgery. The first bill was for $100,000, which was sent to the insurance company. Then the insurance company got a letter (cough) "reminding" the hospital of the negotiated rates. The next bill was $20,000. On a follow-up visit, they did an X-ray, and sent me the bill. I sat on it, and then called my insurance company. The insurance company called the hospital to (cough) "remind" them that the negotiated rate for that kind of X-ray was $0.
Pretty much every 4+ figure civil violation, fine, etc, etc, is assessed on the basis of "what's the most we can get away with that won't have them taking us to court where it'll get knocked down or cause a public outcry if they tell the news"
Not only does the actual court case and appeals process take years, but even after you “win”, the collection process takes years after it has already been determined who owes what.
See Alex Jones for a ridiculous example. He should have been homeless and shirtless a long time ago.
1. Single-payer health insurance.
2. Laws that insurance-companies must actually use X% of their premiums on payouts.
3. Laws requiring disclosure of negotiated prices, to encourage competition via free-market forces.
Or where you as a guest announce that you now go home, and the hosts have to insist you stay for some more tea or whatever and then you have to again and again say you're now going really and they insist you stay so you chat more in the hallway etc. And it's just how it always is and it would be super rude to just leave or if the host didn't demand that you stay.
Similarly the US developed this traditional ritual that the first bill is outrageously expensive and everyone knows that everyone know, but the ritual protocol say you gotta start with that, we are civilized people, we say hello, so in Healthcare the hello is the huge price, and the interaction always ends in a lowered rate, because that's also part of the protocol.
It's just a cultural difference.
The insurance company has no reason to make the health recipient happy and the health recipient has little agency in pricing.
An average person cannot call up $750K in a year to pay for cancer treatment. But for-profit businesses (and any organization for that matter) treat you much better if keep the carrot of another payment in front of their face. If you've forked over the whole wad of cash upfront they immediately de-prioritize keeping you satisfied.
I don't have an employer, but I still only have one company selling health insurance in my county, so... that's all I can buy.
And hey! Silver lining: in a year when we max the out of pocket limit, no more cost-sharing on any other services for that calendar year! Time to pack in some care we have been deferring mostly due to cost. Except the care providers and insurance company are well aware of this, so they don't bill you for up to a year from the date of service, so you can't be sure you "hit your max" until the subsequent year.
It is enough to induce strong negative emotions.
https://surgerycenterok.com/surgery-prices/
They're the pioneer, but there are other clinics like that.
A hospital is vastly more complex. They have huge costs (for things they must have) that can’t be recovered 1:1 with services.
If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).
The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."
That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.
Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)
Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.
That's basically the way all medical billing to private and government insurance providers in this country works.
"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.
I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.
Interestingly enough, the FBI considers double billing and phantom billing by medical providers, to be fraud.
https://www.fbi.gov/investigate/white-collar-crime/health-ca...
If I sound like I'm defending the morality of the hospital for billing a private individual $190k for services they'd expect to be paid $37k for, please know that I'm not. But it helps to understand WHY the hospital billed that much, and whether it's legal for the hospital to bill that much.
The biggest semantic "mistake" the author makes in their thread is saying, "Claude figured out that the biggest rule for Medicare was that one of the codes meant all other procedures and supplies during the encounter were unbillable."
The Medicare rule does not make those codes "unbillable" - it makes them unreimburseable.
The hospital can both bill Medicare for a bigger procedure code, and the individual components of that procedure, but Medicare is gonna say, "Thanks for the bill, you're only entitled to be paid for the bigger procedure code, not the stuff in there."
Neither the FBI nor Medicare is gonna go after the hospital for submitting covered procedure codes and individual codes that are unreimbursable under those procedure codes. That's not crime, that's just medical billing.
Actual double billing would occur if, say, your insurnace paid the hospital for a procedure, and then they came after you for more money, or billed a secondary insurance for the same procedure. Or if they'd said, "Oh no, the OP's brother in law wasn't here for just 4-hours, they were here overnight so now we're billing for that as well."
NOW - a much better way for the hospital to handle this scenario would be to see that the patient is cash-pay, and then have separate cash-pay rates that they get billed that essentially mirror Medicare reimbursement. That's essentially what the author got them to do, and it absolutely sucks that's what he had to do.
Then, they negotiate with all of the in-network providers for some number that’s well below the billed amount. That number varies a bit based on how effective various negotiations are.
Realistically, OP simply found the number that insurance was going to pay out anyways.
The hospital double billed for over $100k worth of services on the original invoice.
At a certain point a pattern of issuing inaccurate invoices crosses the line into negligence.
If a business just have a habit of blasting out invoices that bill for services never received, and they know that they keep doing this, and only correct it when the customer points it out, at a certain point it turns into a crime.
Tons of institutions that specialize in screwing people are built this way because it's pretty hard to "overtly" build an institution to screw people.
Below that, lots of haggling and informal trade often help people get by. The costs of that process can be another burden on the poor. At the high end, it's worth involving people with discretion on the sell side. Additionally, sales are often one-off and customized. They may also bundle a bunch of different items and benefits without clear line-item breakdowns.
When hiring a lawyer, I'd nearly always recommend getting terms down in a written and signed engagement letter before work starts. That is very much a negotiation, but it's fine to ask questions and comparison shop.
If you're starting with a call, it's perfectly normal to start by asking whether initial consultation will be billed or not. If it will be, ask the rate. If it won't be, expect some limits on what can be discussed. The best lawyers I know aren't cheap or easily tricked into giving free advice on consultation calls with speedrunners, but they are up-front about what they charge for and how.
Disclosure: Am lawyer. Negotiate professionally.
Hospital: "Here's your bill for $1,000,000." (a figure which is 100% fictional) Patient: <panic> "Oh shit, I don't have $1,000,000!" Hospital: "Oh, we'll reduce it to $30,000. Aren't we nice!" Patient: <slightly less panic> "I don't have $30,000 either, but it might not bankrupt me immediately, so I guess that'll do..."
Never mind that the same procedure in most of the EU was either "free" (to consumer at time of care) or a fraction of the cost.
The whole system is fucked.
Im increasingly of the opinion that AI gives people more confidence than insight. The author probably could have just thought of the same or similar things to assert to the hospital and gotten the same result. However, he wouldn't have necessarily though his assertions would be convincing, since he has no idea whats going on. AI doesn't either, but it seems like it does.
But in the past, once I got to the point where I know I could maybe do something about it, but not exactly what, and I don't know any of the domain words used, you got pretty much stuck unless you asked other people, either locally or on the internet.
At least now I can explore what I don't know, and decide if it's relevant or not. It's really helpful when diving into new topics, because it gives you a starting point.
I would never send something to a real human that a LLM composed without me, I still want to write and decide everything 100% myself, but I use more LLMs as a powerful search engine where you can put synonyms or questions and get somewhat fine answers from it.
This will always happen, especially if you don't have health insurance. I had to have surgery without insurance in the early 2000s, and I was able to knock off a large percentage of the bill (don't remember how much, it's been decades) by literally just writing back to the hospital and asking them to double check and verify the line items I was being charged.
(edit: more stories along similar lines in this thread: https://news.ycombinator.com/item?id=45735136)
But you better believe that hospitals all over the place are also using AI to find ways around Medicare/Insurance rules to maximize their profit too.
The rules are probably going to get WAY more complex because they will rely less on a few humans, and more on very powerful AIs.
Poker has nothing on Commercial Lawfare.
People keep trying to enact rules to stick it to the elites and make the downtrodden better off.
And as the rules get more and more complex, the position of the elites gets more and more solid.
I really don't get people who see this kind of thing as empowering because in the end your (now strictly necessary) appeal with lawyers or AI to get a more fair deal just becomes a new tax on your time/money; you are worse off than before. A good capitalist will notice these dynamics, and invest in AI once it's as required for life as healthcare is, and then work on driving up the costs of AI. Big win for someone but not the downtrodden.
It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.
The IRS disagrees every single year.
They say they can easily recover significant revenue from tax cheats if they were staffed and funded enough, to the point that every dollar you fund the IRS recovers 1.6 dollars.
The rich people who say they are just getting their fair deductions then refuse to fund the IRS.
If they weren't cheating, they wouldn't have to kneecap the IRS.
Yaaaaaaaaaaaaaaaay.
I just did this with a pet insurance bill, and ChatGPT was very helpful. They denied based on the pre-existing condition exclusion even where it was obviously not valid (my dog chipped her tooth severely enough to need a root canal, and they denied because years before when she wasn't covered under the policy, she had chipped the same tooth in a minor, completely cosmetic way).
I was sure they were in the wrong and would've written a demand letter even in the pre-AI days, but ChatGPT helped me articulate it in a way that made me sound vastly more competent than the average consumer threatening a lawsuit. It helped make my language as legally formal as possible, and it gave me specific statutes around what comprises a pre-existing condition in CA as well as case law that placed very high standards on insurers seeking to decline coverage by invoking an exclusion (yes I checked, and they were real cases that said what it thought they said).
Gave them fourteen days to reverse the denial before I filed in small claims court, and on day fourteen got a letter informing me that the claim would be paid in full. It's of basically no cost to them to deny even remotely borderline cases, so you have to make them believe that you will use the court system or whatever other escalation paths there are to impose costs, and LLMs are great for that.
What exactly do you think negotiating is? Real negotiation in business transactions is more often based on agreements around certain facts than emotional manipulation.
Yes, because, there is an entire department _dedicated_ to this function. You just call them and say "I can't pay this" and you'll get the same result.
I'm a cofounder of Turquoise Health and this is all we do, all day. Our purpose is to make it really easy to know the entire, all-in, upfront cost of a complex healthcare encounter under any insurance plan. You can see upfront bills for many procedures paid by various healthcare plans on our website.
The information posted in the thread is generally correct. Hospitals have fictional list prices and they on average only expect to collect ~30% of that list price from commercial insurance plans. For Medicare patients, they collect around 15%. The amount the user finally settled for was ~15% of the billed amount, so it all checks out.
The reason for fictional list prices (like everything in US healthcare) is historical, but that doesn't make it any more logical. Many hospital insurance contracts are written as "insurer will pay X% of hospital's billed charges for Y treatment" where X% is a number like 30. No one is 'supposed' to pay anywhere near the list price. Yes, this is a terrible way to do things. Yes, there are shenanigans with logging expected price reductions are 'charity' for tax purposes. But there isn't a single bad guy here. The whole system that is a mess on all sides.
Part of the problem is that the US healthcare billing system is incredibly complex. Billing is as granular as possible. It's like paying for a burger at a restaurant by paying for separate line items like the sesame seeds on the bun, the flour in the bun, the employee time to set the bun on the burger, the level of experience of the bun-setter (was it a Dr. Bun Setter or an RN bun setter?), etc. But like the user said, some of these granular charges get rolled up into a fixed rate for the main service.
However, the roll-up rules are different for every insurance contract. So saying the hospital 'billed them twice' is only maybe true. The answer would be different based on the patient's specific insurance plan and how that insurance company negotiated it. Hospitals often have little idea how much they will get paid to do X service before it happens. They just bill the insurance company and see what comes back. When a patient comes in without insurance, they don't know how to estimate the bill since there is no insurance agreement to follow. So they start from the imaginary list prices and send the patient an astronomically high bill, expecting it to be negotiated down. In some areas, there are now laws like 'you can't charge an uninsured patient more than your highest negotiated insurance rate' but these are not universal.
If you find yourself in this situation, there are good charities like 'Dollar For' that can help patients negotiate this bill down for you. We are trying to address this complexity with software and have made a lot of progress, but there is much more to do. The government has legislation (the No Surprises Act) that requires hospitals to provide upfront estimates and enter mediation if the bill varies more than $400 from that amount. But some parts of the law don't have an enforcement date set yet, which we hope changes soon.
EDIT: adding in a link to 'Dollar For'.
Which is a great description of the American health care industry, even before its involvement with AI in any capacity.
But the raw numbers like $200k for this poor gentleman’s heart attack or $500k aren’t the most alarming. It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question. Even though one of my providers just recently started offering estimates, those are off by 100-200% , and completely missing for about half of what has been ordered.
We are both very strong accountants, and despite trying to do audits of these services, it’s impossible. There are 3-4 levels of referred services, bundled codes, nested codes, complication / technical / professional codes , exceptional status codes . Providers overbill, double bill. On accident and on purpose. When we call to get it corrected there is no way to make corrections.
You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
Supply and demand and finding a better vendor doesn’t work. There are some rare exceptions like elective MRIs – but those aren’t the norm. Nearly every service is something time sensitive or your disease will get significantly worse. Moreover, signing up a new provider has $1000+ in billing and a few hours in paperwork to make the transfer. is it worth saving $500 for one MRI when $250k worth of services are unaccountable?
The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
I went through this with my ex after a surgery. It was totally insane to figure out where the numbers are coming from and basically a full time job.
Even if we don't want to go to single player or similar, I don't understand why it's not at least possible to mandate clear and binding estimates and billing a normal person can understand. And let the market work its magic through competition.
Moving to another provider is like starting over with paperwork, records , diagnostics tests, building relationships . We already did one transfer due to insurance requirements and lost about 90 critical days that we can never get back. Images were lost preventing a proper diagnosis.
I’m not against free market medicine in principle but the current billing, records and regulations make it impossible with our setup.
America has doubled down on middlemen controlling the prices of medical care and making sure that there is no set price for anything. With the ACA effectively falling apart in the new budget, we do have a chance to move to a different reality, one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries. Instead, we are stuck in a situation where companies get to dictate prices and access to care while we get diminishing returns in health quality and longevity.
Medical billing is like a massive centuries-old tenement building with a patchwork of legacy plumbing, electrical , framing, sewage all patched together with decades of duct tape, wood shards, and rusty couplings. But in this case there’s massive incentives to keep it all bodged because each pipe and crevice hides billions of un-audited income.
His most notable attributes on Twitter are he constantly lies about everything and that he spends all his time promoting Republicans who are clearly not going to implement his anti-monopoly agenda.
So not only would they be against deregulation (they think painful regulations are good because pain for the sake of it is good), but the previous admin actually tried this with Lina Khan and it didn't really work.
The issue here is Democrats are "mainstream" coded, so all populist politics works by fighting them even when they're trying to do your own policy.
You're missing the part where the Stated and objective goal of popular politicians from one party is not to let that happen.
They don't get elected because someone scheming to control their funding (though that is a proximal cause of Republican candidates getting more extreme: Align with MAGA or get primaried)
They get elected because a huge portion of the USA are divorced from reality and utterly deny said reality. They say "government is less efficient" as we sit on top of this atrocious system, a system where we already have the government version and it's radically cheaper and we could literally just sign up everyone for that, save everyone time, money, and headache, and then improve service quality.
These people deny that nearly all developed countries and lots of undeveloped countries have vastly better healthcare outcomes than the USA, extremely better healthcare access, and pay way way less overall, taxes included.
These people just consume propaganda, and purposely refuse to engage with any clear or obvious evidence that contradicts said propaganda.
i'm potentially on board with signing up everyone for medicare, but only if we actually can get voters to vote for the taxes necessary to fund that. i doubt we will be able to given we can't get voters to vote for the taxes necessary to fund existing medicare consumption.
2. Refuse to pay. Medical debt doesn't count against your credit and, based on my own experience, is almost impossible for the other party to collect, except some annoying phone calls.
As I alluded in another post I do often let debt go to collections. The issue is often not the collections calls, but that your provider will be even more aggressive about demanding up front payment to continue receiving care. Or stop seeing you. I have a rare neuro muscular disease that only a handful of doctors are even very knowledgeable about where I live.
I was talking about individual hospital programs. They typically have those programs as part of whatever hospital system that is.
Something like this:
https://www.adventisthealthcare.com/patients-visitors/billin...
But you would probably not qualify for something like this due to income. I happened to have a minor accident while unemployed (<$10k income that year) about 10 years ago, and the hospital financial aid forgave most of the cost.
His mom died poor.
Crazy country.
You don't necessarily need to pay back those loans, and most of the time the hospital has to negotiate a feasible repayment plan.
Medical bills have to lowest life-improvement rating of them all. That is to say paying off someones medical bills will have one of the lowest impacts to their lives compared to another financial intervention.
Here in India when my dad underwent bypass surgery, I checked the bills the breakdown is insane. This how a charge goes, Nurse comes to see you, so she wears a pair of gloves, that gloves is billed. And often something like 10x the price those are available in the regular pharmacy. Each and everything is billed, and you would be surprised just how many things like these can be be billed.
>>You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
Often some 'visiting doctor' comes to see you. Like in the case of my dad we were billed for a diabetic consultation, despite clearly telling them he wasn't diabetic, even more so, the same doctor came in the day before and had to told the same. We didn't need it. But you will see they bill you like 2000 rupees just for the person to enter the room say 'Hi' and exit.
>>The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
In these situations most people are so stressed and anxious often people just have no mental bandwidth to fight side battles.
Its really a corrupt system to the core, and I don't see hospitals and doctors giving all this up anytime soon. Or even ever.
We were laughing at some of the bills. Blood draw $500 . 10 minutes of work and a few dollars in disposables. Billed at $3k / hour.
> You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000
I feel this in my bones and it makes me irrationally (or maybe it's rational actually) angry. Find me any other industry where you can get away with not telling how much something will cost (or even a realistic range) before services are rendered.
I had a medical procedure a year or so ago and when I asked how much it would cost I got an eye roll, a lengthy and exasperated lecture, and in the end the number they quoted was wildly different. I knew I was going to hit my out-of-pocket maximum so I gave up after a while and moved on but it makes me so mad. I _wish_ I could "vote with my wallet" but good luck doing that unless you have unlimited time and energy. By the time I finally got to asking about the price I had been through multiple appointments that took forever to schedule, were weeks or months in the future, all while I needed relief. After being strung along for 6 months I gave up and rolled the dice even though I disliked how they treated me when I asked for the price.
People talk about how you need to be an informed customer but I have to assume those people are lying snakes, have never used the system, or just too stupid to understand that it's impossible.
"I don't know" should _not_ be a valid answer when asking how much something costs, it's ridiculous.
Plus, your life is on the line. If they don’t run the test, it means the wrong treatment and your prognosis goes from 80% survival to 80% mortality
This is the part that is galling to me. Apparently no healthcare worker I've ever spoken with about billing has ever had the same considerations I do re: finances. My inquiries have almost always been met with zero empathy and contempt that I would even be so gauche as to ask.
(It's 1000x worse when you're talking to them about your child's medical care. My daughter, at 3 y/o, had a short fall and received a small cut on her face. It bled profusely so we took her to the ER. We ended up with x-rays because I couldn't successful "negotiate" that we didn't want that. The shaming was intense.)
Bill arrives and the insurer denies coverage. Provider says "oh well <shrug> you owe us $$$ now".
Since I am the resident argumentative asshole in the family I dig into the situation a bit. After many phone calls I am eventually told that the hospital routinely records all phone calls with insurance companies and furthermore has found the recording where they gave advance guarantee of coverage for the procedure.
At this point I realized we are being shaken down by a corrupt/criminal enterprise. Even with the recorded phone call the insurer refused to pay and so the patient had to pay off the $$$ over many months.
It took me a week and hours of phone calls to figure out what would be covered, and how much the non-covered tests would cost. The doctor pointed at the lab, the lab pointed at insurance, insurance pointed at the doctor.
Finally it was the lab that was able to produce numbers.
And when I was finally billed those numbers were still incorrect! (and thankfully cheaper)
> The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
The world does not move in a positive direction at the direction and discretion of “great technical minds”. They are too busy being narrowly technically brilliant that they fail to see what a sufficiently generalist and curious 15-year-old could figure out what is the root cause. Which this post demonstrates.
the real challenge is that many diseases are asymptomatic and the diagnostics are also inaccurate. so there's no real way to tell if you have the disease
I got a bill for $250,000. Uninsured at the time. I have refused to pay it (due to inability), consequences to my credit be darned.
Of course that would only work if you can take the time off from work, have the same treatment available elsewhere, and being able to actually travel with whatever illness you have.
I’m guessing there has to be a queue on that. Even those countries must be getting backlogged right? I haven’t looked into it besides what I’ve heard on social media.
I can see them being out of network this year, but can't you change insurance in the following year to one where it will be in network?
Is this a somewhat remote location? With all the insurance options I've had from work, the "in-network overlap" was something like 90-95%. People didn't change insurance to get access to providers - it was mostly a better rate, etc.
The common perception of “providers” and “network coverage” are the frontline doctors you visit.
But in this case, and what is common, is that there are many degrees of providers. Your doctor refers to pathologist refers to lab 1 refers to lab 2.
So 95% doesn’t tell you much. If only 1-2 of your providers are out of network (e.g. specialized labs ) , that’s $10k+ right there.
- turn into whackamole every year?
- expose someone to "preexisting conditions aren't covered" issues?
From our perspective the real blocker is the “lock in” due to timing and the referral process. We’re paying bills to providers like specialized labs that are 2-3 degrees down the chain from our doctor (e.g. radiologist refers pathologist refers lab1 refers lab2 – we only see radiologist) .
Even if there was a “amazon for labs” we wouldn’t be able to order this stuff because the decision is 2 degrees away.
We contacted the service and provided our info (the context of the situation, the billing information, the actions we'd taken so far, etc) and a couple weeks later, the service reported that they had converted the ambulance ride from an uncovered insurance to covered by insurance (since the transport was between a covered urgent care to a covered EHR) and had our insurance cover the majority- we ended up paying $500 to the ambulance company.
While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.
If there is anything that will bankrupt the US, it's excessive medical charges and a lack of knowledge of how to address them. Maybe AI will help, but I really doubt it long term.
> we ended up paying $500 to the ambulance company
I get where you’re coming from but that’s still a loss to me from the perspective of the broken system.
You should see some of the proposed rules. Pre-authorization will start to use a medical language called CQL and there will be literally thousands of queries EHRs will need to implement to ensure their customers can get the care they need.
If you want to see true rationing, look to the UK (especially) or Canada (less so) where I know plenty of people who have to wait over a year to see a specialist even after doctor referral.
Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.
I live in U.S. and know people on ACA Marketplace plans, employer HDHP, Medicaid, Medicare, Medicare Advantage, people who are uninsured, people who are overinsured, and people who have crazy expensive fly-me-out-of-the-jungle emergency plans (one who actually used it in the U.S.).
I have never heard any of them get an MRI or CT scan same day "just in case." And for the one who got an MRI close to same day for stroke symptoms, it wasn't free. (And even in that case, the earliest appointment with the specialist to assess the MRI was nearly a month later.)
Someone getting their first colonoscopy had an appointment two months out.
Someone getting shoulder surgery four months out.
A person on Medicaid with Stage 4 cancer waiting a week and a half for a fentanyl patch because the pharmacy couldn't get approval from the Medicaid subcontractor for whatever reason.
People from the U.S. who post on HN: please tell HN which is more common:
* my stories
* your parents getting free MRIs and CT scans "just in case"
My primary point was comparative - wait times are considerably longer for the NHS than in the US.
So we're talking about a situation where a doctor thought a patient required an MRI-- using your word-- "immediately."
In the NHS when a doctor requests a patient get an immediate MRI, what are you claiming is the average wait time?
Edit: clarification
It depends what it's for. If you want something non-urgent, you may be waiting a bit longer.
If you go to A&E you'll be seen very quickly in the UK, but unless you're lucky with which hospital you pay to get into you could be waiting quite a while in the US.
In the UK, you can pay more (say 30%-40% the cost of a US health insurance plan), get treated like royalty in private care, skip all the lines for specialists, still be covered by the NHS to pay 0 for anything catastrophic, and still never get a bill in the mail from anyone.
It's not an either/or situation. The US has the least efficient healthcare system of any country in the world. It provides less treatment per dollar than anywhere else. You can provide universal basic coverage and still provide luxury insurance plans.
US healthcare is a mess and I'm not defending the cost - but it does have the highest number of top specialists in the world & strong R&D.
I bet we could cut down NHS waiting lists a fair bit if we arbitrarily decided that ~10% of the population were no longer entitled to a wide range of non-emergency treatments.
I think there are lessons to learn and improvements from both systems - for instance, catastrophic healthcare is a disaster in the US (in terms of cost), but we are better at timely care and providing incentives for pharma R&D.
“Ah,” someone says, “but the government negotiates huge discounts with the phone makers since it buys in bulk!” I think this misses the forest for the trees when it comes to cost control.
I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.
> I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.
Doctors would recommend fewer tests if their patients were more price sensitive, I think. I'm not sure a more direct route to making doctors price sensitive when they are on the provider-side, why would they want you to utilize less? There probably also needs to be malpractice/tort reform in the US.
My understanding of both of those studies is that (particularly for pre-registered analyses), we saw that adding some sort of cost-sharing substantially reduced utilization of healthcare services (~30%) without any impact on health indicators even multiple decades down the line, with the possible exception of mental health indicators. Nowadays people try to p-hack their way out of these conclusions, but it is pretty strong high-N experimental evidence.
Obama phones were literally a thing and
>Over the years, they’d get used to replacing their phones for the smallest reason — a scratch, a tiny crack, dropped it a little hard — because it costs them nothing.
Did not happen because this is absurd and not how any entitlement program anywhere has ever worked, and more importantly, in healthcare you WANT THIS TO HAPPEN
It's cheaper for someone to go see their doctor when they "think I might have something wrong" then once they actually know something is wrong, and so substantially cheaper that even US insurance companies try to entice it by making yearly physicals free or other preventative care, but it doesn't work as well for the US because even with insurance incentivizing it, you still end up with all the billing BS that can leave you harmed by going to the doctor
> I think this misses the forest for the trees when it comes to cost control.
Sorry, the actual empirical evidence is that the government setting prices has done better all over the world than whatever the US does. This magic belief that allowing the government to control access magically produces bad systems is just wrong. Government is capable when you vote for people who want to make good government
Provider availability is non-uniform across the US.
Comparing getting imaging work done to actually seeing a specialist is comparing apples to oranges. They're both healthcare related things but are massively different.
There's tons of imaging clinics staffed by people who only needed an associates degree from a community college, radiologists work remotely all over the place spending little time on each patient and writing a report. Overall its really cheap and easy to build and staff an imaging location.
Seeing a specialist requires actually going to the doctor in person, that doctor had to spend many many many more years and limited spots for an education, and probably only sees patients in clinic a few days of the week. You'll have a whole staff of nurses & PAs (who quite probably had more education than the rad tech) and office staff to support the small handful of specialists.
As a personal example, I had an issue with my knee, locking up from time to time bending with weight on it. I looked up kinesologists in my area covered under my insurance. Dozens within a short drive, awesome. Calling up, "sorry, we're not taking new patients", "we can see you in four months", etc. A few months go by, I finally get in to see the doctor. He has me do some motions, asks me a lot of questions, takes a quick x-ray in the clinic, recommends I go get an MRI and come back. I am able to find an MRI clinic that's covered and can get the imaging done that same day. However, its several more weeks until I can see the doctor again to actually review the radiologists notes. I finally go back, the doctor recommends surgery, a prior authorization gets filed. We wait. We wait. Denial, no MRI, imaging required to determine medical necessity. Huh, they paid the bill, didn't they wonder what the MRI said? Resubmit. We wait. Denial, MRI was inconclusive (it wasn't). Resubmit. We wait. Denial, physical therapy is recommended instead (except the thing they call out as a reason to have surgery is verbatim what the radiologist notes say). Resubmit. We wait. Denial, same response. Its now been almost a year of intense joint pain every time I crouch down, walking is starting to be difficult. I'm in a brace and crutches and the pain is getting worse. I finally just wait at the clinic all day, we spend hours and hours on the phone with the insurance company to try and get an approval over the phone directly. I finally get approval, and manage to get in for surgery several weeks later. I have the surgery in the morning, and I'm back to walking without any pain and without crutches or the brace by lunch.
And in the end, after the surgery, the insurance company complains they shouldn't have covered the procedure because supposedly I didn't have an MRI of that knee. Idiots.
This is just one of several shitty stories I have of dealing with health insurance companies. Multiple over the years.
And that's on the insurance side, not even the care side of things! One time, while waiting multiple hours in an ER complaining about becoming massively lightheaded and weak and barely able to sit, I finally passed out and fell on the floor out of my seat. The shock of hitting the floor woke me up a bit, and the first thing I heard was "sir, you're not allowed to lay on the floor, stand up." Uh, I would if I could!
All in all it took over a year of joint pain before I managed to get surgery to fix my knee, all because the insurance company was rationing care. A year I won't have playing with my toddler at the time (I couldn't easily crouch down to play and expect to stand back up easily). Arguments of "bUt RaTioNinG!" ring extremely hollow to my ears. We already have rationing in America, you just haven't experienced it yet.
I'm sure people from first world countries would be stunned by this number. And that makes it even sadder.
> Maybe AI will help, but I really doubt it long term.
I'm guessing it will help up until the point where hospitals start using AI for this process.
America doesn’t have the same kind of social cohesion as most countries. We’re a nation of individualists. The general feeling here (rightly or wrongly) is that healthcare costs are largely driven by your choices in life, and Americans don’t want to feel like they’re on the hook for other people’s bad choices.
100 years ago I used to work for the fruit company in phone support.
My KPI's were 100% customer satisfaction. However, I needed to get approval from another team to advance any kind of free/gratis repairs replacements or gifts.
That team's KPIs were opaque to me, but my understanding is that they were find as long as they offered some resistance.
Between those two pillars we got a lot of good done for customers. I dont think theres anything necessarily wrong with having internal friction like that if its designed correctly. Its probably better than having both responsibilities in a single person.
In terms of health insurance however it seems ghoulish.
This is the core truth that all of healthcare in the US spins out from. A few personal experiences which back this up:
1. I received a $1500 bill because an ambulance that was sent when I called 911 was an "out of network ambulance". I looked it up: One small ambulance company in SF is in-network with that insurer. The SFFD runs the vast majority of ambulances and is "out of network." Insurance companies of course are not allowed to penalize you for accepting the first ambulance that arrives in an emergency. I filed a formal complaint with the California regulator that regulates that insurer and within 2 weeks the bill had been properly taken care of.
2. Our family has met its family Out of Pocket Maximum this year. Twice in the past month I've had doctor's offices lie to me and say that we still have to pay a copay. The last one claimed "well, you still have to meet your individual one though." Lie. That's literally the opposite of the way it works. We've paid copays to these people accidentally in previous years and they would never give the money back, they just keep it and also double dip since insurance pays them anyway.
In all cases, both hospitals and insurance companies simply ask for the maximum possible thing they can ask for, knowing that a frightening majority of people are afraid of them, and will pay whatever they're told. In OP's case, an unsophisticated payer would have gotten a $195k bill, been sent to collections, the hospital would have sold the bad debt, and then the person would have maybe "gotten a good deal" by getting it cut down to $50k over many years of high-interest payments and having ruined credit.
Insurance and hospitals are both filthy, money-grubbing machines. To paraphrase a famous cartoon character, their business is bad and they should feel bad.
The California Department of Insurance may be the regulator for your health insurer, but it may not be. If not, it's the Department of Managed Health Care. You should be able to find a reference to who their regulator is in their plan documents.
# DOI:
complaints start here: https://www.insurance.ca.gov/01-consumers/110-health/50-h-rf...
list of who they regulate here: https://www.insurance.ca.gov/01-consumers/110-health/20-look...
# CDMHC:
complaints start here: https://www.dmhc.ca.gov/FileaComplaint.aspx
list of who they regulate here: https://wpso.dmhc.ca.gov/hpsearch/viewall.aspx
My original ambulance thing was with an insurer regulated by DOI. Much more recently than my original story, I went to file with CDMHC, which requires that you first file a formal grievance with your health insurer first. I would definitely recommend to file a grievance. In my case, I filed a grievance and also contacted the office of the CEO, who emailed back and miraculously made another made-up problem go away even faster than the grievance process did.
But anyway, yours is an interesting case here. I can't be sure if the insurer is the one who screwed up here, also the ambulance company may not be allowed to balance bill you. The only thing I'm pretty sure of is that you shouldn't be responsible for more than an in-network ambulance would cost you, presuming you didn't just take an ambulance in a non-emergency, just for fun (as they seem to always assume).
The threads says this was 4 hours of work and they billed for things that weren't even used.
Food for thought:
- this approach produces systemic outcomes that are worse and cost more than other approaches
- there are lots of ways for people to get paid to provide medical care. Medical professionals do not work for free in other countries, and they buy the same equipment and drugs from the same suppliers as Americans do.
- we are allowed to look at how other countries have solved this problem without hitting people with giant medical bills. We are allowed to apply those solutions here.
- the US standard of care is overall not particularly high in the global rankings. We may decide that we don't want to continue providing this standard of care, we may decide we want to be in the top 10 globally.
> Bills were a few thousand here for the cardiologist, another few there for the ER docs, a bit for the radiologist. I helped my sister-in-law negotiate these down but they weren’t back breakers. Then the hospital bill came: $195k. This is a story about that.
I think a public option is the only feasible path forward.
Not once have I had a sleepless night since been diagnosed over a decade ago about insurance, co-pay or how to afford my drugs/medical treatment.
I’m on two prescriptions per month, total cost to me is £114 a year (about 150 bucks).
Folks over in the US are getting hosed, twice the per capita with a worse outcome and it costs you a fortune on top personally.
That healthcare is tied to employment is just the insane cherry on top (I’m aware of the historical reasons why that happened but should have been fixed not long after).
I believe the reason for higher US success rates was that the US used more aggressive treatments that the UK would not, since neither does the NHS pay for them nor do their doctors offer them. It is easy to complain about the US system, but the reason that the per capita cost of health care in the US is high could be because the US will try expensive things that the UK’s NHS never would have attempted (since spending exorbitant amounts on aggressive treatments with low chances of success to attain US success rates would drive the per capita cost of medicine to what could be US levels). The high US pricing of those treatments could be further amplified by attempts to take advantage of ignorance. Amplification to take advantage of ignorance was clearly the case in the article author’s case.
I feel like the opposite viewpoint in favor of the US system is not well represented in online discourse, which could very well be because those who were not served well by the UK’s NHS are dead. There are anecdotes about people coming to the US for treatments that they could not receive in the UK or Europe, which is consistent with that.
That said, I have only looked at data for cancer survival rates and not other illnesses, but the cancer data alone contradicts what you wrote. Perhaps reality is in the middle where the UK system is better for routine issues (i.e. you avoid sticker shock), but the US system is better for anything that falls outside of that (i.e. you have a better chance to live). There is evidence both systems have plenty of room for improvement.
A higher survival rate is to be expected when the doctors have a financial incentive to treat benign growths which the patient would have survived anyway. It can indicate overdiagnosis rather than indicating successful treatment.
For what it is worth, I take a prescription medication for a non-life threatening condition. I had once called Costco in Canada to find out how much the price is there out of curiosity. They do not sell it. I then discovered that the drug my doctor prescribed is exclusive to the US and is not sold anywhere else in the world. Presumably, nobody else is willing to pay the exorbitant price that is charged for it. Even the generic is expensive. The US system is expensive, but it gives people access to more expensive treatments that simply are not available elsewhere.
That said, I might have an elective operation in the future. It would have been covered by insurance as a necessity when I was young, but my parents never pursued it and the underlying condition’s severity decreased when I became an adult such that it is now elective surgery. I expect to engage in medical tourism to have that done.
I notice regular doctors and dentists do this too. They’ll bill my insurance for extras in case they’ll pay and when insurance says no, the doctor doesn’t bill me either.
Everyone is just trying to suck the most money out of everyone else. It sucks if you’re self-pay because you don’t have the weight of a whole company to do that due diligence for you.
OP agrees: "Ultimately, my big takeaway is that individuals on self-pay shouldn’t pay any more than an insurance company would pay—and which a hospital would accept as profitable business—than the largest medical payer in the country. I had access to tools that helped me land on that number, but the moral issue is clear. Nobody should pay more out of pocket than Medicare would pay. No one. ... Hospitals know they are the criminals they are and if you properly call them on it they will back down."
> I've heard a ton of cases where folks basically "pay what they can" for the bill and that's good enough for both parties. I doubt the reasoning Claude provided was ultimately what got the hospital to knock the bill down, probably more around the legal action and PR threats. Ironically, the hospital will probably count this as charity even though OP didn't want to be considered charity, as they had to write off part of the bill.
I read that OP refused to sign something that fraudulently said the full price was $195k but rather insisted on signing on a bill that said the full price was $33k or $37k or something. (Maybe $4k was called charity.) They might have presented a completely different bill to the IRS to justify tax-exempt status, but that illegal action would be totally on them; OP is not participating in their tax fraud. I applaud OP for that and hope this becomes the norm.
in truth, they are doing nothing but racketeering.
I'm sure they also have a long arsenal of various legal tricks they bundle into offerings like they did in the linked thread with respect to attempting to relabel it a charitable donation, etc.
They can't really claim their records are any kind of proof if apparently they now agree that 82% of it was wrong?
The past few years, I've been receiving some very expensive treatments for my eyes... given the job market, I've been without and switched jobs a couple times... been caught with a few unexpected bills for around $15k... it just sucks. I'm currently making about 2/3 of what I was a couple years ago, with no better job prospects, the insurance I have is "emergency" based and doesn't cover my regular doctor bills... I'm at my max at this point, thinking about bankruptcy for a while now.
The system sucks... the billing system(s) suck and the fact that it's as messed up as it is, is so much worse. From monopoly positions, to messed up billing, to everything else... I don't even know. Even on a six figure salary, I cannot afford private insurance and the multiple $300-400 doctor and pharmacy bills each month are seriously destroying me.
I think the correct solution is stronger laws for price disclosure, strong penalties for the kinds of abuses mentioned in this thread, and incentives for patients to question every charge.
I don't know a single Canadian who would swap their system for the USA's. Theirs might not be perfect, but nobody argues that it isn't at least better than the literal worst system the world has ever come up with.
One thing to consider is that doctors seemingly prefer things about how the U.S. system works (I'm not just talking about the amounts charged, but inefficiencies and red tape in the Canadian system, some of which seem to be a consequence of socialized health care). Ultimately this does lead to some brain drain which then compounds the issues with our system.
I'm sorry but I don't understand this discourse. While we have gripes with the state of some hospitals that fall short of first world standards (e.g. Gatineau Hospital) and wait times for specialists for non-urgent care (it can take 2-3 months to see a dermatologist after referral for non-cancerous skin conditions in Manitoba for example), I really can't think of more than 3 Canadian residents having ever said in my lifetime that they prefer the US system (and for all of them, their objection had to do with the fact that the government funds treatments they don't like for gender dysphoria and abortions, not that they felt the US system was an effective economy of scale).
On top of that, there is a myth perpetuated in the US that we are constantly at the brink of a healthcare system collapse. We are certainly not - there is room for improvement and health inequalities that we must address, but to say that we're all an ER wait away from dying is simply untrue. [1]
I have been on the receiving end of health care inequalities here in Canada (in Manitoba and Quebec), but I don't go as far as to write off the achievement of having set up an effective single payer health system in a federal state.
Triage priorities in referrals are an acceptable trade-off for broadly improved access to health care. The reality is that my eczema doesn't need to be seen before someone else's melanoma.
While I appreciate being able to see a specialist earlier in the US with my health insurance, I know that many ordinary American citizens aren't able to at all and that my insurance displaces incentives to serve underserved communities. I'm not yet an American citizen so I will not preach what the US should or should not do, but I do think it is unfortunate that is the case and I hope that improves.
The alleged shooter was clearly referencing this book which talks about it: https://en.wikipedia.org/wiki/Delay,_Deny,_Defend
I haven't read the book, I'm just recalling what I've read about it.
we have a capitalist bastard child of for-profit "insurance" companies who are heavily subsidized (yet are still allowed to profit massively and turn profits over to shareholders) and in cahoots with hospitals who often employ more "billing specialists" and lawyers than they do actual doctors and nurses.
the whole thing is a racket.
using AI to deny claims to maximize profit seems bad enough to me. More Luigi please.
And when the bills started coming in, it helped there too. Hard to say if we actually saved anything — but it certainly didn’t hurt.
LLMs are a good way to double check if the service you're getting is about right or steer them onto the right hypothesis when they have some confirmation bias. This assumes that you know how to prompt it with plenty of information and open questions that don't contain leading presuppositions.
An LLM read my wife's blood lab results and found something the doctor was ignoring.
By the way, Private is cheaper when you are younger, gets more expensive when you are older. So if you choose private, under very phew circumstances you can switch to Public.
In the other side, you have the US health care which is probably one of the worst in the world. Crazy.
Not really. If you have money, the US system is one of the best. It just really, really sucks if you don't have money.
[0] "in some cases, the wealthiest Americans have survival rates on par with the poorest Europeans in western parts of Europe such as Germany, France and the Netherlands." https://www.brown.edu/news/2025-04-02/wealth-mortality-gap
Would a household making $250,000 have enough to pay for that best care? That would mean 2% [1] of US household. Other comment in the thread mentioned earning "6 figures" and not being able to pay.
A health system that is affordable to 2% of the population is definitely not working.
[1] https://www.factcheck.org/2008/04/americans-making-more-than...
Quality of care available to wealthy people is an important factor in evaluating a system. In the US, there are many millions of wealthy people who the system is great for.
At ~$250k TC I get better care than I could in any of the socialized systems. Concierge care, advanced treatments if I want/need them, out of pocket max that is easily affordable, etc
Can you elaborate on concierge care? I have never heard of anyone in tech around or below that compensation receiving https://wikipedia.org/wiki/Concierge_medicine
Typically hospitals are overwhelmed by the sheer amount of patients. Waiting times for procedures are incredibly long.
Where the system kind of shines is emergency care and long term illnesses, you go in and they save your life for free.
For any other kind of treatment you are generally better off turning to the private sector in Europe. You are going to have to pay depending on the country the cost might be outrageous but typically you will get access to procedures in days vs months.
Stop lying. It's trivial in Europe to end up without any health insurance even as a citizen, e.g. in Poland without employment and without unemployed status (the offices make it very difficult to register and keep the unemployed status).
Not saying the doctors did anything wrong but… oof
Using the latest in technology to move an a bill from existential to merely crippling
All said and done, you end up with a very small sliver of people who are legitimately uninsured, which means the problem mostly exists as scary stories rather than people actually experiencing it.
Nobody should have to be wondering what company an ambulance works for. It's crazy. The whole world thinks it's crazy.
People getting surprise bills that their insurance will not cover is rare, because being in a situation where it's a possibly is rare. Insurance pre-approves or denies care before it is done, so you really need to be in the ER and getting odd-ball care that falls outside standard procedure.
I'm also not defending them system, it is a mess (even I posted a story in this thread), but the fact of the matter is that the system largely works for most people, so things like inflation, wages, housing which have daily reminders of shittyness for huge swaths of people gets political priority.
A better way to think of this is like bad car accidents. They are horrific and most people know someone who knows someone with a story, but we don't put a lot of political capital into improving vehicle safety. Most people go their whole lives with no accident.
> People getting surprise bills that their insurance will not cover is rare
Define rare. Because millions of people per year are forced into uninsured ER visits.
> A better way to think of this is like bad car accidents
A hard disagree.
Most people avoid the hospital until they need to go to the ER, because taking time off work to find out if you're even allowed to be treated is prohibitive. I can't talk to any medical professional anymore without going in. And with the doctor shortage, if I go to a hospital, I will be dismissed unless I'm experiencing severe sickness or pain because I'm wasting their time.
People are driving all the time. People avoid the hospital as much as possible, because they are understaffed and predatory, and there are many pitfalls where you can be ripped off. This is all assuming you even know how this stuff works. Not everyone realizes an uninsured visit could cost as much as a house. You don't get the bill until it's done. That's the fucked up part.
I don't know a single person making under 100k who is comfortable with their healthcare situation. They are terrified to be unconscious or misinformed, making a mistake that could financially cripple them for life. There are no guardrails for this. Yet there is more vitriol for AWS bills then there are for the healthcare system.
Is this real?!
There are also subsidies for middle-low earners, and most full time jobs offer insurance (which people foolishly wave to save a few bucks, but end up being another horror story).
The situation is not nearly as dire as the young American crowd that dominates social media makes it out to be. It could be much better, but as I alluded to in my other comment, don't let stories of car crashes scare you from getting a license.
The American healthcare system creates an immense amount of waste and is a parasite on society.
You go to the doctor and then the provider comes up with some reason why the service isn't covered by insurance. Then your insurance comes up with some reason why they don't need to cover you. Sometimes you contest it and the bill is removed or lowered.
But regardless, at every step in American healthcare, people are being paid full time salaries to overbill or missbill you for services, to invent arbitrary reasons to deny coverage, and to do everything possible so that people who pay thousands a year for a healthcare plan get as little out of it as possible.
The only silver lining is that medical debt is legally hard to collect, so non-payment is a real option for those who don't mind trashing their credit.
It's awful and the only hope for change is either a left-wing populist who guts the whole system, collective action where people withhold paymet, or an increased rate of Luigi-esque incidents that motivate the industry to self-reform. But these all seem unrealistic and liable to worsen the situation.
Or when an ambulance from the wrong company shows up.
Or as in OP when the hospital makes up the charge.
And add the 8% of uninsured Americans, which is still almost 30 million people!
Only in America will this all add up to "scary stories" and they will shrug and defend the system.
I'm Argentinian and while we might be a country lagging behind in so many things these kind of ripoffs do not happen.
How come the US government allows this? From other stories sometimes posted, the US seems to be one of the worst countries in the world to either die or get sick.
Allows? The government works for the wealthy and powerful. That includes the masses, who (if they organize) have their own power, but it also includes every other powerful group or individual.
Why would the government want to stop this? It's the average person who would want to disallow this, and they'd have to pressure the government enough that the pain of popular opposition outweighs the brazillions of dollars they're making.
So the hospital is still getting paid something, and the billee has the option to take a bigger credit hit or to negotiate down
But not hard to imagine United Health "investing" in OpenAI and Anthropic to "curate" the information they generate.
This suggests an 'AI can't see gorillas' problem here in that, during an AI-human interaction, identification of relevant big-picture context that a human advisor could have helped with is also missed.
As OP says: "I had access to tools that helped me land on that number, but the moral issue is clear"
https://fighthealthinsurance.com/ was previously posted about a year ago, but I see no traction. There is no moat, just build and distribute, right?
Show HN: Make your health insurance company cry too Fight Health Insurance - https://news.ycombinator.com/item?id=41356832 - August 2024
(broadly speaking, my thesis is generative AI can be weaponized to break down bureaucracy designed to extract from the human, from cost efficiency and power asymmetry perspectives)
- Can’t just cancel credit cards to reset subscriptions/memberships, because new card info now gets forwarded to your vendors.
- Chargebacks are now much less successful, even when the consumer has clearly been wronged.
Politics are strategic, long term system improvements. Technology serves for tactical solutions in the near term.
Not mentioned, and I'm interested, is how accurate Claude's reading of the various medicare rules are. I presume these letters went to someone who had only slightly more knowledge of medicare billing rules than the author -- hospitals are arcane and cryptic places, most especially the billing departments.
The good news is this should be easy to reproduce to see how it does - just google around for an example medical bill with billing codes and feed it to Claude.
I think given this story they totally messed up.
normalizing harassment and fraud, great
After having this same thing happen a few times I now ask at the beginning of the appointment to confirm that it's a wellness visit. Then I ask the provider to tell me if I inadvertently ask a question that will turn it into not a wellness visit. Then I ask at the end to confirm it will be billed with the wellness visit billing code.
The Stanford visit was predated by a two night stay at Eastern Plumas Hospital (rural, interesting experience). EPH wanted as much for two days and Stanford charged for three. Seeing the billed amount and what insurance agreed to in each case was enlightening -- basically 1/3-1/2.
I would not want to deal with fighting this if I was chronically ill.
The usual benchmark is the "usual and customary" charges for a procedure. You can look it up for a procedure for your area. You then go to the hospital and point out these charges. My guess is they're much more likely to agree with this than the Medicare rates.
It's also the rate your insurance will use if you go out of network. So if your insurance pays 40% out of network, and you get billed $1000 for a $100 procedure, your insurance will pay only $40 (4%).
(Although by all means, you can start your negotiation with whatever is lower).
Yes - Medicare is typically lower than private insurance plans, but if you can't deliver care for the reimbursement that Medicare offers as a health system/plan/office/provider, you're probably overcharging.
More than that, Medicare is the de facto starting place for most reimbursement negotiations between providers and payers. One of its benefits is that it's transparent and readily available. Blue Cross isn't gonna tell you what it's contracted to pay an individual provider (and that individual provider often won't know what they'll be reimbursed untill after they submit a bill) - but with Medicare the data's out there.
I know a good number of private clinics that'll offer cash pay discounts that effectively mirror Medicare or even slightly below Medicare, since you're saving them the trouble and expense of going through the medical billing process.
So is the usual and customary rate - I think it's been available since before Obamacare.
> Blue Cross isn't gonna tell you what it's contracted to pay an individual provider (and that individual provider often won't know what they'll be reimbursed untill after they submit a bill)
You'll find out when you get the bill :-) The bills I get have:
- Cost the provider is charging (e.g. $1000)
- Agreed upon cost with the insurance company ($600)
- Amount due ($60 assuming 10% and deductible met).
I don't know if they publish it transparently, but for common procedures, it's easy to find out. They're not going to prevent you from posting your bill online.
I got ChatGPT to come up with some plausible interpretations of the electrical code that allowed the install to continue, including citations. I don't know how accurate it all was, but I sent the argument off to the installer, and he came back and did the work the next day. Even if it gets audited, the chances of the auditor picking apart the arguments are probably slim to none. He has plausible deniability.
This is also why schools and colleges are struggling. No one expected superficially "high quality" work from average and poor students, and now that they have to carefully evaluate everyone's work, they've been caught with their pants down.
Someday superficial AIs will talk to other superficial AIs and they'll deadlock, requiring humans back into the mix. Until then, it's a useful way to do bureaucratic judo.
Their contracts with insurers says they can't bill the insurer more than what's on the standard price list, but the insurer won't pay more than the contracted amount for each billing code. As a result, the standard way to make a price list is to periodically review what insurance has paid on all the billing codes you've used lately, and if there's any billing code for which insurance has fully paid, increase the price.
This is exacerbated by the fact that a single encounter might be encoded into multiple billing codes. One billing code for an aspirin, one for the nursing time to administer it, for example. Suppose insurance A pays reasonably for the nursing time but in exchange pays a pittance for the aspirin, but insurance B pays enough for the aspirin to cover the nursing time to administer it, but doesn't pay the nursing time billing code, but insurance C pays for an omnibus code for "spent a couple hours in the ER", but doesn't pay for nursing time or aspirin separately at all. A provider can agree to all three contracts, because they each give them enough money to profitably provide the service, but that requires that their price list has a high price for the aspirin, an high price for the nursing time, and a high price for the omnibus billing code.
A cash payer gets the same bill an insurance company would - high prices on all three items. But insurance companies never pay that. In the old days, you would just have a totally separate cash pay price list, but medicare rules don't allow that anymore, and limit the magnitude of cash discounts.
Fix the insurance system, and the bogus hospital bills that the hospital doesn't actually expect people to pay go away.
I've had $10k+ bills brought down to $200. $2k+ tests re-coded and fully covered, etc.
There is definitely a business in a LLM-powered medical billing agent that could handle this end to end (esp, contacting hospitals/insurance, waiting on hold, etc).
Every EOB I receive shows medical charges many multiples of what insurance actually pays (and the provider actually accepts). IMO that is not only prima facie evidence of fraud, but - since every provider does the same thing - of collusion on fees amongst and within the medical industry - worthy of anti-trust investigations (I have no anti-trust experience).
Here in Australia, our 2nd biggest private hospital owner has just gone broke.
At a fire sale, there was so little interest in buying the hospitals that many will be shut down.
The rest of the unsalable hospitals will be shoved into a stripped down charitable tax exempt trust so that the creditors ( banks and pension funds ) can recoup a small amount of the money they lent the hospitals.
Provider wants to do procedure. You need it right away, or the procedure allows pre approval with the assumption insurance won’t haggle or deny payment
insurance company denies payment
provider bills you
what i learned is, often, the provider will eventually be paid. do they tell you? not usually. oh woops. I haven’t very successfully fought these other than just hours of phone calls with both companies chasing down what actually got paid and when, and they on purpose make it difficult. If you find yourself in this situation do NOT pay the hospital until the last possible moment it will go to collections. often, you’ll find it mysteriously disappears. it also doesnt hurt your credit very much anyway if it does.
There’s no real defense of these practices or of the industry in general as it exists in the USA.
anything <$500 now by CA law cant show up on credit report so I basically stopped paying those. unethical? sure. will it affect the quality of my care? probably. sometimes though being a deliberate pain in the ass feels better than letting the system fuck you over and over.
Hospitals will pull all sorts of shady stuff to strongly imply that you should pay for a family members medical bill, however. From very strongly hinting that you're obligated to, through to impugning honor, "It would be doing the right thing by your dad", etc.
My SO had to take a medevac helicopter once: we got a $65k bill just for the 20-minute helicopter ride which suddenly became under $4k with insurance. The discount made me feel like I was getting a deal, so I gladly paid.
You could probably tell them to eat dirt,the receiver of services can't be collected against as he's no longer physically here.
Getting the money from his estate would probably take years, if possible at all. I am not a lawyer, so I might be completely wrong, but suing a widow for 200k would be a nightmare for any hospital.
Anyway, maybe one day we'll join the civilized world and not bankrupt families for the crime of being suck.
CMS maintains a service and set of tools to help prevent payers from getting hit with this called the National Correct Coding Initiative (NCCI) [1]. NCCI only applies to provider services and outpatient billing codes, but is still applicable for emergency room services.
There are a bunch of technical details for implementing the edits in the NCCI, but I think it's worth taking a moment to reflect on this.
It's pretty popular to point to the insurance company as the "bad guy" in healthcare, but this is the sort of stuff they deal with thousands of times per day.
As frustrating and horrible as this story is, it's not unique to an uninsured individual. A big problem in US healthcare is provider overbilling.
One of the most tragic jobs I held in healthcare tech was developing software for billing negotiation between providers and insurance companies. It was pretty eye-opening how terribly everyone behaves, and I learned to have a lot more sympathy for what insurance companies/government payers have to deal with.
As a patient trying to have necessary treatment paid for, it's incredibly frustrating to have a claim denied, and these are what we see in the news and experience personally.
As an insurance company, building robust systems that authorize necessary care while catching overbilling, overutilization and outright fraud is unfathomably complex and error prone.
This one of the reasons I've become a fan of DPC (direct primary care) models [2] with HSAs and supplement high-deductible catastrophic insurance to protect against hospital stays. It puts primary care back into a direct relationship with the patient, and lets insurance companies do what they are good at: pricing risk.
Some of the unintended consequences of how insurance companies are currently regulated is that in some states it can be difficult or impossible for an insurance company to provide a low cost, high deductible plan. They are forced to cover things that drive the costs up, so it's hard to do a DPC + catastrophic insurance option.
[1] https://www.cms.gov/national-correct-coding-initiative-ncci
[2] https://www.aafp.org/family-physician/practice-and-career/de...
As a result, the nominal general charge to the uninsured public is generally inflated, but also tend to be very easy to negotiate down.
The problem is that America's healthcare system is ridiculously broken. The symptom of that problem is that prices are astronomically high.
I am happy AI is useful for things like this, but I want to focus on CURING the problem and not just making the symptoms more tolerable.
A meager amount of AI will insulate you from a lifetime of woe, exactly as it was designed to.
NPR Investigation: Many U.S. hospitals sue patients for debts or threaten their credit - https://www.npr.org/sections/health-shots/2022/12/21/1144491... - December 21st, 2022
Some Hospitals Kept Suing Patients Over Medical Debt Through the Pandemic - https://www.propublica.org/article/some-hospitals-kept-suing... - June 14th, 2021
Of course, I hadn't actually lived there since I was a teenager over a decade ago, and I'm sure they knew that, but the harassment tactic worked and I just paid it.
As a not-American, I wonder what are the rules of this "game". Can anyone in the US just ignore their bills and debt and it's all ignored anyway?
Because in most European countries, debt is a very serious thing. Even small debt like an unpaid 50 Euro bill can be sold to debt collectors who can seize your property or garnish your wage, pension or bank accounts to pay your debt plus the collection fee, so people here are incredibly weary of unpaid bills or taking debt for unnecessary things other than houses or cars.
Edit: also credit score of course. Almost anything does affect your score. Except for medical stuff for me for some reason - I have a good credit score.
Without a high score, you don't get the best interest rates on loans. Or, might not be eligible for a security clearance (government work) or jobs in some industries (banking and other "high trust" fields). Or might not be able to rent an apartment.
But, the other response wasn't incorrect. We don't have debtors prisons (unless the debt is owed to the government, then they might be able to jail you).
It's funny that your parent says "I just prefer rule of law than these hacks on society", when Germany's credit check institution, Schufa, acts like that, not super different to China's social credit score he mentioned.
You can't get a rental in China with a bad credit score, and like that, good luck getting a landlord in Germany to lent you his property with a bad Schufa.
Because in most of Europe even a 50 Euro debt will be collected, medical or not. while in the US it seems you can live just fine with a lot of debt that somehow nobody bothers to collect.
And your hospital in Europe DOES collect the half million Euro bill, for say a heart transplant, from your insurance company. You just never see the massive bill because it goes directly to your insurer but someone always pays.
The 50 buck debt in europe will be collected because it is an actual debt, not something some hospital made up. See TFA.
For a second time in a row now you're deviating again from the topic of my point of debt collection just to go on an off-topic rant again on how expensive the US is compared to what you did in Europe. Why do you keep doing this? Are you trolling or is it some attention deficit disorder I should account for?
Forget about medical bills. Let's say you have 50 Euro debt from an unpaid internet/electricity bill if that makes it easier for you to get out of the medical conversation into the debt collation US vs EU topic. In the US you can doge unpaid bills and rack up debt with little to no consequences, while in the EU not since the government goes after you, which makes the debt situation for US citizens incomparable to Europeans. Are you following so far or are you still fixated on how cheap medical bills are for you in Europe?
>The 50 buck debt in europe will be collected because it is an actual debt, not something some hospital made up.
How do you decide what is actual debt and what is made up?
With that logic then all debt is made up because all money in circulation is made up and all prices are made up. I'm gonna walk out of the restaurant without paying the bill because we all know the 200 Euros for a steak is a made up price.
https://www.nytimes.com/2025/07/17/business/medical-debt-cre...
> Senate Bill 5480, sponsored by Sen. Marcus Riccelli (D-Spokane), will protect Washington consumers by prohibiting collection agencies from reporting medical debt to credit agencies.
https://senatedemocrats.wa.gov/riccelli/2025/04/22/governor-...
What state is this? At least in Minnesota my understanding is I'm not on the hook for my wife's medical bills if she were to pass.
America in a nutshell.
To be fair, I'm taking this whole twitter thread at face value.
If you are not going to do universal healthcare at least do outcome based charging.
The bigger concern, IMO, is insurance is tied to employment. The time you get your massive bill is when you get very sick after being fired/laid off and your COBRA is up.
The next biggest concern is the ACA which is the greatest scam ever pulled on Americans. It started out as, what would've been, universal healthcare. Instead, it simply played into the insurance company profit centers by forcing people (now by law) to hold some kind of insurance or pay a large tax fine. So you're stuck paying $1,500 for sub-par care on a bronze plan with a massive deductible and no limit. So much for "increasing the competitiveness of the market".
Healthcare spends more money on lobbying than any other sector in America. The solution isn't to start breaking it down with crap like the ACA. That will get gutted by the bought and paid for politicians (which it did). What we need to do is begin by repealing citizen's united, limiting campaign contributions to 0 from industry professionals (in both their professional and personal capacity), and fire the congressmen taking the most money from them.
They don't have hearts. They have large wallets. Hit them where it hurts.
No, it didn't. Universal coverage between the mandatory coverage and the Medicare expansion was the goal, but universal coverage separate from the mandate you criticize was never part of the ACA or Obama’s proposals before Congress actually crafted the ACA (which differed somewhat from what the President proposed, and actually was closer in many ways to Clinton’s proposal from the campaign.)
> Instead, it simply played into the insurance company profit centers by forcing people (now by law) to hold some kind of insurance or pay a large tax fine.
...except the tax penalty was small, and it only existed for three years (first coming into play in 2014 and being set at 0 since 2017.)
> So you're stuck paying $1,500 for sub-par care on a bronze plan with a massive deductible and no limit.
"No limit" for...what? This sounds like you are talking about out-of-pocket limits, but there are out-of-pocket limits for bronze plans.
I appreciate the author’s disclaimers about that and especially about double checking AI output.
Also...having heard a talk given by the hospital administrator's association lobby...you can kinda get a sense where this funny math comes from....
what would the outcome of the charity option have been? they did not change any practice here, the hospital almost got caught, once, for one bed that was occupied for 4 hours in a single day
This sums up my experience with US Healthcare. They bill expecting you to autopay, and either have no incentive to bill correctly or they outright are trying to scam but the result is that every hospital bill is sus.
This also makes insurance a lot less inherently valuable: you are paying for someone to do this untangling shitshow on top of the actual insurance. As if the hospitals just put the billing burden on the client.
There has to be a penalty for sending wrong bills, or they should pay me for my time wasted.
Finally, the prices are so inflated that often the price without insurance in Europe is the same as the copay/coinsurance in the US.
Its a fucking catastrophe.
I don’t think the ai is being particularly smart in my case, and its occasionally flat wrong.
What it does give me is persistence and motivation. I have a nice workflow cobbled together that lets me dump OCRd scans and digital comms into “workspaces” organized by topic. With that workflow, I can basically dump a letter in, say “wtf is it now?”, and have the llm spit out a response. I do basic due diligence and send. Done. They don’t have to be that accurate, and neither do I.
I feel like I have a new superpower now: outlasting it, whatever it is this time.
Or, more likely, they’ll just sell enterprise products to wealthy hospitals and look the other way.
Negotiating with a hospital caught double and triple billing and somehow being happy with a bill for four hours down to just $33k? This should have ended in litigation.
Elsewhere I see people facing $4k Ambulance rides jubilant at only paying $500. People laughing that they've already paid so many tens of thousands out of pocket that year so can't be gouged any further. And so many others just saying "Oh that's how hospital billing works" as if you've just explained how central locking works.
Guys, this isn't civilised. It's exploitative and in many cases just outright fraud. Why can't you fix it?
Uh. Call me naïve, but how is this not fraud?
So close, yet so, so far! If a corporation commits fraud against you, and you literally ask if the corporation has committed fraud against you, and you proceed to voluntarily send that corporation THIRTY-THREE THOUSAND DOLLARS anyway, are you not a willing co-conspirator in the fraud?
Why are we accepting this?
The system is totally absurd.
I work in healthcare RCM. I have no trouble believing the staff here that nothing in their system works.
Medicaid and Medicare pay fixed fees set by the government.
Insurance companies negotiate "reasonable" fees for services.
As I have insurance, my medical bill usually looks something like...
Procedure A...... Amt Billed: $2000.......Paid by insurer: $100.... Amt Owed: $25
Where $25 is my co-pay and $100 is the fee the insurance company negotiated as "reasonable". For in-network care, the contracts disallow "balance billing" (trying to collect the $1900 in make-believe charges). For out-of-network (no negotiated rates), the hospital often will balance bill (except where prohibited by law).
It's a completely ridiculous system in which "non-profit" hospitals make billions (and write off those imaginary "losses") and insurance companies (who have to pay our ~80% of revenue on care) are happy to have inflated numbers all over the place because 20% of 100 billion is more than 20% of 10 billion.