A lot of folks are looking at the higher US comp but aren't correctly pricing in the long-term risk.

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.

The whole time I was reading this, as someone from the U.S., I was wondering what country the writer was from, because it sure as #$@! wasn't written by someone in the U.S. When I got to that part, I was, "Oh. Okay. That makes sense."

> too much oxygen in the blood can lead to problems with the cornea or something

You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).

The norwegian healthcare is really bad at specific sectors if they deem you as a 2nd class citizen (for example trans healthcare, where there is a lot of malicious gatekeeping and multi-year long waitlists)

> How comfortable are you with naming and shaming the company?

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.

I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.

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.

The United States is a democracy, but more specifically, a representative democracy. That means citizens don’t directly vote on most laws or policies—aside from certain state or local measures—but instead elect representatives to make those decisions on our behalf. The idea is that we trust them to act in our best interests.

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.

No one is "putting up with it." We don't have a choice.

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.

Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.

Add a French and American person, in the US you hear "insurance did not approve", in France it's more "you can't get an appointment / the surgery provider does not have any spots unless you go to their spots in their private hospital".

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.

Ideologically, just enough voters in the right places believe that unless you’re old, or a military veteran, in which case government healthcare is just fine, your sickness should not be their problem, even if it means they pay more for their own care.

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.)

This frame assumes several things:

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.

Great question. No one "wants" insurance. Everyone wants to be able to get covered for care. The problem is that Govt decided decades ago that Health Insurance is the only way to get care even for mundane things like a regular doctor visit. To make it worse, they tied it to Employers needing to provide insurance. Insurance companies love this bureaucracy and became too powerful over the last few decades.

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.

To the extent that U.S. voters want to maintain the status quo, which many (though not most) voters do wish to do, it's largely driven by an individualist mindset in which the worst thing that can happen is somebody else getting something that they didn't "earn".

In European countries the procedures that are denied or very expensive in the US are often simply not offered. There is a national health budget, and not everything fits in it. The doctors have to tell the patients that there is nothing they can do, and that's that.

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.

In part because hospital bills are monopoly money and most people just play a game of chicken with debt collectors, and the only actually sue a small fraction of the time and mostly either settle for a small fraction, give up besides annoying phone calls, or it gets discharged in bankruptcy.

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.

We are a "binocracy", where our democratic function has been reduced to a binary choice, and unfortunately both choices have been fully captured by the healthcare industry.

One thing also to keep in mind, is that this experience is not uniform throughout the US. Many Americans like -their- employer based insurance, even if they don’t like the system. I personally pay nothing for visits and nominal fees ($1-10) for prescriptions. I have not been hospitalized while on this insurance, but my understanding is that it is relatively low cost. I also have no monthly premium. Meanwhile, my mother works at a small business, pays a significant percentage of her income for insurance from the ACA marketplaces (the public marketplaces created during the Obama administration) with the current subsidies, subsidies that are in question under the current administration. The American healthcare payment system is broken, but we aren’t all living through the worst case scenario experiences that get the attention. Add to that the amount of money and effort that went into turning healthcare reform into yet another partisan issue, and there’s a good recipe for maintaining a broken status quo for a while yet.

Edit: just saw an earlier better comment saying the same thing: https://news.ycombinator.com/item?id=45737190

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.

> I have heard the US is a democracy.

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.

America is trapped in a cycle where political parties have discovered that fear and anger drives voters whereas contentment with status quo does not motivate turnout. This leads to a scenario where parties will actively sabotage the resolution of painpoint issues such as immigration, healthcare, gun control etc. so long as it continues to create anger and fear that they can successfully blame on the other party. This behavior extends to voting against their own proposed policies in the interest of seizing/maintaining power over problem solving. And now deliberately creating crises (both real and fictional ones) has become the game-theory dominant strategy in American politics.

Why do you put up with long wait times and lower-quality care in your home country?

A lot of employed people like the status quo for the healthcare that they receive.

"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-...

US person here.

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.

> Though why do you Americans put up with all this? I have heard the US is a democracy. So then insurance-based healthcare is what American people truly want?

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

[3] https://www.youtube.com/watch?v=QFgcqB8-AxE

> I have heard the US is a democracy

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).

Yes, but we also want universal healthcare. What we don't want is only universal healthcare with death panels like the UK and Canada has. Give us universal health care where we can also get insurance if we want, and we'll vote it in. That's never what comes up though. I firmly believe we could gut medicare/medicaid and the savings from the bureaucratic administration costs alone could pay for universal healthcare.

The US is gigantic. Imagine if every EU member, however rich, poor, or corrupt from Bulgaria to Germany had to enact one healthcare system.

Well there is lot of shit we Europeans put up with, for instance EU moving court every few weeks voor 200m per year. But systems are hard to change.

Hum.. At least where I live in europe, you still need to battle with insurances for any non trivial problem.. We get a health care coverage for the common stuff, but many things are not covered, or not covered enough.. Then you need insurances.. And it's always a battle..

Same for other kind of insurances such as issues with the house, etc..

The US money machine has one of the most sophisticated propaganda networks in the history of the world working to make sure nothing ever gets better for working class people. In George Orwell's vision of a dystopian future, "The party told you to reject the evidence of your eyes and ears. It was their final, most essential command." In the US, the party didn't even have to issue the command, they just asked a few thousand talking heads to do it.

You've implied the answer to your own question. The USA is not a democracy. The opinions of almost all Americans have no impact on policy. It's a well researched fact.

Having an election day where people vote doesn't mean you live in a democracy.

Then what sort of feel good stories about AI would we have . The US needs to adopt a single flat income / corp tax, government provided healthcare, and move on to the rest of life.

Non-US person here too. From what I understand the majority of Americans want a single-payer healthcare system, but too many people in government are paid by insurance companies and affiliates to not change how things work.

Without making a claim about whether it's what most people actually want or not, there's not much that an individual can do about this by changing their voting preference. The US doesn't have proportional representation, and the overwhelming majority of elections are "first past the post" rather than one of the more "modern" alternatives like ranked choice votes, so in practice very few elections ever swing to anyone outside of the two major political parties (neither of which have a particularly large contingent of politicians who have come out in favor of something like single-payer healthcare). Even for a purely single-issue voter who only cares about this, from a game theoretic perspective you're likely to be essentially throwing your vote away if you vote for someone outside of those two major parties because it's unlikely enough others will.

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).

Its too easy to convince enough of the population to actively vote against their own interests.

It's not a democracy. You were told wrong, it's a republic.

-Democracy in name only

-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

Just Pharmaceuticals not even all medicine is literally over half of all advertising spend in the US. And that is just the tip of the iceberg and doesn't go into the incestuous and conflicting interest relationships between pharma, pharmacies, medical providers and insurance companies all inter-invested in each-other to simply grow the pie larger since ACA limited profit percentages.

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.

One can argue what people wants is to be ruled by old convicted felon dictator.

As soon as someone introduce these ideas people think they're a communist. See Mamdani in NY right now.

I don't think this has much to do with being a democracy. I, for one, wouldn't trust our federal government to competently run an efficient, most uncorrupted healthcare system for all.

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.

The same way European people put up with the insane NHS and its refusal to care for the people who support it financially and supposedly support it politically.

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.

I think the root cause of the problem is not insurance companies but they definitely do play a part. The real reasons are multiple but can be listed as below.

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.

It's precisely as many have said over decades at this point: the poor in our country hate themselves to the extent that they view being poor as a personal failing, and voting for free services for everyone is therefore dishonorable. I talk to people like this every day and it's frustrating.

The US is only ostensibly a democracy. It's not a functioning one, due to widespread voter disenfranchisement.

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.

The are advertised as a democracy, but ever since Citizens United was passed we became an Oligarchy. Money now takes the place of votes since the rich can donate unlimited funds to a candidate. Candidates have zero incentive to serve the public.

The alternative is no surgery and no choice, which is what happens with government-run healthcare.

No, we all hate it, but the number of senators and members of congress who would vote to replace it could be counted with one hand. The reason is simple: the insurance companies give those senators millions and millions of dollars and nobody has the cash to beat them. And we've given up at this point.

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"

We have a lot of people being constantly brainwashed that we have the most amazing system in the world and that any attempt to change it is communism.

I think you’re just believing whatever the author says, and not considering the fact that reasonable people can disagree and be wrong and make mistakes. For all we know the procedure was entirely unnecessary and they agreed because he pushed for it. Also, what’s the alternative? The only system where you can go get procedures that authorities think unnecessary is a free market where you self-pay. A government-run system could equally decide that the procedure isn’t recommended.

Decades of right-wing propaganda, unfortunately. They tend to have an emotional reaction against any sort of socialized anything, including healthcare.

Medicare has a total enrollment of approximately 69 million people, while Medicaid has around 83 million people. That is 152 million people. We already have socialized medicine we just run it poorly and don't apply it to people that can pay.

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.

We fucking hate it don't worry

Non US as well. Life saving saving surgeries get denied, delayed and otherwise screwed all the time. Not sure where exactly it is worse since absolutely atrocious cases can be found in every G7 country never mind the rest

Yes, it is what they want.

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.

not sure why you're getting downmodded. People will say M4A ("medicare for all") polls at super high levels, and they're right, it does. But poll those same people telling them "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on, and that poll turns right upside down.

There's a difference between immediate stabilization, required by law, and life saving surgery in general, not required by law.

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.

> I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.

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".

Seems like GP is trying to refer to the child without reference to sex.

I shudder to think when insurance companies use AI to counteract customers using AI to navigate through their system. They'll eventually catch up, and people who don't use any kind of AI will be disadvantaged.

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.

if the kid has a steel spike through his abdomen then they will perform that surgery. If he's having seizures because of a brain tumor all they're required to do is stabilize and release.

Presumably parent is describing a non-emergency situation.

>A code is not an artistic expression and so can't be copyrightable.

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.

Judging by Judge Alsup's ruling even if the codes were copyrighted it would most likely not be copyright infringement to train on them either, and as such even if they are copyrightable and they do own copyright on them it remains beyond their abilities to forbid training on them. (Also opinion, also not legal advice, I'm also not a lawyer and sort of doubt the person I'm responding to is).

Software I write at work is not artistic expression yet is covered by copyright.

This isn't a counter argument, just pointing out how absurd copyright is.

> The layout of a book of codes, for sure, but the information in it

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?

And yet people are collectively paying $300M licensing these non-copyrightable codes? With that kind of money somebody must have looked into not paying for licensing

Doesn't the AMA serve the medical industry? They don't have to make profits themselves. If a byzantine coding process raises medical treatment costs, they'll do it. Just like how they intentionally cap med school admissions to keep doctors in demand and inflate their salaries.

Any non-profit can always claim to inflate their expenditures up to (and above) their expenses and pay lavish bonuses to their employees, like you said.

Doesn't change what it basically is - aka Scamming the Public, and privatising the gains.

It has been forever, what planet are you on? Their official policy would be to make any native american cure (upon which many of the medications we use from big pharma, are based on in origin) to be illegal. They would want all profit going through them, whether that is good for you or not.

It’s quite literally a cartel and it acts like one. They heavily restrict the supply of doctors, which means our medical costs are higher in favor of higher doctor salaries.

Anything related to healthcare (except some genuine minority of doctors and staff) is almost openly hostile to Americans.

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.

You could argue the lawmakers that granted copyright protections are openly hostile to Americans. Many fine people are saying that Congress values profits over people.

The opaque costs add up. If nothing else all the layers make things slow, when time is the difference between life/health and death/illness.

He literally did a prisoner's dilemma on them. Love it.

Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

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.

We are self-employed in the US and buy our own high deductible plan on our state's marketplace. One of my family members needed a fairly routine planned surgery, so I went through the effort to try to determine in advance how much I would be billed. What a waste of time. My favorite was the hospital who told me the fee for a one night stay would be 73k. But, good news! Your insurance has a contracted discount that brings it down to 13k. So what does the 73k price even mean? At this point I shelved the effort as I correctly concluded we would hit our household max out of pocket for the year, so anything above that would not affect us.

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.

> What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

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...

I briefly worked in adjacent space. While I hate the way it works, it makes a lot more sense when you understand that the billed amount is essentially just a negotiation tactic that represents a price well above what they ever expect to be paid (and a bit added to that for safety).

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.

I think the argument is that it’s criminal to take advantage of the patient without insurance and ask them to ruin their life trying to come up with 195k when your system is setup to reasonably profit off the 37k you get from the insured patients. I firmly believe that even in a capitalist society the idea of profiting off of anything let alone healthcare in the thousands of percentage points is criminal.

double charging on purpose systematically sounds slightly criminal to me

This! People underestimate the extent to which lawyers are negotiable also. “I’m not paying that” is a surprisingly effective method; they’re often willing to compromise on payment terms, work at-risk subject to a successful outcome, significantly reduce their rates, etc.

Not just arcane subject matter, but numbers so high any sane person panics.

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.

I've found LLMs helpful for figuring out what I don't know, then I can go and look up how those things work, again together with an LLM.

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.

"But fight with knowledge. My $20/month subscription to Claude more than paid for itself. Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right. I also had ChatGPT, to which I subscribed for one month just to do this, read the letter and fact check it. No notes."

Old poker adage: "The more wild cards and crazy rules, the greater the expert's advantage."

Poker has nothing on Commercial Lawfare.

I suppose a saving grace there is that Medicare is incentivized to help people or at least not incentivized to provide the minimum amount of value for maximum profit.

So what you're saying is we've injected a whole smorgasbord of electrical dumbasses into a system already rife with corruption, greed and exploitation that provides services no person can do without and is frustrating to use at every juncture.

Yaaaaaaaaaaaaaaaay.

The funniest bit about all this is that this is all just laziness all the way down. People complain about AI-written articles. When the article is written about a human, they fall over themselves to point out potential flaws, like "well it looks like AI hallucinated" and it gets voted to the top. Then it turns out that they themselves did not read the article. Just a damning indictment of the quality of online discourse in year 2025.

I guess I would think that negotiating at least involves communicating with your counter-party. Its role here feels more similar to being a billing consultant. There are plenty of people (and systems) that pass messaging over to the actual AI - which was my expectation from the title and why I noted it didn't happen.

People want so badly that AI won't be useful that I feel like they will diminish everything they do. I also get that they probably feel like it's all hype, but there are plenty of examples of real value that AI brings to the table.

I was going to say please use and donate to 'Dollar For' [1] which provides this service, which is likely a better choice for this type of problem than trying DIY.

[1] https://dollarfor.org

EDIT: adding in a link to 'Dollar For'.

Thanks for your insight!

I’ll look into it. From what I can tell it’s not a simple hero vs villain story. It feels more like an industrial disaster or the AWS outage where there are like a dozen compounding system failures leading to where we are today.

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.

Matt Stoller is properly described as an insane person who thinks every single problem in the world is caused by monopolies (yes, including whatever random problem you're thinking of now).

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.

> 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.

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.

thank you for saying that and I share your sadness / anger . A lot of people do. It’s not your fault, or ours. Healthcare is a truly evil bureaucracy staffed with some of the most loving and capable people I’ve seen. So I’ve been able to admire the beauty of the situation while remaining angry at “the system”.

1. There are assistances available for low-net-worth and low income individuals. Have you tried those options?

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.

It's probably unsaid that she died with a good credit rating as well.

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.

We had felt invulnerable until we weren’t. I’m sorry about your friend’s mom it’s vile and even more infuriating that there’s no clear “villain”. But you reach a point where you focus on what you have. Good doctors, admirable and compassionate nurses , loving and supportive family. The money is toilet paper really – we conceded that a long time ago. Make the most of it while you can but you can’t hold onto too tightly.

That’s exactly what we experienced. There is no way to be an informed customer or “vote with your wallet”. For many diagnostics and services, the “provider” is 2 referrals downstream – the patient never elects or engages with them.

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

> I got an eye roll, a lengthy and exasperated lecture...

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.)

It’s just so insane that the entire industry accepts that no one knows how much things are. Even the “financial services” team will just say “yeah that estimate is wrong” and not blush. What are you guys all doing?

I recommend making a good faith effort to negotiate and start a payment plan (reading the fine print on the overall commitment). But bankruptcy is a viable option if you don’t have a ton of assets at risk.

From other comments, it sounds like you could rescue your credit by simply telling them you can't, but you'd like to pay something more reasonable.

Aren't medical debts not supposed to be on your credit score?

in every single case those estimates have been wrong. In most cases by 200% or more. And a many case there are no figures.

There are two “provider networks” in our region: BCBS & The United Healthcare network. BCBS is supposed to be better. Were we to switch, let’s say they did cover the 1/10 out of network cases, we risk losing the 9/10 that we currently have . The “whack a mole” is a good example. In this case it’s whack a mole and one could be $50-$100k worth of coverage gone. And more importantly, when you find a good doctor, you need to hold onto them. The difference between a good doctor and a bad one is life or death for this condition.

Does that

- turn into whackamole every year?

- expose someone to "preexisting conditions aren't covered" issues?

You’re right and there are some provider segments like MRIs that have succeeded with this model.

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.

Fun fact is that most such obvious innovative solutions are prohibited by law. There are many layers of turtles the lowest two are: corrupt politicians and, population that doesn't care about corrupt politicians.

you’re right it’s a great idea for a hip replacement and many other procedures. Our condition doesn’t fit into that model well because of the duration and frequency of treatments.

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.

Phase 1 is well underway, no worries

I don't know, I don't run an ambulance company- what should the cost be (either to me, my insurance company, or to the government)? Can't be cheap to fully staff an ambulance with EMTs.

Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.

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.

The idea of an injured patient having to pay at all for an emergency ambulance ride to a hospital should stun any normal human being living in a civilized society.

I'm always happy to help people stick it to crooks. Here's what I know:

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).

Surprise ambulance bills are mostly (but not completely) illegal in California as of Jan 1 2024. Ask the LLM of your choice about AB 716 and whether it applies to your situation (it likely but not certainly does). Have the LLM draft a letter and send the physical letter to the ambulance company. If they are bothering you, request they only contact you by US mail.

Their brother presumably didn't have insurance, and it sounds like some pretty major procedures involving specialists, equipment, and hospital intake. While the outcome was horrible, all of those people need to get paid for the services rendered somehow if we want folks in the US to continue receiving this standard of care.

$30K NOT counting some expenses (cardiologist, ER docs)???

> 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.

To a lot of people, that's out of the fire and into the frying pan.

Hospital billing involves the 'mafia'-like influence game of having good insurance (which means being hired at the right company, with the right 'influence' over the hospital network in question) and covering the costs of the other patients who cannot afford it and refuse to pay. Hospital billing has the least teeth of any debt in the US. If you haggle a billing department long enough, they'll desperately take anything you give them.

Are the outcomes in the US worse? Not that long ago (a couple months ago in fact), I looked at public data comparing cancer survival rates, which put the outcomes in the US at least 10% better than those in the UK. That was additive, such that a 20% survival rate in the UK for a type of cancer is at least a 30% survival rate in the US. The 10%+ better outcome in the US applied to all types of cancers for which I found public data.

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.

Look at when all the "No Kings" protests are happening: on the weekend. Because there is no way the vast majority of Americans can go on strike, because healthcare is tied to employment. This is why healthcare is never getting "fixed" in America--it's doing its job quite well.

The hospitals and insurers are locked in a Red Queen Race. The hospital bills for 10x actual market value. The insurer touts they are getting you a 90% discount. The individual who got sick or injured gets crushed in the middle.

I'm getting that most people don't know the sticker price is fraudulent (e.g. the overlapping "master procedure" and component codes) and/or are so relieved to have the charity out that they agree to it without any further questions. But OP points out that the charity out is just further fraud, victimizing tax-payers.

the medical insurance industry and the hospitals do this whole song-and-dance charade where they pretend that they are charitable, public-protecting institutions who serve noble goals of helping sick people.

in truth, they are doing nothing but racketeering.

Where are the class action law suits?

Google and friends has made sure the hospital knows among other things how much you make, your life insurance policy payout, the value of your home, etc.

Canadian here; our system has some pretty extreme issues. The vast majority of Canadians still prefer it to the U.S. Wealthy Canadians (>$500M net worth) would likely prefer the U.S. system in all cases though. Even moderately wealthy Canadians ($1M+ net worth) would likely get better treatment from the American system 95% of the time (when they don't have extreme issues which result in exceptionally costly treatment)

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.

Many Americans desperately want to believe that other countries' healthcare systems are "just as bad" as a form of coping.

The wait time you alluded to is indeed the issue. The issue is not limited to dermatologists.

All these things are language parsing and transforming. That's the kind of thing llms are good at.

Capacity issues are dependent on country. In my country (Netherlands) is it not that bad and you can easily switch Hospitals if there are queues for certain operations (that are not urgent).

US health care outcomes are really not great, even if you are rich. Yes, you live longer than poor people in the US, but still do worse than Europeans, even those with lower incomes [0]. All while spending much more [1]. It's a system designed to siphon money from wherever it can (individuals, governments, companies, etc.), not to provide the best health care.

[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

[1] https://ourworldindata.org/us-life-expectancy-low

Isn't it universally true that if you're rich your life can be much easier? With enough wealth the actual health care system does not matter much. Neither does the country in which health care services are rendered. You just pay and get things done, and maybe even take some vacation while at it. However, given that not every one of us is rich, the point is to optimize the whole thing such that the little folk can still survive and get their health issues addressed.

What % of the US population would you think have to pay to get that "best" care?

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...

Well, everything is great if you have money. I was talking about the health care as a system.

I have money and it still sucks. Perhaps you're thinking of billionaire money?

I assume it'd get sold to a collection agency for something like $500, which would then try to get you to pay as much as possible, possibly settling for as low as $2000).

So the hospital is still getting paid something, and the billee has the option to take a bigger credit hit or to negotiate down

As a non-American, I think the thing I'm hung up on in what you said is that I don't understand why a developed country should allow anyone to be "uninsured".

Sure 92% of Americans have insurance, but they pay 5-10x the monthly premium compared to most Europeans and then on top of that the co-pay is thousands of dollars more than the small (or zero) amounts Europeans have. And insurance is not guaranteed, it's all linked to your employer. It's bad for nearly everyone, but enough people accept it so it doesn't change.

Even if you're insured it sucks.

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.

Wildly false. This thread is full of people sharing stories of being supposedly "insured" and getting fucked anyway. The complete lack of transparency around what your insurance covers, something you can't be expected to verify while in the middle of a dire medical crisis, can lead to a life destroying bill.

Nobody should have to be wondering what company an ambulance works for. It's crazy. The whole world thinks it's crazy.

Having insurance you still wind up paying 30k+ a year for that privilege whether you use it or not.

Except if you have health insurance and the medics choose the "wrong" medicine which isn't covered by your particular insurance.

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.

It happens. A friend flew to France to have a tricky heart procedure done. But most people aren't going to have the time or resources to do that.

> besides a few months of annoying calls.

normalizing harassment and fraud, great

A lot of people are unaware of who is responsible for what, and may be convinced to pay debts they don't owe. And creditors absolutely take advantage of this. Any debt collector worth his salt will hound everyone they can identify until they are told to stop in the particular way the law prescribes.

It seems like every time consumers automate against the-powers-that-be, the powers change the rules.

- 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.

I like the idea but I'm sure that's a YC startup working on juicing revenue from patients being spun at the same time.

> One of its benefits is that it's transparent and readily available.

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.

Basically the only thing debt collectors can do in the US (if the amount is too small to justify a lawsuit) is harass you with phone calls. I have DND except for contacts on anyway so I dont notice it.

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.

Homeless people do. Personally I rather pay something, but I'm not spending tens of thousands if that's not what everyone else is paying uniform. This is why there's no transparency on hospital prices, because nobody is ever billed the same, ever. Someone's bill is offsetting the losses from someone else.

It would be quite hard to run up a million euros in debt to a hospital in Europe, but in the USA that is not at all unheard of.

I have been doing this since before the initial law was passed as it happens

Unless you live in WA:

> 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-...

Agree. Also, it looks a lot like the USSR system, where general healthcare was underfinanced and had poor education quality (although, mostly worked against infectious diseases), hence some ministries and even enterprises (were part of ministries) had their own clinics and so-called sanatoriums (recreation and healthcare facilities for vacations). ...and also built their own residential apartment buildings (they'd order the construction enterprises, but had the housing themselves). So it mattered a lot where you worked and where you retired from.

> 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.

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.

Services were rendered for just 4 hours is somehow worth $30k?