It takes a very... special... attitude to use sick kids for fundraising while your "nonprofit" is making $2 billion a year in PROFIT, even after paying dozens of execs millions each.
Alex, I will continue my refrain. There is plenty of blame to go around. But the foundational bad actors are the providers and the reason is the incentives put in under Obamacare make such actions almost impossible to resist. Providing full dollar coverage to everyone for everything is the road to ruin -- and it is unreasonable to think that people will look at free money and just ignore it.
Health plans make money, but there are limits on what they are allowed to make...unlike providers where there are none. Pharmas are their own problem, but under the Trump administration they actually have retreated on many of the drugs that are most used, bringing prices down substantially and, one hopes continuing to do so because of the new inability to differentially price from other countries....MFN is a great way to lower costs.
The foundational issue is the complete decoupling of patients from ANY financial decision with regard to their health. This puts large numbers of people (not including the unfortunate middle class that cannot get free insurance like illegals, anyone that claims to be poor, etc.) in the enviable position of requiring every procedure known to man for every ache and pain every day. I could tell you stories that would make your blood curdle.
The health systems have a spigot that always pays -- the wonder of government. In fact, the only modest impediment is health plans who try to restrict payouts, usually to the hew and cry of everyone who is agitated that great grandma is not getting her third hip surgery.
Remove the government intervention and this all self cures easily. Go back to selling catastrophic insurance....there are catastrophes and it is good that they can be covered. But that is NOT the expensive part of health. Let everyone (not just high deductible plan folks) keep an HSA where they can put discretionary dollars away for health.. They can then spend it on more insurance, the gym, doctor's visits -- what ever makes sense to them. And return to Direct Primary Care (really taking off...no insurance involved) for better, family-oriented care at at fraction of what is being spent now.
When offered an MRI with a 0,1% chance of finding something, patients will likely say no if it is their first dollar to decide; today they say yes because why not? When offered exactly the same colonoscopy with exactly the same anesthesia/doctors/etc. as an outpatient for $1000 or as a "hospital outpatient" (like at Intermountain) for $15,000 (fairly real numbers) they will likely take the regular out patient option if they are paying first dollar. Today, the hospitals make a ridiculous amount of undeserved money from the HOPD business (with these kinds of price differentials for, essentially, indistinguishable services) and there is nothing to stop it because the actual consumer has no skin in the game. Heaven knows the insurers have tried. Doctors cannot fix this because Obamacare forced them all to be hospital employees so they just nod their heads and watch the impossibly overpriced colonoscopy feed $$ to the administration for important things like DEI officers and very high salaries.
So you are right -- people are not mad enough. The substantive changes to fix this are not that difficult. But they will take away a lot of wealth transfer and thus a lot of cheap votes. As long as Obamacare forces me to buy a sex change inclusive policy (as Obamacare does) and insists on full coverage of anything someone in the mental health industry (yes it is an industry) decides to label in the next DSM as a disease instead of living normal life, this will go on. The question is, will anyone upset the apple cart? You are trying, so this should give you more directions to think through.
Be careful who you are rolling up into “decoupling” of patients from any financial decision. I have been paying healthcare insurance out of my own pocket entirely for 30 years. I, people like me who have no actual political representation, are very COUPLED with the financial decisions of healthcare.
Like you I've been paying my own health insurance for the past 12 years because I'm self-employed. All I can do is optimize for protecting against catastrophe, lowest cost, and customer service.
The cheapest coverage I could get here in California for my wife and I and my two early 20s kids was $29,000 this year. That was through HealthNet. Blue shield wanted $36,000.
When I started my own business 12-ish years ago, my gold-plated, the best you could buy health insurance was about $12,000 a year which I thought was reasonable. Now I have literally the cheapest insurance I could buy and it's $29,000 a year.
A big part of the reason for the massive increases in our premiums is healthcare price inflation.
But there is another reason. Obamacare put us into risk pools that we were not in before Obamacare. It lumped lots of unhealthy people in with us and put the burden on us without spreading it around to everyone.
There are no many people like you and me that run our own businesses. Most people are employees under group plans. Politicians respond to where ghe votes are. There are, I think (don’t hold me to the exact numbers), 5-10m of us that are stuck in Obamacare and not receiving subsidies. Meanwhile, there are how many employees and their dependents that are in employer provided healthcare plans? I don’t know the exact numbers but I would guess about 150-200M. Those are the numbers that politicians care about. Plus, the employers have enormous political clout. Thus, politicians are quite happy to dump more and more costs on you and me. Our numbers are relatively small and we are not organized with lobbying power.
Mark, You have been paying insurance (in that unlucky middle class I mentioned). It is not that you have no stake in health care because you do. But you have no first dollar interaction with any particular expense. You pay your insurance and whatever gets ordered, whether it is the $1000 or the $15000 identical colonoscopy they pay and it is mostly opaque to you. So it is not that you are being gouged -- you are.. It is that you have virtually no control over reducing the gouging that is where you should be involved.
Large deductibles and co-pays are pretty significant first dollar interactions. As are +$2000 dollar per month per person premiums. In fact, that is the very first dollar.
I’m skeptical when hearing that people have no idea how much their medical care costs. There may be a slice of people like that, but most see their bills, see there EOB’s, and have an idea of the absurdity. People can make the connection between high medical care costs and the premiums they are paying.
The problem is at least as much supply-side as demand-side. Having built companies and experiencing first hand how technology costs decline by astonishing amounts, and seeing how that phenomenon does not occur in two specific arenas - higher education and healthcare - I believe most of the problems is supply side. In any case, I’m am 100% that no politically acceptable solution in the U.S. can involve making people feel even more financially strained. So that means most of the solution needs to be supply-side.
The supply-side problems are the reason that throwing more taxpayer money at health care only exacerbates healthcare inflation.
Since apparently you are a medical doctor, I am curious what you think requiring prescriptions for ED “meds” and antidepressants? And have you ever living outside the U.S. and been a consumer of healthcare in other countries?
These are all good points. I have lived in many countries both in the Far East, the MidEast and Europe over the years and have done health care work in all of them. The UK is a marvelous case in point. In the UK, the NHS is a sacrosanct "free health care for all" shtick since the days of Bevan and Sylvia Diggery. It is a rail that cannot be touched.
The instinct to "just copy the UK" that some suggest (virtually the same issues for Canada but let's use the UK) mistakes the absence of a bill for the absence of a price. When care is free at the point of use, it does not stop being scarce — it simply gets rationed by time instead of money. England now has roughly 7.2 million people on the elective waiting list, only about 62 percent treated within 18 weeks against a 92 percent standard last met in 2015, and a median wait near twelve weeks. The front door is no better: fully qualified GPs per capita have fallen to a record low, patients describe the daily "8am scramble" of redialing the surgery only to be told the day's slots are gone, and emergency care is worse still, with roughly 137,000 people waiting more than twelve hours in A&E in a single recent month. None of this is a copay problem or a deductible problem. It is what happens when you remove the price signal entirely and let the calendar do the allocating.
And here is the part that should end the romance: the UK has not abolished the two-tier system — it has formalized it and hidden it. Private hospital admissions just hit a fourth consecutive record at 953,000 a year, about one in seven adults now carries private insurance, and the care is delivered by nearly the same thirteen thousand consultants who staff the NHS. The British Medical Association itself concedes that the NHS and the private sector draw on the same pool of doctors. So the identical surgeon who will see you in five months on the public list will see you in five days if you pay cash. The queue is the price, denominated in months instead of dollars, and the people who can afford to step out of it do exactly that. That is not equality. It is a means test administered by a waiting room.
Every system rations; ours rations by price and insurance status, theirs by time. The real question is not whether to ration but which form allocates better and treats people more honestly. I would rather make the price visible and hand the patient the savings when they choose the more cost efficient site, than make the wait invisible until the day they are the one lying on the trolley. A signal on which you can act beats a queue you can only endure.
To be clear, I am not suggesting that adopting the UK system would be a good idea. However, I will note one thing about UK results. Despite the UK having an notoriously unhealthy population due to lifestyle, their overall life expectancy is 81.5 years. Life expectancy in the US is 79.5. In a case of choose your poison, statistically, the UK poison is better.
Our disagreement is in the degree to which people are or are not aware of the cost of healthcare in the US. I believe that is a relatively minor issue. You believe it is the entire issue.
True, both the US and UK systems effectively ration care. If price were not at work, this would not be happening. More fundamentally, what is really at work are the laws of economics. Supply and demand. You are entirely focused on the demand aspect of price discovery. That is indeed a factor. But not as much as you think because demand for many types of healthcare is close to inelastic. You are mostly focused on relatively minor moves up and down the existing demand curve.
The more important factor is supply. All of the great economic progress throughout human history has been due to shifting the supply curve to the right. The US system is set up to at least deliberately hold the supply curve static, and in some circumstances, where the sectors of the industry can get away with it, shift the supply curve to the left. Combine that with the ever increasing amounts of money thrown at healthcare - which actually shifts the demand curve to the right - and we get obscene inflation in healthcare prices.
Minor progress can be made in affecting demand. But the progress that improves the picture for everyone is on the supply side. For example, MRI's should not cost a fortune. If an MRI machine cannot be reduced in price (I believe it can be), then an entirely new technology is needed. We need to rethink all aspects of supply.
One final point - you did not answer my question regarding requiring prescriptions for as many classes of drugs as we do in the US. Of course, you don't have to. But I am interested in knowing what you think. That topic was the primary reason I asked you if you have international experience. Since you have, you are aware that prescriptions are not required in other many other developed nations for classes of drugs where they are in the US. I am curious what you think of that.
Sorry...got distracted by my doctoring in the UK. I agree completely -- although this is not unique to the US. Many things requiring a prescription in the US are nonsense. Case in point in which I was personally involved: Ivermectin, which actually shows substantial potential value not just in parasitic disease but in anticancer and antiviral applications is a prescription drug in the US even though it has perhaps a better safety profile than rutabagas. (Please, no one write to me about the relative safety of rutabagas...I am just making a point.) During covid it was radically restricted in the US (together with hydroxychloroquine which, while safe, does require management) because it did not make anyone any money. (Long off patent.) After much wrangling, Tennessee took it off of prescription in the state. Has anything gone wrong...nope, not a thing. But the cartel lost business and the ability to influence choices. As you can tell, I think most people are smart enough to make many/most decisions for themselves in this area, so I surely agree about many of the restrictions being nonsense. That, too, would drop prices for many things by making the consumer choices instead of cartel choices. But if you follow the money, you see why it just almost never happens (hooray for Tennessee and the few other rare exceptions clawed out from time to time with difficulty).
Physicians by and large the last 25 or so years recite the Hypocritical Oath, not the Hippocratic oath.
Again, humanity as a whole, and it is more than 50.1%, do what is popular easy and convenient, oh, and add cheap as a more recent qualifier. The cheap here by physicians is the minimal effort to give the illusion they are providing care.
Wow, did Covid really expose how the health care system as a whole really does NOT give a damn about people.
Oh, and I work in it, for some time now, so I know what providers have abandoned and still claim to care…
How many people go to bed praying there is no afterlife?…
As in the other articles: when there are no public prices and insurance covers everything from oil changes to wiper fluid (human equivalents) because "somebody else is paying" there are no market forces or competition to stop it. It is disgusting.
Hey, great piece. But it’s not just big systems. I’ve been a practicing physician for 46 years, mainly at not for profit hospitals called “Critical Access Hospitals.” These are 25 bed or smaller and have to be located in an “underserved” area with no other close hospital, I think the definition of close was within 25 miles. These hospitals get treated differently for government reimbursement, and are allowed to charge exorbitant rates. Additionally, they are allowed to buy physicians practices and incorporate them into specially designated rural health clinics that get reimbursed at higher rates than other clinics. Of course, they are located in small towns where small cliques that run the town control everything, including the hospital boards. None of them have a clue about medicine and basically rubber stamp whatever the administrator asks for, including huge salaries, not usually in the millions, but many hundreds of thousands. Every one I worked with was a charlatan. It’s a disgusting and wasteful system.
Yes, charlatans come in many disguises, don't they? The epidemic of obscene greed that has swept through our country has infected those in the highest positions and those in the lowest of places. The fraud that was exposed in Minnesota barely holds a candle to the fraud bedecked in the cloak of respectability -- gain-of-function-enhanced into our very systems of operation
and thus made easy or even mandatory to rationalize.
I actually don't understand what makes these hospital systems non-profit. As far as I can tell, they behave like what I would expect a for-profit hospital to behave like.
I came to make this comment. I don't EVER round up, and it's a disgusting way for a grocery store like Publix to ask its customers to pay for a donation that it's going to make anyway.
I love capitalism. It's a great system. Nothing else has lifted so many out of abject serfdom. That being said, capitalism cannot be the primary system. Capitalism untethered from a moral framework is a disaster. I'm just going to say it - the abandonment, nay, disparagement, of our Judeo-Christian founding principles is reaping tragically awful consequences.
I hear what you’re saying and don’t disagree with your point. However, you have to add to it the fact that these big chain hospitals: 1) draw huge support from OUR tax money, and 2) position themselves to monopolize the local market, often running small community hospitals out of business. So it’s not really “capitalism.” It’s actually crony capitalism with a good dose of unfair business practices (i. e., monopoly).
Exactly what I'm saying. Capitalism freed from the restraints of a moral system runs right over people. One must answer to a higher authority than the dollar. Or as somebody famous once said, "The love of money is the root of all kinds of evil." Not the money itself, the warped relationship to money.
In what way is the healthcare system capitalistic? In order to start a new hospital in an area, a board has to approve the project and say it's needed. Who is on this board? People who run other hospitals in the area since they know so much about it, of course. How much does a hernia operation cost at a hospital? How much of regular - not unexpected or emergency - expenses does the patient cover?
What other business operates that way? Does a guy who wants to start a grocery store have to go before his competitors and justify his plans? When you buy just about any thing else, do you buy it without knowing at least an estimate of the costs? Insurance is to indemnify your loss, not pay for regular charges.
The deeper you look the more you realize just how badly our medical system was allowed to develop. Every distortion is the direct result of some governmental policy decision.
You are right. People are not angry enough. Obamacare started this fiasco creating a horrifically convoluted health insurance law that mutilated private insurance, cost a whole lot more, and gives citizens so much less. It never came close to providing a legal framework that supports and improves health care. Please recall: Congress knew this and carefully exempted themselves from Obamacare requirements. They continue to maintain their own separate, gold-plated medical insurance program. Over the years, Obamacare has forced all my independent doctors into joining mega-medical firms where protocols & decisions are taken out of their hands. Most have now pursued early retirement. And care level is worse. Medical university conglomerates are allowed to hire foreign trained doctors who are excused from completing the typical US 2 year medical residency requirement. University hospitals argue critical experience gained in residency programs is not important nor necessary because they work for a "teaching university". (Ha!) Obamacare pushed independent doctors and clinic into working for big hospitals while greatly increasing the cost of procedures to the consumer. An independent radiologist told me whereas they can provide an MRI for about $800, big hospitals readily charge $2000+. As you've pointed out, CEO salaries remain an outrageous disgrace as is the attendant growth of the "administrator" class. Yet somehow, these days many primary care doctors aren't paid enough to afford big-blue city housing prices, nor costs of their liablity insurance. Hence, we now have a shortage of primary care doctors. Again, an excuse to bring in foreign doctors who probably take the job at a lower wage. Unfortunately, hospitals and medical groups remain the darling of Wall Street investors who are always looking for businesses they can readily purge for profit. Obamacare pushes doctors further toward centralized monopoly-- which cuts the service level, doctor competence, and costs a lot more. For example, in my city, at a major medical group w/a charitable history, if you pay your bill the day-of-service so they automatically reduce the price of your bill by 30 percent. Why? This avoids the hassle of meeting Obamacare billing requirements. On the consumer level, working class folks employed by most medium to small businesses are offered Obamacare policies, but they come with lousy, expensive coverage, high deductibles, and extensive coverage restrictions. Yet these policies still cost the companies a fortune and are all most businesses can afford. Many small businesses can't competitively hire as they can't afford to offer medical insurance. In contrast, government and big corporations (big tech) subsidize employees and have profit margins or taxpayer support so they can afford to offer Cadillac-level medical insurance. Finally, sadly, big corporate medical works hand-in-hand with big corporate Pharma to control the consumer and the doctors. Note the list of doctors who permanently lost their medical licenses for daring to prescribe ivermectin which threatened the covid vaccine EUA legal standing. Also appalling: doctors and hospitals were paid based on number of covid vaccines shots given and deaths blamed on Covid. Two months after her passing, we were shocked to see my mother-in-law's death certificate listed Covid as her cause of death..Whoops, sorry Charlie. Yes, in her 90's, she had a number of body failures, but absolutely no trace of Covid flu infection. Note that pediatricians are still paid by the government for giving childhood vaccines. Yep. Paid to comply with big corporate interests. Ugh.
So in 2024 he made $9.7 million. That’s $26,575.34 EACH DAY, including the weekends when he didn’t work. MBA!?!?!?! What in the hell does he do to make that kind of money?
Just makes me so mad. Healthcare quality is horrible! But instead of putting money into improving care, they look for the Almighty dollar. Sickening. (Pun intended).
They don't need more money. They need more competition. They need less regulation from Obamacare. They need to be required to tell you what everything they are doing costs, from the least cotton swab to the most expensive procedures and tests.
They aren't interested in fixing it. They don't participate in it, so it doesn't affect them. But as time goes by, I am thinking more and more that they like their pre-set boogeyman insurance villains- "See what I am doing to fight for you little guy!" What a crock, because even more than ready-made villains, they like the donations to their campaigns from industry that keep them in office. So very tiresome. (I am not saying that insurance should get a pass, but as mentioned above, it is government who sets the guidelines they have to follow.) Call me jaded.
Alex this subject is your calling. The MDs posting here show you are skillfully reporting on profound issues in health care. Suggestion - keep your focus here and strategize how to leverage your reporting and this sophisticated audience you’ve built into something even bigger and more influential.
Makes me wonder about a couple of others; St Jude’s by all indications is a wonderful hospital and does not charge the patients. They’re always fundraising, and probably are legit. Another that comes to mind is Shriners Hospital and also Children’s Hospital in Birmingham at UAB. Any possibility of taking t least a cursory look into these. I really need to feel good about them…
Alex, thank you for continuing to shine a light on this issue. You're right -- I haven't been angry enough, either about healthcare costs in this country, or about the way in which non-profits have been permitted to abuse their charters to enrich insiders.
I worked for Vision Service Plan about 25 years ago. They are the dominant eyecare HMO. At the time they held 80% of the total eyecare insurance market in the US. They got audited by the IRS and then had to go to court to oppose the IRS decision that they were not operating as a non-profit. They lost their non-profit status. I supported that outcome based on their business practices, even though as an executive working there, it impacted my annual executive bonus compensation.
Today I am a CEO of a non-profit 501 C 4. The business operates in a highly competitive space. I have to compete with private for-profit operators, including paying higher compensation for employee talent.
I have non-profit peers in my market that piss me off. They piss me off because they operate like they want to take over the entire market. They pick up business practices that are a race to the bottom, including paying referral sources extra for new business. Our operations are lean... with the fee revenue we earn getting us to just better than break even. This includes a budget for doing special outreach to for additional help for our clients. Any additional spending to compete in the market erodes that budget and our ability to provide the additional help.
Our business is risk subsidized by a federal program... almost 100%. It is a non-subsidy program... the fee revenue from end user clients pays for everything.
I operate with the focus on our missions to take care of these clients... and NOT to try and destroy all my competition so I can grow my profit and fatten my pay. I report to a board of directors and some of them keep pushing me to expand and grow, and I ask them why? We don't have any ownership of the business. There are plenty of good operators in the market other than us, and there is no real need to expand. However, there are other states where the service levels are lower, and we are expanding some there as we know we can add value in giving clients a better service experience. But I temper everything to come back to mission... and the fact that we are tax-exempt for a reason... and that it is not ethical to leverage the non-profit status and federal guarantees to take away market share from everyone else.
I am furious at every non-profit leader that does this... that ignores the fact that the reason they get non-profit status is that they are there for a specific mission, and the net-excess they earn should be put back into the operation to benefit the intended beneficiary of their mission.
My idea is that all non-profits need to every two years state their mission and their related goals that is tied to their strategy and budget, and they need to report on their 990 tax return their performance related to those stated goals. If they fail to demonstrate they are sticking within their mission and/or fail to meet their recorded goals, then they need to be audited for non-compliance of their non-profit charter and risk losing IRS authorization.
Please continue your crusade against these “nonprofit “ hospitals and insurers with ranks of overpaid administrators who have never contributed to the care of a single patient, only conspired to withhold care.
Thank you for this and all your work on fraud and abuses in both public and private sectors. We are a rich country and need to demand better for all of us, especially those in need. I think our biggest problem is that we have no accountability ('08 market crash, NGO fraud, droning a citizen, 2020 election and subsequent manchurian administration, Covid (funding for it and lockdown actions), pre-emptive wars, extrajudicial killings (drug boats), de-banking, seizures of foreign subjects funds i could go on). We'll never fix anything without accountability.
Alex, I will continue my refrain. There is plenty of blame to go around. But the foundational bad actors are the providers and the reason is the incentives put in under Obamacare make such actions almost impossible to resist. Providing full dollar coverage to everyone for everything is the road to ruin -- and it is unreasonable to think that people will look at free money and just ignore it.
Health plans make money, but there are limits on what they are allowed to make...unlike providers where there are none. Pharmas are their own problem, but under the Trump administration they actually have retreated on many of the drugs that are most used, bringing prices down substantially and, one hopes continuing to do so because of the new inability to differentially price from other countries....MFN is a great way to lower costs.
The foundational issue is the complete decoupling of patients from ANY financial decision with regard to their health. This puts large numbers of people (not including the unfortunate middle class that cannot get free insurance like illegals, anyone that claims to be poor, etc.) in the enviable position of requiring every procedure known to man for every ache and pain every day. I could tell you stories that would make your blood curdle.
The health systems have a spigot that always pays -- the wonder of government. In fact, the only modest impediment is health plans who try to restrict payouts, usually to the hew and cry of everyone who is agitated that great grandma is not getting her third hip surgery.
Remove the government intervention and this all self cures easily. Go back to selling catastrophic insurance....there are catastrophes and it is good that they can be covered. But that is NOT the expensive part of health. Let everyone (not just high deductible plan folks) keep an HSA where they can put discretionary dollars away for health.. They can then spend it on more insurance, the gym, doctor's visits -- what ever makes sense to them. And return to Direct Primary Care (really taking off...no insurance involved) for better, family-oriented care at at fraction of what is being spent now.
When offered an MRI with a 0,1% chance of finding something, patients will likely say no if it is their first dollar to decide; today they say yes because why not? When offered exactly the same colonoscopy with exactly the same anesthesia/doctors/etc. as an outpatient for $1000 or as a "hospital outpatient" (like at Intermountain) for $15,000 (fairly real numbers) they will likely take the regular out patient option if they are paying first dollar. Today, the hospitals make a ridiculous amount of undeserved money from the HOPD business (with these kinds of price differentials for, essentially, indistinguishable services) and there is nothing to stop it because the actual consumer has no skin in the game. Heaven knows the insurers have tried. Doctors cannot fix this because Obamacare forced them all to be hospital employees so they just nod their heads and watch the impossibly overpriced colonoscopy feed $$ to the administration for important things like DEI officers and very high salaries.
So you are right -- people are not mad enough. The substantive changes to fix this are not that difficult. But they will take away a lot of wealth transfer and thus a lot of cheap votes. As long as Obamacare forces me to buy a sex change inclusive policy (as Obamacare does) and insists on full coverage of anything someone in the mental health industry (yes it is an industry) decides to label in the next DSM as a disease instead of living normal life, this will go on. The question is, will anyone upset the apple cart? You are trying, so this should give you more directions to think through.
Dr K, I'd like to give you a like for every paragraph - even, every WORD!!
except the word, "providers" don't like that one.
You nailed it Dr K! Perfectly explained! As I always say “the good ole days”, we need to try to get back there.
Be careful who you are rolling up into “decoupling” of patients from any financial decision. I have been paying healthcare insurance out of my own pocket entirely for 30 years. I, people like me who have no actual political representation, are very COUPLED with the financial decisions of healthcare.
Like you I've been paying my own health insurance for the past 12 years because I'm self-employed. All I can do is optimize for protecting against catastrophe, lowest cost, and customer service.
The cheapest coverage I could get here in California for my wife and I and my two early 20s kids was $29,000 this year. That was through HealthNet. Blue shield wanted $36,000.
When I started my own business 12-ish years ago, my gold-plated, the best you could buy health insurance was about $12,000 a year which I thought was reasonable. Now I have literally the cheapest insurance I could buy and it's $29,000 a year.
The money's going somewhere.
A big part of the reason for the massive increases in our premiums is healthcare price inflation.
But there is another reason. Obamacare put us into risk pools that we were not in before Obamacare. It lumped lots of unhealthy people in with us and put the burden on us without spreading it around to everyone.
There are no many people like you and me that run our own businesses. Most people are employees under group plans. Politicians respond to where ghe votes are. There are, I think (don’t hold me to the exact numbers), 5-10m of us that are stuck in Obamacare and not receiving subsidies. Meanwhile, there are how many employees and their dependents that are in employer provided healthcare plans? I don’t know the exact numbers but I would guess about 150-200M. Those are the numbers that politicians care about. Plus, the employers have enormous political clout. Thus, politicians are quite happy to dump more and more costs on you and me. Our numbers are relatively small and we are not organized with lobbying power.
So, we get screwed.
Mark, You have been paying insurance (in that unlucky middle class I mentioned). It is not that you have no stake in health care because you do. But you have no first dollar interaction with any particular expense. You pay your insurance and whatever gets ordered, whether it is the $1000 or the $15000 identical colonoscopy they pay and it is mostly opaque to you. So it is not that you are being gouged -- you are.. It is that you have virtually no control over reducing the gouging that is where you should be involved.
Large deductibles and co-pays are pretty significant first dollar interactions. As are +$2000 dollar per month per person premiums. In fact, that is the very first dollar.
I’m skeptical when hearing that people have no idea how much their medical care costs. There may be a slice of people like that, but most see their bills, see there EOB’s, and have an idea of the absurdity. People can make the connection between high medical care costs and the premiums they are paying.
The problem is at least as much supply-side as demand-side. Having built companies and experiencing first hand how technology costs decline by astonishing amounts, and seeing how that phenomenon does not occur in two specific arenas - higher education and healthcare - I believe most of the problems is supply side. In any case, I’m am 100% that no politically acceptable solution in the U.S. can involve making people feel even more financially strained. So that means most of the solution needs to be supply-side.
The supply-side problems are the reason that throwing more taxpayer money at health care only exacerbates healthcare inflation.
Since apparently you are a medical doctor, I am curious what you think requiring prescriptions for ED “meds” and antidepressants? And have you ever living outside the U.S. and been a consumer of healthcare in other countries?
These are all good points. I have lived in many countries both in the Far East, the MidEast and Europe over the years and have done health care work in all of them. The UK is a marvelous case in point. In the UK, the NHS is a sacrosanct "free health care for all" shtick since the days of Bevan and Sylvia Diggery. It is a rail that cannot be touched.
The instinct to "just copy the UK" that some suggest (virtually the same issues for Canada but let's use the UK) mistakes the absence of a bill for the absence of a price. When care is free at the point of use, it does not stop being scarce — it simply gets rationed by time instead of money. England now has roughly 7.2 million people on the elective waiting list, only about 62 percent treated within 18 weeks against a 92 percent standard last met in 2015, and a median wait near twelve weeks. The front door is no better: fully qualified GPs per capita have fallen to a record low, patients describe the daily "8am scramble" of redialing the surgery only to be told the day's slots are gone, and emergency care is worse still, with roughly 137,000 people waiting more than twelve hours in A&E in a single recent month. None of this is a copay problem or a deductible problem. It is what happens when you remove the price signal entirely and let the calendar do the allocating.
And here is the part that should end the romance: the UK has not abolished the two-tier system — it has formalized it and hidden it. Private hospital admissions just hit a fourth consecutive record at 953,000 a year, about one in seven adults now carries private insurance, and the care is delivered by nearly the same thirteen thousand consultants who staff the NHS. The British Medical Association itself concedes that the NHS and the private sector draw on the same pool of doctors. So the identical surgeon who will see you in five months on the public list will see you in five days if you pay cash. The queue is the price, denominated in months instead of dollars, and the people who can afford to step out of it do exactly that. That is not equality. It is a means test administered by a waiting room.
Every system rations; ours rations by price and insurance status, theirs by time. The real question is not whether to ration but which form allocates better and treats people more honestly. I would rather make the price visible and hand the patient the savings when they choose the more cost efficient site, than make the wait invisible until the day they are the one lying on the trolley. A signal on which you can act beats a queue you can only endure.
To be clear, I am not suggesting that adopting the UK system would be a good idea. However, I will note one thing about UK results. Despite the UK having an notoriously unhealthy population due to lifestyle, their overall life expectancy is 81.5 years. Life expectancy in the US is 79.5. In a case of choose your poison, statistically, the UK poison is better.
Our disagreement is in the degree to which people are or are not aware of the cost of healthcare in the US. I believe that is a relatively minor issue. You believe it is the entire issue.
True, both the US and UK systems effectively ration care. If price were not at work, this would not be happening. More fundamentally, what is really at work are the laws of economics. Supply and demand. You are entirely focused on the demand aspect of price discovery. That is indeed a factor. But not as much as you think because demand for many types of healthcare is close to inelastic. You are mostly focused on relatively minor moves up and down the existing demand curve.
The more important factor is supply. All of the great economic progress throughout human history has been due to shifting the supply curve to the right. The US system is set up to at least deliberately hold the supply curve static, and in some circumstances, where the sectors of the industry can get away with it, shift the supply curve to the left. Combine that with the ever increasing amounts of money thrown at healthcare - which actually shifts the demand curve to the right - and we get obscene inflation in healthcare prices.
Minor progress can be made in affecting demand. But the progress that improves the picture for everyone is on the supply side. For example, MRI's should not cost a fortune. If an MRI machine cannot be reduced in price (I believe it can be), then an entirely new technology is needed. We need to rethink all aspects of supply.
One final point - you did not answer my question regarding requiring prescriptions for as many classes of drugs as we do in the US. Of course, you don't have to. But I am interested in knowing what you think. That topic was the primary reason I asked you if you have international experience. Since you have, you are aware that prescriptions are not required in other many other developed nations for classes of drugs where they are in the US. I am curious what you think of that.
Sorry...got distracted by my doctoring in the UK. I agree completely -- although this is not unique to the US. Many things requiring a prescription in the US are nonsense. Case in point in which I was personally involved: Ivermectin, which actually shows substantial potential value not just in parasitic disease but in anticancer and antiviral applications is a prescription drug in the US even though it has perhaps a better safety profile than rutabagas. (Please, no one write to me about the relative safety of rutabagas...I am just making a point.) During covid it was radically restricted in the US (together with hydroxychloroquine which, while safe, does require management) because it did not make anyone any money. (Long off patent.) After much wrangling, Tennessee took it off of prescription in the state. Has anything gone wrong...nope, not a thing. But the cartel lost business and the ability to influence choices. As you can tell, I think most people are smart enough to make many/most decisions for themselves in this area, so I surely agree about many of the restrictions being nonsense. That, too, would drop prices for many things by making the consumer choices instead of cartel choices. But if you follow the money, you see why it just almost never happens (hooray for Tennessee and the few other rare exceptions clawed out from time to time with difficulty).
Going for the free money doesn’t make them any less sociopathic
Physicians by and large the last 25 or so years recite the Hypocritical Oath, not the Hippocratic oath.
Again, humanity as a whole, and it is more than 50.1%, do what is popular easy and convenient, oh, and add cheap as a more recent qualifier. The cheap here by physicians is the minimal effort to give the illusion they are providing care.
Wow, did Covid really expose how the health care system as a whole really does NOT give a damn about people.
Oh, and I work in it, for some time now, so I know what providers have abandoned and still claim to care…
How many people go to bed praying there is no afterlife?…
Read this and wonder why this country is in florid decay?
https://townhall.com/columnists/marklewis/2026/06/28/if-half-of-the-body-is-saturated-with-cancer-whats-the-prognosis-n2678398
It is about a cancer. But, there is no way to treat it without excising it.
Oh well, let the body of America continue to rot away.
As in the other articles: when there are no public prices and insurance covers everything from oil changes to wiper fluid (human equivalents) because "somebody else is paying" there are no market forces or competition to stop it. It is disgusting.
Hey, great piece. But it’s not just big systems. I’ve been a practicing physician for 46 years, mainly at not for profit hospitals called “Critical Access Hospitals.” These are 25 bed or smaller and have to be located in an “underserved” area with no other close hospital, I think the definition of close was within 25 miles. These hospitals get treated differently for government reimbursement, and are allowed to charge exorbitant rates. Additionally, they are allowed to buy physicians practices and incorporate them into specially designated rural health clinics that get reimbursed at higher rates than other clinics. Of course, they are located in small towns where small cliques that run the town control everything, including the hospital boards. None of them have a clue about medicine and basically rubber stamp whatever the administrator asks for, including huge salaries, not usually in the millions, but many hundreds of thousands. Every one I worked with was a charlatan. It’s a disgusting and wasteful system.
Thank for your continued work.
Gary
Yes, charlatans come in many disguises, don't they? The epidemic of obscene greed that has swept through our country has infected those in the highest positions and those in the lowest of places. The fraud that was exposed in Minnesota barely holds a candle to the fraud bedecked in the cloak of respectability -- gain-of-function-enhanced into our very systems of operation
and thus made easy or even mandatory to rationalize.
Great article and so very true. I have never understood the amount of pay these non profit CEOs make.
I actually don't understand what makes these hospital systems non-profit. As far as I can tell, they behave like what I would expect a for-profit hospital to behave like.
I totally agree. Here they get grocery stores to ask you to round up for the local Children's Hospital. I laugh. They get enough money
I came to make this comment. I don't EVER round up, and it's a disgusting way for a grocery store like Publix to ask its customers to pay for a donation that it's going to make anyway.
A tax deduction for them with your money!
I love capitalism. It's a great system. Nothing else has lifted so many out of abject serfdom. That being said, capitalism cannot be the primary system. Capitalism untethered from a moral framework is a disaster. I'm just going to say it - the abandonment, nay, disparagement, of our Judeo-Christian founding principles is reaping tragically awful consequences.
I hear what you’re saying and don’t disagree with your point. However, you have to add to it the fact that these big chain hospitals: 1) draw huge support from OUR tax money, and 2) position themselves to monopolize the local market, often running small community hospitals out of business. So it’s not really “capitalism.” It’s actually crony capitalism with a good dose of unfair business practices (i. e., monopoly).
Exactly what I'm saying. Capitalism freed from the restraints of a moral system runs right over people. One must answer to a higher authority than the dollar. Or as somebody famous once said, "The love of money is the root of all kinds of evil." Not the money itself, the warped relationship to money.
Right! The “Two Masters” caveat. 🙏
Our current health care system is not capitalism. It is an oligarchy running a scam and will ruin this country into the ground if left the way it is .
In what way is the healthcare system capitalistic? In order to start a new hospital in an area, a board has to approve the project and say it's needed. Who is on this board? People who run other hospitals in the area since they know so much about it, of course. How much does a hernia operation cost at a hospital? How much of regular - not unexpected or emergency - expenses does the patient cover?
What other business operates that way? Does a guy who wants to start a grocery store have to go before his competitors and justify his plans? When you buy just about any thing else, do you buy it without knowing at least an estimate of the costs? Insurance is to indemnify your loss, not pay for regular charges.
I don't see a lot of capitalism in this system.
Totally agree. Preach it.
The deeper you look the more you realize just how badly our medical system was allowed to develop. Every distortion is the direct result of some governmental policy decision.
You are right. People are not angry enough. Obamacare started this fiasco creating a horrifically convoluted health insurance law that mutilated private insurance, cost a whole lot more, and gives citizens so much less. It never came close to providing a legal framework that supports and improves health care. Please recall: Congress knew this and carefully exempted themselves from Obamacare requirements. They continue to maintain their own separate, gold-plated medical insurance program. Over the years, Obamacare has forced all my independent doctors into joining mega-medical firms where protocols & decisions are taken out of their hands. Most have now pursued early retirement. And care level is worse. Medical university conglomerates are allowed to hire foreign trained doctors who are excused from completing the typical US 2 year medical residency requirement. University hospitals argue critical experience gained in residency programs is not important nor necessary because they work for a "teaching university". (Ha!) Obamacare pushed independent doctors and clinic into working for big hospitals while greatly increasing the cost of procedures to the consumer. An independent radiologist told me whereas they can provide an MRI for about $800, big hospitals readily charge $2000+. As you've pointed out, CEO salaries remain an outrageous disgrace as is the attendant growth of the "administrator" class. Yet somehow, these days many primary care doctors aren't paid enough to afford big-blue city housing prices, nor costs of their liablity insurance. Hence, we now have a shortage of primary care doctors. Again, an excuse to bring in foreign doctors who probably take the job at a lower wage. Unfortunately, hospitals and medical groups remain the darling of Wall Street investors who are always looking for businesses they can readily purge for profit. Obamacare pushes doctors further toward centralized monopoly-- which cuts the service level, doctor competence, and costs a lot more. For example, in my city, at a major medical group w/a charitable history, if you pay your bill the day-of-service so they automatically reduce the price of your bill by 30 percent. Why? This avoids the hassle of meeting Obamacare billing requirements. On the consumer level, working class folks employed by most medium to small businesses are offered Obamacare policies, but they come with lousy, expensive coverage, high deductibles, and extensive coverage restrictions. Yet these policies still cost the companies a fortune and are all most businesses can afford. Many small businesses can't competitively hire as they can't afford to offer medical insurance. In contrast, government and big corporations (big tech) subsidize employees and have profit margins or taxpayer support so they can afford to offer Cadillac-level medical insurance. Finally, sadly, big corporate medical works hand-in-hand with big corporate Pharma to control the consumer and the doctors. Note the list of doctors who permanently lost their medical licenses for daring to prescribe ivermectin which threatened the covid vaccine EUA legal standing. Also appalling: doctors and hospitals were paid based on number of covid vaccines shots given and deaths blamed on Covid. Two months after her passing, we were shocked to see my mother-in-law's death certificate listed Covid as her cause of death..Whoops, sorry Charlie. Yes, in her 90's, she had a number of body failures, but absolutely no trace of Covid flu infection. Note that pediatricians are still paid by the government for giving childhood vaccines. Yep. Paid to comply with big corporate interests. Ugh.
So in 2024 he made $9.7 million. That’s $26,575.34 EACH DAY, including the weekends when he didn’t work. MBA!?!?!?! What in the hell does he do to make that kind of money?
Just makes me so mad. Healthcare quality is horrible! But instead of putting money into improving care, they look for the Almighty dollar. Sickening. (Pun intended).
They don't need more money. They need more competition. They need less regulation from Obamacare. They need to be required to tell you what everything they are doing costs, from the least cotton swab to the most expensive procedures and tests.
Sadly, the 535 useless midwits that can rid the US of Obamacare ........... are on vacation again.
They aren't interested in fixing it. They don't participate in it, so it doesn't affect them. But as time goes by, I am thinking more and more that they like their pre-set boogeyman insurance villains- "See what I am doing to fight for you little guy!" What a crock, because even more than ready-made villains, they like the donations to their campaigns from industry that keep them in office. So very tiresome. (I am not saying that insurance should get a pass, but as mentioned above, it is government who sets the guidelines they have to follow.) Call me jaded.
Alex this subject is your calling. The MDs posting here show you are skillfully reporting on profound issues in health care. Suggestion - keep your focus here and strategize how to leverage your reporting and this sophisticated audience you’ve built into something even bigger and more influential.
Makes me wonder about a couple of others; St Jude’s by all indications is a wonderful hospital and does not charge the patients. They’re always fundraising, and probably are legit. Another that comes to mind is Shriners Hospital and also Children’s Hospital in Birmingham at UAB. Any possibility of taking t least a cursory look into these. I really need to feel good about them…
Alex, thank you for continuing to shine a light on this issue. You're right -- I haven't been angry enough, either about healthcare costs in this country, or about the way in which non-profits have been permitted to abuse their charters to enrich insiders.
I worked for Vision Service Plan about 25 years ago. They are the dominant eyecare HMO. At the time they held 80% of the total eyecare insurance market in the US. They got audited by the IRS and then had to go to court to oppose the IRS decision that they were not operating as a non-profit. They lost their non-profit status. I supported that outcome based on their business practices, even though as an executive working there, it impacted my annual executive bonus compensation.
Today I am a CEO of a non-profit 501 C 4. The business operates in a highly competitive space. I have to compete with private for-profit operators, including paying higher compensation for employee talent.
I have non-profit peers in my market that piss me off. They piss me off because they operate like they want to take over the entire market. They pick up business practices that are a race to the bottom, including paying referral sources extra for new business. Our operations are lean... with the fee revenue we earn getting us to just better than break even. This includes a budget for doing special outreach to for additional help for our clients. Any additional spending to compete in the market erodes that budget and our ability to provide the additional help.
Our business is risk subsidized by a federal program... almost 100%. It is a non-subsidy program... the fee revenue from end user clients pays for everything.
I operate with the focus on our missions to take care of these clients... and NOT to try and destroy all my competition so I can grow my profit and fatten my pay. I report to a board of directors and some of them keep pushing me to expand and grow, and I ask them why? We don't have any ownership of the business. There are plenty of good operators in the market other than us, and there is no real need to expand. However, there are other states where the service levels are lower, and we are expanding some there as we know we can add value in giving clients a better service experience. But I temper everything to come back to mission... and the fact that we are tax-exempt for a reason... and that it is not ethical to leverage the non-profit status and federal guarantees to take away market share from everyone else.
I am furious at every non-profit leader that does this... that ignores the fact that the reason they get non-profit status is that they are there for a specific mission, and the net-excess they earn should be put back into the operation to benefit the intended beneficiary of their mission.
My idea is that all non-profits need to every two years state their mission and their related goals that is tied to their strategy and budget, and they need to report on their 990 tax return their performance related to those stated goals. If they fail to demonstrate they are sticking within their mission and/or fail to meet their recorded goals, then they need to be audited for non-compliance of their non-profit charter and risk losing IRS authorization.
Please continue your crusade against these “nonprofit “ hospitals and insurers with ranks of overpaid administrators who have never contributed to the care of a single patient, only conspired to withhold care.
Thank you for this and all your work on fraud and abuses in both public and private sectors. We are a rich country and need to demand better for all of us, especially those in need. I think our biggest problem is that we have no accountability ('08 market crash, NGO fraud, droning a citizen, 2020 election and subsequent manchurian administration, Covid (funding for it and lockdown actions), pre-emptive wars, extrajudicial killings (drug boats), de-banking, seizures of foreign subjects funds i could go on). We'll never fix anything without accountability.