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PaperclipPerfector  2d ago (text post)   7512 thread views

Culture War Roundup for the week of November 17, 2025

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Whelp, I just got screwed again by the lack of price transparency in the American Healthcare System. feelsbad.man.jpg

Thankfully, it's not a huge dollar figure, but it's the sheer stupidity of clinging to price opacity, which inevitably finds some way to reach into my pocket and pull out more money, that annoys me.

It was not a situation where the provider didn't have the necessary information to understand why the price ended up being what it was. When I called them to ask WTH, it took all of three minutes for them to just go through the steps of verifying the process and then explaining it to me. But that's three minutes that they should have spent going through the steps in order to give me a price before they performed the service, rather than blindsiding me with a bill after the fact.

Yes, yes, I know, they don't want to spend three minutes per patient; that adds up! And of course they don't want to; it's not only their time being spent; it's not in any way in their favor to spend those three minutes. It's my pocket that it comes out of, after all.

Moreover, it was a situation where, had they spent the three minutes and we could have then had a conversation about the price, in hindsight, I am extremely confident about how I would have made a different choice as to the way that I arranged the services that I would have liked to acquire. I literally, actually, could have personally made a different choice if I had had price information, and it's a choice that I would have preferred in terms of my personal cost/benefit analysis.

Of course, it must be remarked on that had I had this information and had I made the choice that I would have preferred, the provider would have made slightly less money. I don't think they were doing this on purpose; it's just convenient for them to not spend three minutes and also probably make more money. They just have near zero incentive to even consider doing things in a way that may be in my own interest. The only danger that they run is that if folks like me eventually get pissed off enough at these shenanigans, we'll either search desperately for a different provider who will bother spending three minutes or simply get so fed up with the constant nonsense that we just eschew that sort of service altogether. Man, it's tempting to do that, because it's just... so... constant a problem. I'm already pretty cynical for how they're going to find a way to screw me over, and apparently even that was not enough cynicism.

The snafu did, in a minor way, relate to the way the insurance policy is written. I mention this only because I would like to hold open at least some amount of plausible blame for them (it's really kind of hard to in this particular situation, but I'll mention it anyway), but the provider legitimately had 100% of the information necessary to provide me an actual price and discuss tradeoffs/courses of action prior to services being rendered. They just didn't bother.

This feeling really makes me sympathize with all the people who are so outraged. I'm sure there are tons and tons of stories where the insurance company is more to blame, too, so I sympathize with those folks feeling gut anger at them, too. It's just monumentally infuriating to have them over and over again find endless ways to screw you over and see that it's not even malevolence. It's pure apathy toward your interests as a patient combined with an addiction to doing everything possible to remain price opaque.

Stories like this are why I just dont have insurance. Urgent care, sketchy unregulated providers, and (maybe) energency room for me. Plus some medical tourism.

Do you go so far as to give fake ID for ER care to avoid debt?

I do the same thing, and the one time I had a medical emergency (pneumonia), I got hit with a bill for $40,000 from the hospital, plus a few more thousand from random other medical entities. I went "lolno" and spent months applying for financial aid and negotiating with the billers, letting them know upfront that my BATNA was to declare bankruptcy (in which case I would have transferred all my money to my mother's bank account first so it could not be seized; she did the same thing with my bank account the time she declared bankruptcy). In the end, I only paid out a couple thousand dollars. feelsgood.jpg

It appears that bankruptcy fraud is a crime (1 2) punishable by a sentence of up to five years in prison. (The federal Sentencing Guidelines prescribe a minimum offense level of 10 for fraud of up to 15 k$ (base 6 for fraud, plus 2 for loss up to 15 k$, plus 2 for bankruptcy fraud). This corresponds to an actual sentence of 6 to 12 months for an offender with no criminal history.)

I simply avoid getting into medical emergencies

Skill issue. Have you tried quantum transpositioning into a different universe where you don't have cancer?

Isn't it easier just to subtly modify your dna to start creating cancer antibodies. Mind over matter.

Another interesting gotcha is that if you have an HDHP/HSA and have an in-network service, you are required to pay the full in-network cost of the service out of your pocket, no haggling allowed because the amount you pay is counted into your deductible and other factors. This leads to interesting cases where that amount is significantly higher than the uninsured self-pay rate, and having insurance (and being in-network) is actually making things much much worse. Though on the other hand it is a form of price discrimination in that the hospitals make more money from patients with insurance, and for patients without insurance but still some money, the hospital can get something instead of nothing.

In this case you unfortunately need to go to your insurance to find out the prices, as the clinics and doctors kind of have no say in the matter. Which is unfortunate because health insurance companies are a huge mess to deal with.

For anyone on HMO/PPO usually this isn't a concern because copays are generally predictable, and the most common cause of a surprise gigabill is due to a service being out of network but nobody checked or told you, or if a claim is denied. And in that case the bill certainly is negotiable and generally you'll have decent success negotiating it down.

But in my personal imo after paying fully out of pocket on HDHP, medical treatment outside of the hospital is actually quite affordable. After seeing multiple specialists and having tons of blood draws and labs, the yearly cost is only a few thousand dollars, far below the premiums of even a basic ACA plan. But the moment you set foot in a hospital the gigabills come out. Just the room in the ER for half an hour will set you back thousands, and that doesn't include the doctor or any of the treatments.

In this case you unfortunately need to go to your insurance to find out the prices, as the clinics and doctors kind of have no say in the matter.

This is not true. It's a lie perpetuated by providers who want to remain price opaque.

Providers and insurance companies sign agreements, where they agree to a list of negotiated prices. They both sign this agreement. They both have a copy of this agreement that they signed. They both have a copy of the negotiated prices. Either party is perfectly capable of looking at their copy of the prices and telling you the number they've agreed to.

Imagine that this lie were actually true, and clinics/doctors truly had "no say in the matter". Well, then the insurance company could just magically decide that the price is $1, right? There's nothing the clinics/doctors could do about it, if they "have no say in the matter". But in reality, they do have a say in the matter, and it happens when they negotiate an agreement on a list of prices. If, prior to signing an agreement on a list of prices, the insurance company were to say, "If you sign this agreement, we'll pay you $1 for services," the provider simply won't sign the agreement; it's not worth it to them to be "in-network" if it only pays $1. If, on the other hand, after signing an agreement on a list of prices, the insurance company were to say, "Lol, whatevs about that whole 'price list' BS, we're gonna only pay you $1, because you have no say in the matter," then the provider will simply point to the agreement that they signed, in writing, with the threat of obviously winning lawsuits.

You know that insurance companies consider complying with their side of the contract to be completely optional and something only to be done under pressure, right? Their first response to a claim or request for pre-authorization or payment is a reflexive denial; that costs them nothing after all, and might make the claimant go away. So then the provider has to have their people spend time arguing with the insurance company and then MAYBE they pay or maybe they'll only pay for some of the codes and disallow others. The insurance company's reluctance to pay what they agreed doesn't appear on any of those contracts.

That's a different problem, though. That's part of the awful adversarial game they play. But that doesn't change the fact that they have negotiated prices, and they both had a say in what those prices are. They (either one) can still just tell you the negotiated price, even if there may still be a fight over whether the insurance is actually going to pay. One problem at a time. Don't let the existence of the harder problem stop you from making the trivial solution to the easier problem. Nothing about this trivial solution to the easier problem makes the harder problem any harder.

I've long assumed that either the insurance companies or the care providers (or both!) want to keep the list prices hidden. I assume for competitive reasons. I thought the first Trump administration passed rules requiring those to be published, but that doesn't seem to have done much in practice (published, behind a door marked "beware of the leopard"?).

My personal suggestion is that we should, as a condition of accepting Medicare patients/payments, require providers to charge no more than a multiple of the Medicare price list, even if that multiple is something like 2 or 3.

Hospitals all post their list prices these days, but unfortunately those are the list price and literally everyone gets a discount of some sort.

Yeah, it sucks.

I got a $500+ bill from a lab recently. Their reasoning? Insurance said I wasn’t covered. Check insurance, nope, they definitely have coverage on the date. Maybe they ran the wrong one? Explain this and ask them to run the current one. Month later: bam. Exact copy of the previous bill.

What do I do at this point? Pay the bill and then file a claim, I guess. Except that feels like accepting liability for what is, ultimately, a bullshit charge. The insurer and the provider are gonna laugh at me for holding the bag. Monkey brain says fuck that.

And all of these steps involve going through some combination of 2FA, patient portals, website “assistants,” and phone dungeons. I don’t want to deal with it. This kind of shit is what makes me feel least like a functioning adult.

It really does surprise me that we don't see more people snap and retaliate directly. Presumably the demographics most likely to do that are also the ones most likely to get free healthcare in the first place.

Seems like the logical next step is to call your insurance company and tell them yourself that they need to pay it. Make sure you have both the bill and the big PDF that explains your benefit plan in detail so you can cite the specific applicable provision if you get pushback.

You tell them that you're not paying it and haggle them down, Indian style.

It’s one of the worst things about this country.

Not knowing the cost should be illegal.

Tear down the entire economy to cull the health insurance industry - it’s one of many things, but imo the most important, that needs to be ripped apart and changed in a manner beneficial to most Americans.

Consider the class of citizen who blows all of their disposable income on, say, online sports betting. The powers that be have determined that it is unacceptable to put these people in the position of making their own cost-beneft decisions about individual health interventions.

Tear down the entire economy to cull the health insurance industry

Random thought: just make it legal for veterinarians to treat consenting humans. Give them immunity for malpractice for anything below gross negligence -- if you want to get a million dollar payout by convincing a jury that a doctor treated you wrong, you should have gone to a hooman hospital. As a bonus, vets are a lot less squeamish about MAID.

Alternatively, disallow health providers from price discriminating. If you bill one insurer X$ for a head CT, you better not charge any other patients more for the same procedure.

Alternatively, disallow health providers from price discriminating. If you bill one insurer X$ for a head CT, you better not charge any other patients more for the same procedure.

Wait, that's not already illegal? How are they sidestepping the whole disparate impact discrimination thing.

Price discrimination is an economic term that means charge the people who NEED something the most and charge people who are barely willing to buy this the least and have some way of preventing the second group from selling their thing to the first.

It can also include charging everyone the maximum they are able to pay. And it can be passed off as "we meet people where they are and offer discounts for low-income patients," which sounds really nice (and may be in some cases), but can in practice take the form of "charging everyone as much as they can afford". This seems to also happen with college tuition: "it costs a million dollars a year to attend, but we'll be nice and settle for the difference between your parents' paychecks and the federal poverty line".

I don't have a firm answer for where I think the ethical line should be on income-based discounts.

It’s discriminating on ability to pay, which isn’t a protected characteristic.

“We’ll charge him more because he’s white” is illegal. “We’ll charge him more because he has good insurance” is, uh. Complicated.

Isn't the point of disparate impact that it's an end-run around needing evidence of explicit discrimination?

"we'll charge him more because he's white" is explicit discrimination.

"We'll charge him more because he has good insurance, which is statistically correlated with whiteness" is disparate impact.

I believe the current administration has started moving against regulatory disparate impact standards generally, but even where it has applied, it's pretty consistently only in specific directions.

If they're doing end-runs I don't see why you'd be surprised that the whole "equal protection" bit has clear caveats on who gets discriminated against. The logic is there to hunt down racists who got slightly smarter after the end of segregation after all.

In other countries (Canada) they just make this clear but people have to be smarter in America.

the whole disparate impact discrimination thing.

The master's tools will never dismantle the master's house.

Anti-White (and anti-Asian, and Anti-Male) discrimination is de-facto legal, and sometimes mandated. See Students for Fair Admissions as another example.

As a bonus, vets are a lot less squeamish about MAID.

That's not a "bonus" that's fucked up.

Vets have a staggeringly high suicidal rate which is atleast partly due to the amount of euthanasia that their jobs tend to involve. I've got veterinary friends and the stories they tell are quite depressing.

just make it legal for veterinarians to treat consenting humans. Give them immunity for malpractice for anything below gross negligence -- if you want to get a million dollar payout by convincing a jury that a doctor treated you wrong, you should have gone to a hooman hospital.

This idea is absurd and I love it even though I can't imagine what second and third-order effects it would have.

To steel-man the idea that "knowing the cost" is always possible, I'm not sure it'd be reasonable to expect my (car) mechanic to define payment terms for a fix before even popping the hood. There are enough potential complications in complex procedures (emergency cesarean sections in childbirth, for example) that probably can't be trivially bundled up front.

That said, most of those cases are ones that don't really seem like they get much benefit from market-based economics either. But presumably somebody has to shoulder the cost of the not-completely-expected procedures that are found to be necessary: I'm actually somewhat sympathetic to the idea of single payer for this specific sort of thing, but haven't thought through all the bounds I'd apply there.

In India it is possible to know the cost. The hospital knows that some procedures have complications and prices that in. If the 4/5 patients cost 75k and 1/5 costs 2 lakh, they charge all of them a flat 1 lakh. You pay 1 lakh before the procedure and your obligation is done.

This is possible. The US having a different situation is a choice the US made.

That's just insurance socialism with extra fewer steps, right? The American public would never accept it. "Why should I, with my beautiful fast clotting blood and strong infection resistance, pay more for a procedure that will barely keep me in a bed for one night?"

To steel-man the idea that "knowing the cost" is always possible, I'm not sure it'd be reasonable to expect my (car) mechanic to define payment terms for a fix before even popping the hood. There are enough potential complications in complex procedures (emergency cesarean sections in childbirth, for example) that probably can't be trivially bundled up front.

The question isn't really do we know the cost, it is who carries the risk that the cost turns out to be higher (or lower) than expected. There are lots of situations where we are unsure about the cost going into a transaction, and the risk has to be distributed. Right now we operate on the system that the Hospital takes on only the risk that they don't get paid, while an "honest" patient takes on all the risk. We could quite easily choose to distribute that risk differently.

I know healthcare is complex, much more so than wrenching, but the idea that we don't know how to price things isn't true. There are codes for all this stuff, there's plenty of data on what a procedure involves (in terms of consumables/times/equipment) that can be used to blend it.

Any healthcare provider already does all of this for P&L reporting, care plans, etc. but they have to hide what they know to negotiate with insurers and the government.

but they have to hide what they know to negotiate with insurers and the government.

They don't have to hide the terms of the agreement that they signed with said insurers. The insurers already have this! They both signed the agreement!

Sure, they can continue hiding their internal costs, but those were never something that the patient cared about anyway. The patient cares about what they're going to get billed, which is a number in an agreement that both the provider and the insurance company have.

In the auto mechanic example, this is like saying that the shop owner hides how he compensates his employees, pays for consumables/times/equipment/etc. That's all perfectly fine. I don't care to know that. Just tell me what number you're planning on putting on my bill.

You're misunderstanding. The medical complex knows how much treatment costs, what margins are, all of it.

An insurer - if they had that information - would use it for more leverage when negotiating their payment agreements. They can put together something like it when they're big enough to compare costs across multiple systems, but that's about it.

You're misunderstanding. No one is asking for their internal treatment costs/margins/etc. They keep that hidden. Then they sign an agreement. That agreement has numbers in it. Different numbers from their internal treatment costs/margins/etc. Those numbers are known to both parties. They both signed a document with those numbers in it! They are not keeping those numbers hidden. Those numbers are the ones that they can give to patients.

Typically, with the car mechanic, the deal is that you agree on a certain amount for diagnosing, and perhaps give them a certain budget for fixing stuff. If things get more expensive, they call you so you can make an informed decision.

Also, I do not see the benefit of making people pay the actual costs of their procedure instead of the expected costs as estimated beforehand.

So, if you want to find a hospital to give birth, different hospitals could make you offers based on your health conditions and date. If they estimate that there is a 10% probability that you will need an emergency C-section, they can just add 10% of the cost of one to the offer.

This would also align incentives way better, because the hospital would only do emergency C-sections if otherwise they would run into malpractice territory. By contrast, if the hospital can just bill the additional costs to the patient, their incentives are to to an 'emergency' C-section at the first sign of troubles and then make the poor schmuck pay for it. 99% of patients will not litigate the overenthusiastic indication, and the ones that do will be dirt cheap to settle because apart from the costs of the operation, there is little in the way of damages. A scar over your abdomen might be worth a few thousand dollars, but that is basically nothing compared to a child which was oxygen deprived during birth.

Yeah but this stuff always runs into the brick wall of chronic conditions and lifetime disability. Even in a universe where disability cover was confined to just exceedingly obvious issues the costs can snowball ridiculously

I would be over the moon thrilled if doctors were as transparent as auto mechanics. They tell you what they're planning on doing, they give you a (usually pretty good) estimated price, and then if they get in there and find something that's going to change their plan/cost, they tell you, give a revised estimate, and get your approval before proceeding.

No one is asking for doctors to be clairvoyant. Just that they do basic communication of what they know, when they know, to whatever extent possible.

Obviously, there could be cases where a patient is under anesthesia, they find something genuinely unexpected, whatever. I think a simple rule for this is to just follow normal informed consent principles. If you'd be comfortable proceeding without getting specific informed consent for the medical costs/benefits, then you probably don't need to give them a price, either. But to use an example based on what one of the doctors here said before, he said that they might know that a surgery typically costs $X, but 1% of the time there's a thing that makes it cost $[Stupid]x[X]. Simple: you know this, so just communicate it to the patient. Sure, it's probably not going to change much in that particular case, but at least they've gotten a heads up that there's about a 1% chance that they'll wake up on the hook for their entire OOPM. [EDIT: I'm pretty sure this is concordant with medical informed consent procedures. If you know there's a 1% chance that there will be a major shift in what you're going to do in a surgery, I'm pretty sure you're kinda supposed to tell the patient, "Hey, so this is a small chance, but it is known to be about a 1% chance."]

It's honestly just basic human decency in business practice.

Yes, but your car mechanic won't rebuild your transmission without letting you know that it's not covered by your insurance.

Thankfully, it's not a huge dollar figure, but it's the sheer stupidity of clinging to price opacity, which inevitably finds some way to reach into my pocket and pull out more money, that annoys me.

Suggestion: consider not paying. My conversations with a few in the know and my personal experience has led me to the understanding that in the US, in many cases, paying hospital bills is essentially optional. Like many modern systems, it's one that relies on the charity of good faith actors to subsidize deadbeats.

A while ago I went to the hospital to get a scan done. After taking an obscene amount of money from my insurance, I got no less than three invoices in the mail: one from the hospital, one from the hospital's network, and one from a radiologist society or something, all claiming that I owed them money. I never paid out a cent, and nothing ever happened.

I am not a lawyer and I don't know your specific situation, but consider the virtues of simply refusing to pay.

I'd suggest caution with this, the rules vary state by state and hospital by hospital. Some almost always go "eh" when people don't pay. Some will fuck you.

I know multiple people who got hospital bills sent to collections. Always the same story: they never got the bill and were certain they paid all they owed and got a nasty surprise of collections coming after them for more. I don't suppose that's good for your credit score, if that eventually happens to you.

Happened to me a couple of times. If your portion of the bill is under 500$, they legally can't report it to credit rating companies.

I move locations frequently, so bills got lost in the move. Collections called me twice. But, because they didn't know where I lived, they gave up.

They were small (100-200$) bills, but still. Odd feeling.

I have one of these from an unnecessary test a pediatrician ordered during a visit in which they did not bother to tell me they stopped accepting my insurance. It was a situation where I'm not unable to pay, or necessarily unwilling, but whenever I saw mail or something about it, I said to myself "I should call some offices and demand an accounting about this bullshit before I pay anything", and then it just sort of slipped through the cracks for six months. Now I get periodic emails from a "collections" agency. There has been no impact on my credit score. According to my nurse mother, they are legally not allowed to follow up on it like a regular debt or missed payment.

From what I've heard, they can certainly "send it to collections", in the sense that they can give it to an internal department to harass you about it. But they can't actually sell it to real collectors who ostensibly have a legally enforceable debt that they can collect from you, and who ostensibly have a legal justification to put marks on your credit score. I'd be curious to know if these individuals you know actually got marks from this specifically.

An even if they do, there's an entire playbook for effectively telling these people to fuck off. I've never had to use it, because in my experience, it never even got to the harassment part. Once again I will say that your experience may vary depending on many, many factors, but I would just urge anyone reading to appreciate that fact that just because someone shoves an invoice at you doesn't mean you have to pay it.

From what I've heard, they can certainly "send it to collections", in the sense that they can give it to an internal department to harass you about it. But they can't actually sell it to real collectors who ostensibly have a legally enforceable debt that they can collect from you, and who ostensibly have a legal justification to put marks on your credit score. I'd be curious to know if these individuals you know actually got marks from this specifically.

Not only can they do so, there are debt collectors who specialize in medical debt.

Well, all I can say for sure is that I've never met one asking about the hospital bills I never paid, and that debt collectors are notorious for collecting on things they have no business doing so. Consult your local and state laws.

Like many modern systems, it's one that relies on the charity of good faith actors to subsidize deadbeats.

Not charity. The good faith actors have something to lose -- credit rating, property, time in court if they're sued by the collections agency. The deadbeats don't. So it's anarcho-tyranny. YOU, respectable working-to-upper-middle-class person, must pay those hospital bills. You might be able to knock them down some but you will pay or you will go to the poorhouse. YOU, Mr. Frequent Flyer drug-seeking deadbeat, you're fine, carry on.

They can't sell it to the real debt collectors. They can sell it to medical debt collectors who can't take your property or hit your credit.

My understanding is that there are many cases in which there is essentially nothing substantive that they can do, not even touching your credit score. I don't know if this changes if you, for example, sign something ahead of time that explicitly says you agree to pay with specified remediation if you don't, etc. This is why I urge the poster to evaluate their position for the freedom to decline paying, and consider taking that option if it exists.

My understanding from a lot of searching old reddit threads on the topic a few years ago is that it varies greatly. Sometimes they send it to collections and you can negotiate paying pennies on the dollar. Sometimes the hospital plays hardball and will get a order order to garnish your wages or bank account.

Personally, I'm speaking from two different articles of personal experience:

  1. Knowing both a nurse and an EMT, who have seen the internals of hospital billing and know how the sausage is made, both of whom have advised me to not pay hospital bills if I do not feel like it;
  2. My doing exactly this multiple times, and suffering no negative consequences whatsoever.

I don't know the parameters of how these reddit people were sought after. Perhaps I've seen so much success because I establish myself as a nonpayer immediately. I've heard from sources on the internet sounding credible that there's some arcane legal black magicks wherein one can be bound to a largely fictitious debt by sending its conjurer so much as a single dollar. Some sign on penalty of perjury that they are owed an imaginary debt on the hopes the legal ritual will coerce payment from targets. I'm sure there's a lot of Weird Tricks that people can use to extract money from hapless victims.

However, my personal experience with medical bills has been as follows: I go to the hospital to get something done, I get something in the mail that says something to the effect of "after your insurance paid 100 gorillion dollars, your remaining balance is 10 gorillion dollars, please send check or money order", I throw this demand directly into the trash, and I never hear about it ever again. It goes to the same black void as the jury summons. One time I got three invoices, from three different organizations, demanding three separate pounds of flesh for one thing I got done at a hospital. I ignored them all, and never heard from any of them ever again.

I'm not saying that this is applicable to all bills one can receive from a hospital, or that this maneuver could be pulled in any American jurisdiction, etc. I'm just saying that people getting demands from hospitals should consider their nonpayment options, if available.

It's been said that you can't con an honest man, but this may be another wisdom that modernity has turned on its head.

Looks like it might vary a lot by state: https://old.reddit.com/r/personalfinance/comments/14towop/what_happens_if_you_can_never_pay_back_your/jr5zc7b/

Also "It's relatively uncommon to sue over medical debt for a lot of reasons - including that the patient often doesn't have the money, also because it's easy to make a bogus counterclaim for medical malpractice , and nobody wants to deal with that over an unpaid $1300 invoice."

Example of someone getting wages garnished: https://old.reddit.com/r/personalfinance/comments/ue3xgd/getting_wage_garnishment_for_medical_bills_was/

Do you sign the documents at the hospital they give you where you agree to be responsible for any bills you accrue? If not, how do you talk them out of making you sign?

Just like ignoring a jury summons, this works until it doesn't. Yes, you can get away with it often. You can also get fucked when someone actually bothers to take the next step instead of saying "Eh, fuck it."

My conversations with a few in the know and my personal experience has led me to the understanding that in the US, in many cases, paying hospital bills is essentially optional. Like many modern systems, it's one that relies on the charity of good faith actors to subsidize deadbeats.

It’s optional if you’re poor or a criminal. If you have fixed, easily confiscated assets like property, a brokerage account etc then I think they can and will just go through the courts and get a lien.

They cannot repo your property or hit your credit score. Medical debt is worth even less than regular debt and normal collections agencies won't touch it. Hospitals will happily negotiate your bill down to pennies on the dollar because the chances are, they just won't get anything if you say 'fuck you'.

Acting like an Indian small business owner dealing with contractors will get the debt cleared easily.

So if I’m a respectable middle class person and I don’t want to pay my deductible or whatever, I just email the hospital and say “I don’t want to pay $10,000, how about $500?” and then…they just say “yeah sure, you got us, here’s the link”?

I'm honestly not sure about the laws around medical debt; I am reasonably sure that they do not do this, but consult a lawyer first. I am not a lawyer.

I would like to stress that I don't know the exact conditions under which this works—so please take this strategy at your own advisement and peril—but I have had multiple hospital visits in my life so far and have gotten away with paying exactly $0 by simply ignoring demands for money. These were organizations that had all of my info, my insurance, knew where I worked and lived, etc—and so far I've experienced no durable negative repercussions.

Your mileage may vary.

This clearly wasn’t an ER/ambulatory emergency I’m guessing, since it’s a little difficult to haggle over pricing or consult the HealthGrades rating when you’re in the midst of a heart attack…

It’s just another reminder though that healthcare in the US is a business. The psychology behind the price point becomes irrelevant in almost all high risk occurrences when the choice is pay whatever X is in terms or cost or die on the other hand. If it’s just a routine check-up, this becomes much more debatable.

To your last point about insurance. I read an interesting paper that a hedge fund credit analyst once sent me of the breakdown behind a lot of the activist/propaganda economics people throw around about the industry. As it turns out, healthcare insurance when totaled amounts to only a 1.1% profitability margin (meaning most healthcare premiums actually go directly to costs). All the regulatory red tape also obscures price signals tremendously. There’s a lot of bad ethics that sits behind the industry as a whole, but it’s also a massive challenge trying to genuinely determine what the price truly is.

It's not about just health insurance, it is about financers and monopolists who own the insurance companies, the hospitals, and their supply chains. (Also a nitpick: the health insurance industry average profit margin in 2020 was 3%.) 34% of health care costs go to pay administrators, so a lot of it is having armies of staff disputing every charge at the insurance company, who in turn pays the hospital to have armies of staff fighting the disputed charges. Insurance companies also can have shared ownership with the hospitals that they pay, as well as with the PBMs and pharmacies where prescription medication is dispensed, and investors can even own the land the hospital is sitting on and rent it back to the hospital at unsustainable rates. Even the suppliers of online after-visit surveys are doing very well indeed. So all along the chain it is monopolies extracting value from the insurance companies, hospitals, and patient, along with a lot of coordinated greasing of palms and inside dealing.

Which is not to mention that the hospital prices are set such that they can cover the costs imposed by freeloaders and insufficient insurance/medicare/medicaid reimbursement. It's the dystopia of Americans being happy to pay more for declining quality of service and inefficient systems, while all the profits go to financiers and all the costs go to the taxpayer/honest payer.

it's worth mentioning how much of the admin is just due to complying with the regulatory burden that comes from being in the health care industry. The typical way we try to control costs is by rolling out complex programs that require more detailed coding, data tracking, etc.

a lot of it is having armies of staff disputing every charge at the insurance company, who in turn pays the hospital to have armies of staff fighting the disputed charges.

I don't really have a dog in this adversarial fight; it's a total cluster. I did see an interesting one recently, though. Some folks discovered a "hack" if you have a patient with BCBS who travels across state lines before getting care. They've found it financially viable to contract with third-party vendors to maximize their payout. Sounds like eventually BCBS will shut it down, but yeah, the extent to which this adversarial game is played is wild. They've let the whole thing get so complex that it pays to play the game hard... and there's certainly not anyone out there trying to play these games on behalf of patients' pocketbooks. They just fight each other, and some number of patients randomly get screwed in the process.

Oh I’m 100% with you on this.

The data my friend sent me was for a different year altogether, but at 3% per your example, that’s still quite consistent to the point that the health insurance industry isn’t sitting on mounds of cash when measured as a percentage of their annual profitability. In dollar terms yes, it’s still a lot; I’m aware.

The fact that that much also goes to the administrative layer is something I’ve suspected and doesn’t surprise me one bit. The growth in that sector is one of the major causes for the neoliberal shift in higher education as well, where a large proportion of that goes directly to. I was shocked years ago when one of my adjunct professors told me how much money (namely how ‘little’) her cohort makes, compared to the upper admins. On the one hand mediocre teachers shouldn’t make substantial salaries. Greater pay that’s untethered to performance causes people to want to go into education that have little interest in it. On the other hand, good teachers should be greatly rewarded for excellent performance. But then you have the problem of avoiding grade inflation.

But back to your point about hospitals specifically. George Halvorson pointed out a number of years ago, one of the largest causes of the growth in hospital costs at every point is just ordinary price inflation. Believe it or not. Cost of labor, cost of supplies, it’s enormous and ever-climbing.

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