My brother in law died in June. Heart attack. Four hours in the hospital and gone. And then the bills came. He’d let his insurance lapse two months prior. Bills were a few thousand here for the…
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By chrisgeleven 2025-10-2818:3920 reply I fought insurance over this past summer after they declined covering a life saving surgery for my 6-year-old child at the last minute. We were in despair that my child's life was at risk each day we waited because of insurance incompetence.
ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.
I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.
10 days post denial, I was able to get the procedure approved from these efforts.
21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.
This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.
By dweekly 2025-10-2818:54 I am so glad to hear your child got the care they needed.
I've found that people often forget to call their state senator or assemblyperson. It has consistently amazed me how quickly a large company that's sitting on their butts about a topic will move lickety-split once their Government Affairs and/or PR teams are on the thread...
Another tip from having worked at a regulated entity: a physical letter to the CEO mailed to HQ creates a mandatory-response paper trail that will produce a very, very different (better) outcome than e.g. asking to talk to a supervisor while on a call that's not going well.
By Brainfood 2025-10-2819:08 Thank you for sharing. I can personally say this same process has driven me to the brink of sanity. 10 years of managing a chronically ill child’s healthcare with multiple surgeries. Being a developer with the ability to navigate complex problems, social engineer people who have turned into robots, and enough income to make it through unforeseen lump sum payments - I cannot fathom how the average person deals with this. I made more $ than I ever did before to cover the costs and afford the best healthcare possible but the system is designed so we still get screwed and have nothing left. Thankful for the people who dedicate their lives to helping others. To everyone else who can justify profiting off of someone else misery, while being the richest and most advanced society on every other level? I have nothing nice to say to you.
By bmurphy1976 2025-10-2819:432 reply How comfortable are you with naming and shaming the company? I don't think things are going to change if we don't call this stuff out loudly and publicly.
That's awful but I'm glad you were able to figure this out. I've had my own problems with insurance companies, but nothing to this level. I can't imagine the frustration, especially with YOUR CHILD'S HEALTH on the line.
Five years back I ended up getting surgery for a herniated disc. I was in immense and crippling pain. Before having the surgery, we decided to go through a round epidural shots. I had done that 20 years previously and it resolved the problem, so why wouldn't I?
Turns out my insurance company (who I will name: BCBSIL) delegated the approval for the epidurals through some kind of extra bureaucratic process with a 3rd party. It took days and additional effort on our end to get approved.
I remind you, I was in crippling pain at the time.
The delays getting this approved lead to me taking more Ibuprofen than I would otherwise have taken, which in turn lead to signs of internal bleeding. I had to ease off the Ibuprofen and significantly increase the amount of codeine (a drug which does not sit well with me) just to get by. Now not only did I have to wait for the approval, but I then had to wait for the signs of internal bleeding to go away before the doctor would give me the shot (which was the right call, even though it sucked).
Delays, compounding delays, compounding delays, all while I was absolutely miserable.
Anyway, I finally got approved and got the shot and it kinda helped, but didn't fix the issue. I had a second shot, got worse, and then decided we had no choice but to schedule the surgery.
The most frustrating thing (but something I am glad for) is that the surgery was approved immediately.
It's so maddening how inconsistent the whole thing is.
By like_any_other 2025-10-2821:54 > How comfortable are you with naming and shaming the company?
Don't forget about the individuals responsible. Both the ones that made the denial decision, and the ones that instituted the internal system that incentivizes such denials.
By chrisgeleven 2025-10-2918:50 It was Anthem Blue Cross.
You know, it is one thing if it is you or I as terrible as that is.
But this was a 6-year-old.
By itissid 2025-10-293:31 A pharmacist once told me that big insurance companies have call centers out in other countries whose job it is to call everyone who has medication approved and any one with misleading line of questioning:"Did you get or approve medication worth $$$$$$..?".
Calling 100's of people Ofc the find one poor guy never heard of such a sum denies this kind of line of questioning. Then the insurance company uses this to deny all claims made by the pharmacy for ALL their patients for that given drug/medication.
The pharmacist told me the mountain of documentary evidence they have to collect to rebut these denials is very large. Once a customer at their pharmacy said he did not want to sign off on a paper that he got a medication, the pharmacist got the customer's ok though to video record his consent, just so he does not have to deal with this mess.
He also mentioned to me that a pharmacist should NEVER pay any kind of reimbursement to an insurance company on a claim that was denied cause that somehow legally can let the insurance company deny future claims. Not entirely sure what exact legal procedure allows them to do that.
By magicalhippo 2025-10-2819:454 reply Relative recently had their baby come several months early. The baby needed intensive care for a couple of months, and breathing support (CPAP) for another two. Mom lived at the hospital hotel for the duration.
Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.
They got billed exactly zero.
Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.
Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.
A lot of folks are looking at the higher US comp but aren't correctly pricing in the long-term risk.
You can be fine for years, but a single, major medical event can zero out those salary gains and lead directly to bankruptcy. It's a systemic flaw that isn't obvious until it's your turn to deal with it.
By jmspring 2025-10-292:58 If one lives in a state like CA, the taxes (income, sales, etc) basically are equal to that of Norway/etc. The downside, we don't get any real benefit from those taxes paid out.
I know of Indian immigrants who suffered for decades/years on H1B, endless anxiety and tensions, eventually make it to GC, then a passport.
Then all of a sudden fall ill, lose everything and return back to India.
People keep forgetting the US society is a giant stack/pyramid ranking system, the structure keeps getting narrow as you move upwards. You get pushed off the sides, in the ever narrowing funnel, and you need increasing levels of luck at every level to survive.
BTW, this is not just with regards to health care. You could lose your job, suffer from ageism. Lose your home, run out of money. A million different things can happen, that can cause the above said phenomenon.
By mothballed 2025-10-2911:521 reply [flagged]
By para_parolu 2025-10-2915:541 reply I’m honestly surprised to see a comment like this on HN. You’re making a pretty negative assumption about someone you only know from a single comment, and nothing in that comment actually supports the assumption.
By mothballed 2025-10-2916:19 Commenter asserted they are US citizen, lost everything (so $0 to their name), and ill.
Take a quick look and note that the person in india in that situation puts them around the bottom 5% of their country, who live on less than $3 a day, commonly in mega-slums (these are the sorts of places you end up when you have absolutely nothing and unable to work) without running water and sewage running through the alley, and economic mobility back into the professional class even worse than USA.
Anyone with a room temperature IQ and a dual US-India citizenship is not moving to India as the place to be completely broke, ill, unable to work, and to go live in a slum that would make Skid Row look an absolute joke. Their story does not make any sense whatsoever. There is money or assets or property squirreled away, if there wasn't they would live on the meager assistance USA provides to citizens (even if stuck outside in a tent for awhile) before living on less than $3 a day in one of the mega slums people end up in when they are in India in that unfortunate situation.
And to be clear, I don't think commenter is lying about what they've been told. I'm not making any sort of dig at them.
By heavyset_go 2025-10-295:21 You can be a small business owner, employer and (low) multimillionaire, and still have it go down the drain via an accident, illness or disability that affects you and/or your family. Over time, disabilities can cost millions of dollars. Surviving a heart attack can cost hundreds of thousands to a million dollars. Long-term care insurance can still deny coverage based on pre-existing conditions, and long-term care is very expensive.
By franczesko 2025-10-294:51 Horrible system.
By kakacik 2025-10-2911:09 That's the 'societal' part of living in society, sharing the risks and yes sharing the gains a bit too. I know some right wing folks see it as unnecessary burden, either they are above the financial cut or (dumbly) believe their health is and will remain stellar for rest of their lives. That tiny minority shouldn't ever decide such societal policies and shouldn't be let to do so.
Its shortsighted and plain stupid and properly selfish move. It works rather well short term if one simply doesn't give a fuck about suffering of others, but even thats shortsighted and stupid long term - we live in hyper-interconnected society and not some prepper wet dream, what goes around always comes around.
Another similar is public education, literally defining future of society. How dumb is to not have it in stellar shape, shitting on one's own kids and mankind future.
But hell will freeze sooner than majority of americans will realize and accept that. Till then, if its important enough for you, you can vote with your feet, its easier than ever.
By rootusrootus 2025-10-294:213 reply You can use the difference in comp to buy a Cadillac level plan with zero deductible, zero out of pocket max. You won’t be going bankrupt.
Does such a thing exist these days? If so I can't find it.
More importantly, it doesn't solve the real problem. You're still subject to the same system. Fighting for prior authorizations, staying in-network, and navigating all the other administrative friction.
More than likely they'd find a way to make you go bankrupt rather than pay up. That or deny till you die.
By BobbyTables2 2025-11-024:29 In my experience (lately), the cost difference between a zero deductible plan and the high deductible plan is about the out-of-pocket max of the latter. Pretty much a wash.
So high deductible it is! Only met the out of pocket max once and it was glorious.
Before Obama, the zero deductible plans were only slightly more expensive than the high deductible plans. (Just an observation)
Seems crazy I was able to make an appointment directly with a specialist and only pay the copay back then…
By rootusrootus 2025-10-3013:56 My company offers us a range of plans, and one of them is always the zero deductible zero out of pocket max policy. More popular with those that have chronic conditions, the premiums are fairly steep.
I’m on the cheapest plan my company negotiated and my premiums are basically zero, because I’m young enough that most years I don’t spend more than a thousand bucks on health care (for me and my kids). Couple years ago I did hit the out of pocket max, though, and they did indeed cover everything from that point at 100%. I would never have gone bankrupt.
By im_down_w_otp 2025-10-294:302 reply This helps with the denials how exactly?
You can pay a lot of money in premiums, have a $0 deductible, and now OoP maximum, and still end up having claims denied.
By rootusrootus 2025-10-3013:59 Avoid UHC and that is mitigated significantly. I’ve never had a claim denied by BCBS.
I realize some people are stuck with UHC. I’d turn down a job unless it was perfect in every other way and paid extremely well if they only had UHC plans.
Do you think countries with even the most coveted universal healthcare just approve everything blindly?
Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?
> Do you think countries with even the most coveted universal healthcare just approve everything blindly?
Yes. Everything that they are trained and able to do here, is covered by the national insurance, at least where I live.
We never even have to explicitly ask them to approve anything, it's all automatic. You don't see the bill.
You might have to pay the difference for "nonessential upgrades", like a plastic cast instead of a normal one when you break your arm. Had to pay 5.00 EUR for that and it was the only time I had to pay out of pocket in my entire life.
By terminalshort 2025-10-2918:15 > You might have to pay the difference for "nonessential upgrades"
This is exactly what happens in the US. It's just that in your case the nonessential upgrade is a $5 cast. Sometimes the nonessential upgrade is an expensive surgery. My grandfather had heart surgery at 86 shortly before he died. My relatives went to 3 surgeons who all refused to perform surgery on the grounds that he was too old and frail for the procedure. Then they went to a fourth who agreed to perform it. The first three doctors were right, and he died a few months later. The insurance company quite correctly denied the claim and my family ended up fighting them over a bill for open heart surgery north of $50,000.
Your government wouldn't (and shouldn't) have paid for that surgery either. I think the real difference is that since you have a government system, that in your country that unnecessary surgery just never would have happened in the first place. I will admit this is a more efficient system, but it is no different in that there is a cost benefit analysis being done over what gets paid for and what doesn't whether you see it happening or not.
Which country do you live in that pays for gene therapies or other biologics?
I love that you're thinking this is what USA insurance companies are denying, not simple diagnostics / medications that save lives.
By 15155 2025-10-2916:16 The point is that there's a value judgment being made somewhere - who should be the arbiter and why?
Diagnostics aren't free, either: many (most?) countries do not have anything remotely resembling the private offerings that Quest Diagnostics and Labcorp provide (breadth of tests, 3+ different methodologies for some tests, etc.)
By Turskarama 2025-10-295:321 reply Everything? No. But routine stuff will NEVER be denied. If your doctor thinks you need a scan, you're getting the scan. I have quite literally NEVER heard of someone in my country (Australia) going bankrupt from medical bills. It can happen but the rate is so low it's not something anyone ever worries about happening to them.
By terminalshort 2025-10-296:262 reply Routine stuff is never denied in the US either. I've never had one thing denied ever and I even have a weird condition that requires expensive testing to diagnose and even more expensive treatment (narcolepsy). The insurance companies will throw up annoying bureaucracy like prior authorizations, and made me switch medication to generic when it came out (reasonable) and then back from the generic to another brand name when it came out (WTF??), but never actually a denial.
By im_down_w_otp 2025-10-299:391 reply Never denied eh? Interesting.
I had an MRI denied for a partial pectoral rupture. Which was a routine diagnostic as a precursor to open shoulder surgery to determine the extent and location of the rupture to figure out if surgery was absolutely necessary and to prep a viable surgical plan.
I had to fight the insurance company with the assistance of both my surgical and non-surgical sports medicine doctors.
The good news though appears to be that I imagined the entire thing, because denials for routine things never happen.
By terminalshort 2025-10-2918:19 Gemini states that an ultrasound is just as good for diagnosis as an MRI and is much cheaper. Could it be that the denial was correct and the mistake was from your doctor ordering a less cost effective diagnostic test, not from the insurance company?
And from my personal experience with narcolepsy, AI is a much better doctor than most human doctors.
Odd that your experience would be so different from mine. I routinely experience denials.
To give an example, about 60 to 80% of the time, when I visit the dentist for a regular cleaning the charge is denied and I have to submit additional paperwork to convince them to pay it. I can't think of any more simple and basic procedure than that.
I have no idea why your experience with healthcare in the US is so much better, but I can assure you that there are many people whose experience is more like mine.
By 15155 2025-10-2914:41 Dental is an entirely different system: dental insurance isn't actually insurance.
By terminalshort 2025-10-2917:55 I am in 100% agreement with you about dental insurance, but that's a completely separate system.
By ErroneousBosh 2025-10-2910:281 reply > Should everyone (anyone?) receive monoclonal antibodies, gene therapies, biologic medications? What criteria should be used to make these determinations?
Yes, if that's an indicated and effective treatment.
Do you think people should just be left to die if they can't pony up the dough in the hospital? Oh, your card's declined, no oncology ward for you?
Where is the limit to how much money is expended on one person?
What if they have a 99% likelihood of death, are unlimited funds expended in this case?
What if there's a shortage on drugs - who should get the limited supply available?
Which country with public health options pays for biologic medications or similar patient-tailored solutions?
By ErroneousBosh 2025-10-2918:31 > Where is the limit to how much money is expended on one person?
It depends on what would be an effective and indicated treatment.
> What if they have a 99% likelihood of death, are unlimited funds expended in this case?
Then treatment would neither be effective nor indicated. But if it was your parent, your child, your granny, wouldn't you rather they at least try?
> What if there's a shortage on drugs - who should get the limited supply available?
The people for whom treatment is most likely to be effective
> Which country with public health options pays for biologic medications or similar patient-tailored solutions?
The UK, for a start.
By washadjeffmad 2025-10-2911:14 I'd much rather not have every part of my society for sale to someone with infinitely deeper pockets.
We're not the customers of healthcare, insurance, mortgages, etc. The planet's wealthiest pensioners are. No difference in comp is going to make that work out best for you.
Also, the existence of Cadillac plans implies that someone in our government doesn't believe the population at large should be receiving world-class care. It's like when Senator Biden had two cranial aneurysms, had top surgeons flown in on taxpayer dime, then fought against universal healthcare.
We're all already paying for the best healthcare in the world, just not for us.
By IG_Semmelweiss 2025-10-295:363 reply This is why insurance plans have out of pocket maximums. To prevent this exact issue.
We can say whether those maximums are still too high (some really are), but the mechanism is there.
The real issue is that most people don't have a rainy day fund to deal with such emergencies. And that they are too expensive anyway.
There are 2 concepts you should always keep in mind.
1. Always avoid the hospital unless you are literally dying. Surgery centers are owned by doctors who will negotiate a fixed fee, because there's someone to negotiate with (unlike Hospitals which run on the CYA principle). Also, most doctors can do procedures in office, if they have the right one.
2. Medical debt will never lead to collections. Hospitals may sue you, depending on the state, but that carriers reputational risk. A good PR push and a decent lawyer to threaten discovery will be enough to fend off even the most aggressive hospitals - this allow you to setle at a very reasonable price vs what insurance would normally pay.
By diob 2025-10-296:23 That analysis is flawed because it misses the systemic nature of the risk. The Out-of-Pocket Max is an annual liability, not a one-time fix. A single serious illness, like cancer, spans multiple plan years. A $9,200 OOPM hitting three years in a row, on top of $15k-$18k in annual premiums, is the bankruptcy. This also assumes 100% in-network care, which is a fantasy in a real emergency when you don't get to pick the ambulance or the anesthesiologist. This isn't a "rainy day fund" problem. This is a system that requires a $50k-$100k emergency fund just to handle a single medical event, all while assuming you're still healthy enough to keep the job that provides the plan.
"Always avoid the hospital" isn't a choice either. You don't "negotiate" with a surgery center for a heart attack, a stroke, or a major car accident, which are some of the common events that cause this. And the claim that "medical debt will never lead to collections" is factually incorrect.
It is the number one cause of collections in the United States. The idea that every citizen can just "hire a decent lawyer" or "run a good PR push" to settle debt isn't a functional or scalable mechanism, nor is it reality.
> Hospitals may sue you, depending on the state, but that carriers reputational risk
I'm sorry but if I need a hospital, my first thought isnt, "well how is their reputation".
I don't understand why people defend the insurance system in the US when you're already paying taxes. If it's not the responsibility of the government who you pay to take care of their people in an emergency then what are taxes for. It's like people just accept it because that's how it's always been.
By IG_Semmelweiss 2025-10-2917:58 What we have is not insurance.
What we have is all-you-can-eat ferrari care
Insurance is what i have when i drive my car , or get water damage insurance for my house.
The monster we have today is not insurance. Instead, it is the frankenstein born out of the womb of bureaucrats and politicians influenced by money. Decades of tinkering politicians without a clue, messing around with the relationship between the doctor and patient, responding to voting patterns of the electorate, led us to today.
Unless you blow it up, (and it will blow up, just like it happened in sweden) there's no solution, except paying more for ferrari all-you-can eat.
By jalapenos 2025-10-2911:04 Your country is twisted dude
The whole time I was reading this, as someone from the U.S., I was wondering what country the writer was from, because it sure as #$@! wasn't written by someone in the U.S. When I got to that part, I was, "Oh. Okay. That makes sense."
By thatfrenchguy 2025-10-2822:372 reply In the US, you'll be billed the maximum out of pocket for your health insurance whether your little one is in the ICU for months or whether it was a easy delivery though, so at least birth is a predictable medical expense.
If you have health insurance... Which is not automatically a thing for many Americans, and it seems even more with current political trends.
By trollbridge 2025-10-292:15 If someone doesn’t have health insurance in my state, they get sent to financial counselling/assistance and signed up for Medicaid, CHIP, or HCAP.
I asked one of their counsellors once if they ever have any ultra wealthy people who don’t have insurance and also don’t qualify for any assistance. (This was at a children’s hospital with a Level IV NICU.) She said she was unaware of that ever happening, other than very wealthy foreigners who would prepare in advance, arrange payment in advance, fly in, and have a special procedure done.
Overall, in many states, it is logistically impossible to have an unaffordable bill and also not qualify for assistance. The worst situation actually is the person who has insurance but has high deductibles and copays.
By fooker 2025-10-299:18 Ah you don’t seem to understand the depravity of the modern American medical system. It’s not as bad in the way you think, and significantly fucked up in a different way.
If you do not have insurance, you tell them you don’t. They’ll give you a bill lower than what you’d pay as deductible if you had insurance. Or you just don’t pay…
This raises insurance premiums and reduces the quality of healthcare in a dystopian AF feedback loop.
By chrisgeleven 2025-10-2918:52 Yeah in my case, for two years in a row now we've maxed out my kid's out of pocket expense within ~30 days of the year starting...that's not fun.
Realistically it's much more likely that someone in the US would be telling this story vs someone from Norway.
Norway has only 50k births a year. The US has 3.6 Million, and >40% of those are 100% free to Medicaid recipients. So 1.4 million each year, meaning a story like this is about 28 times more likely to be told from someone in the US than Norway.
By heavyset_go 2025-10-295:282 reply Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.
When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.
>Medicaid isn't paying parents to not work. New parents will still have to worry about paying bills and the economy.
That would be up to their job if they had one of course, but Medicaid does have some cash benefits and if you have a baby on Medicaid you typically get auto-qualified for TANF so that covers a lot of bills.
>When those parents die, any potential generational wealth for their children will be taken by the state to pay back the benefits they received from Medicaid.
This would only be true if the parents received long-term care or something. And this happens to TONS of people who have otherwise been financially well off, they have to exhaust their assets before Medicaid starts paying for a nursing home. It's got nothing to do with pregnancy benefits.
By heavyset_go 2025-10-298:14 I just looked it up and I'm wrong, estate recovery is for anyone at any age who is institutionalized and/or anyone over 55 receiving care. States can additionally choose care and populations from which they do estate recovery for their Medicaid programs.
All I know is a family member would get the Medicaid warnings about their estate each month in the mail.
By terminalshort 2025-10-296:28 Well of course it will because medicaid is healthcare for poor people, not people with generational wealth. If you are rich and use medicaid that's fraud, and medicaid should take double for that.
By Sammi 2025-10-298:35 That is misuse of statistics if I ever saw it. You could count the people that are screwed in the US and also get a much larger number than in Norway. The US has a relative problem.
By necovek 2025-10-294:41 > too much oxygen in the blood can lead to problems with the cornea or something
You are likely thinking of ROP (retinopathy of prematurity, where retina starts detaching due to prolonged stay in the incubator).
By seethedeaduu 2025-10-295:271 reply The norwegian healthcare is really bad at specific sectors if they deem you as a 2nd class citizen (for example trans healthcare, where there is a lot of malicious gatekeeping and multi-year long waitlists)
By seethedeaduu 2025-10-2912:06 Where did you pull this number from? And even if so, what is your point? Seeing how a nation treats its minorities helps judge whether they have any humanity left.
By brightball 2025-10-292:291 reply In that same vein, I used a public adjuster once after a small electrical fire torched a room in my house. The insurance adjuster was great, his manager was awful and made a difficult experience much worse.
Without getting into details, the moment I realized that he was being intentionally obtuse I started looking into options.
First contacted an attorney who essentially said, “Yes, I can do it but I’m going to cost a lot and the insurance company won’t reimburse you for my time.”
Kept looking and discovered public adjusters were a thing. Did some research, found one who was reputable and he took me on for free. Pretty sure we used net, about 2-4 hours of his time.
He told me exactly what was going to happen, how the insurance company was going to react and it played out exactly as he said.
1. He requested a process to take the valuation of everything damaged in the fire to a 3rd party arbiter.
2. Insurance company will send you a letter saying it’s not time for that yet. We will proceed anyway. And we did.
3. He will nominate 3 arbiters and the insurance company will nominate 3 arbiters. Neither will select either of the others nominees and an independent 3rd party will select one instead.
4. The moment the insurance company realizes the valuation of your things will be outside of their control, they will become extremely agreeable. And they did.
And honestly the only thing I really wanted was another week in a hotel for my family because the company cleaning my house of smoke was short staffed over the holidays. Would have cost them likely $1,000 but instead he escalated the situation dramatically.
By DesiLurker 2025-11-0416:51 thank you for this comment, learnt a new defensive trick today.
By georgeecollins 2025-10-2818:5213 reply I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.
But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.
I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.
As a non-american (from South America) who lived in both USA an Europe:
Yes, in USA you get much more money, like you said 2x~5x, but then:
University is expensive as fck. Health care is expensive as fck. You have 5 days of paid sick leave per year in most companies. You have 10 days of paid holidays per year in most companies.
In contrast, in Europe: University was cheap or free. Healthcare is cheap and universal. If you are sick you are sick, either the company or the health insurance pay. You have between 20 and 30 days of paid holidays.
This is why quality of life in Europe, is so superior. And again, I am saying this as a non-European.
> University is expensive as fck.
One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $60K/year tuition prices. US universities charge on a sliding scale based on the applicants' families' ability to pay.
For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.
For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.
That said, it's entirely possible or someone to go out and sign up for bad investment private university with no aid and rack up $300K of debt by graduation if they're not paying attention to anything, but it's a myth to think that everyone does this.
The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.
By StackRanker3000 2025-10-2821:521 reply > For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.
As someone from a country (Sweden) that to a larger extent has decreased people’s reliance on their families, and grown the welfare state instead, it’s weird to think that your parents wealth or income should have any impact on things like tuition, once you’ve reached the age of majority
Once I finished high school, my parents had nothing to do with my business as far as any institutions were concerned, and vice versa. But uni was tax-funded and free at the point of use. And when they get too old to care for themselves, it will likely be the government supporting them financially, not me (unless I strike it rich first, in which case I suppose they’ll spend their sunset years in style)
There's always this subtext that Europeans solve these problems just by caring more about human values, but the truth usually involves interesting sets of tradeoffs. So in Europe the norm, besides free university, is extensive tracking: in the US, your choice of major is essentially a consumer decision, where in many European systems it's fixed at a relatively early age by your performance on things like the Abitur.
I'm not saying the European system is bad. Certainly there's a lot to complain about with a system that asks 18 year olds to make life-defining decisions about both their career and their financial prospects. But the differences do go beyond whether or not you're on the hook for your tuition.
By cycomanic 2025-10-295:13 I don't quite understand what you mean by "tracking". Speaking of Germany, because you mentioned the Abitur. Yes your ability to enter certain universities and studies depends on your performance during the Abitur. That is to enter e.g. law or medicine at you chosen university immediately (there is a wait time multiplier, so you can wait if you don't get in immediately) requires a certain grade point average. However I don't understand how this is different from SAT scores in the US (except for maybe the ability to bypass SAT requirements by being super wealthy, but I'm not sure that would be a good thing). In my experience kids in the US tend to be obsessed about their university choices much earlier than the ones in Europe.
Also talking about Germany, unless things changed dramatically in the last few years, most natural sciences and engineering degrees don't require a grade point average.
I agree that European schools are heavily tracked, but I’m not seeing the connection between that and the tuition costs.
It seems like these are unrelated issues.
Does the wider freedom of choice in US education somehow cause college to cost more? Because more people want to go?? I don’t get it.
> Europeans solve these problems just by caring more about human values
In the US, to make tuition free, you'd have to answer the question "who gets to enter university programs". In Europe, the answer isn't "everybody".
By StackRanker3000 2025-10-2911:19 I can mainly speak for Sweden, but basically the answer there actually is ”everybody who wants to and meets the minimum requirements (essentially having graduated high school)”
Sweden has higher gross enrolment in tertiary education than the US, and a larger proportion of older students (people who go back later in life to progress their education or change paths)
I’ve heard that in countries like Germany people are often ”locked in” by choices they’ve made at an early age. There’s an element of that in Sweden too (more vocationally-focused high school programs may not give you all the courses that you need to enter all university programs), but that is not too onerous to overcome if you change your mind later (you can do ”foundational studies” to bridge the gap, or just sit exams to prove that you’re qualified)
Edit: but it’s maybe also to your point that universities have limited seats, just like everywhere. Maybe your high school grades or score at the equivalent of the SAT aren’t high enough to study mathematics at the top-rated institution even if you’re qualified, because there are too many people ahead of you. But you will be able to go to uni somewhere to study something
By throwforfeds 2025-10-2820:102 reply Yes, but Americans have an incredible amount of student loan debt too. Something like $1.7 trillion. If you can get into one of the best schools in the world that has a huge endowment, then sure, you'll get grants and whatnot. It may even be free, in the case of Harvard. But then there's a long tail of schools that are honestly not that great, charging only slightly less than the top schools per year, with smaller aid packages, and kids sign up for crazy loans because they think they have to.
Personally I think the government should get out of the business of these loans, fully fund state schools to make them all free, and let the private schools and the private banking market deal with the rest of it. We were going down that path in CA until Reagan killed it when he was governor. [1]
[1] https://newuniversity.org/2023/02/13/ronald-reagans-legacy-t...
Public service loan forgiveness (PSLF) exists and a huge number of people in medical professions actually take advantage of it. I know of multiple medical students and residents with over $500k in debt that are in the process of having all of their loans forgiven after 10 years in training and a total cost of approximately $75–150k for their entire education. Sure, that's still a decent amount of money, but it's very much worth the ROI.
https://en.wikipedia.org/wiki/Public_Service_Loan_Forgivenes...
How successful are those people being?
IIUC, there was a bit of a scandal where the companies the DoE where paying to manage those 10 year forgiveness plans where giving incorrect advice and so a lot of people aren't going to qualify.
https://oag.ca.gov/news/press-releases/attorney-general-bece...
By apparent 2025-10-293:59 Lots of hospitals are nonprofits, and doctors can make lots of money working at hospitals. There is no income cap for PSLF IIRC, as long as you're working for a qualifying entity (including nonprofits).
By sxg 2025-10-2823:54 Anecdotally, it's worked out for a number of friends and people on /r/PSLF. There's definitely poor communication around PSLF, but it is a real program.
American student loan debt skews sharply towards the top income quartile.
Yes, granted it was over 20 years ago, but I came from a pretty broke household in the United States, and I went to a cheap state school instead of a nicer university or private school because I couldn’t imagine borrowing for school. The folks I know who were much more well off, seem to have had no problem borrowing what I considered to be exorbitant sums to both pay for school and live off of.
By tptacek 2025-10-2820:40 In a redistributive sense it is very much like American homeowners complaining about their mortgage debt.
By throwforfeds 2025-10-2915:48 Yes, but I also know plenty of people that can't afford the loans that they have. I have friends and family that after a decade or more of repayment still owe the same amount they did when they got out of school. Some aren't paying theirs at all. It's going to be a problem, as only a third of borrowers are actually making payments [1], and debt forgiveness isn't going to solve the root of the problem.
Of course we can blame them for taking $60k out for studying something that will never get them a good paying job, but these are 18 year olds. I was lucky in that my parents are immigrants and were like "absolutely not, this is crazy, go to the flagship state school and study science". I paid off my $24k in loans in a couple years. Many didn't take that path.
[1] Bloomberg archive link: https://archive.ph/IBuzw
By gonzobonzo 2025-10-290:081 reply > For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.
This is an extremely important point that keeps getting ignored. People keep comparing _public_ schools in Europe to _private_ schools in America.
To further your point, just about every place has a community college where you can do the first two years of your education for about half the price of the state school. The total tuition for this route (2 years at community college, 2 years at a state school) is going to average just under $30,000 for 4 years. Which is definitely in the "work your way through college" range.
And this is before any financial assistance, which the majority of students receive.
Foreigners talking about how crazy expensive college is in the U.S., but they're likely mislead by people who took out large loans to go to extremely expensive private colleges. There's an easy way to stop this kind of debt - don't allow federal loans for private institutions. But no one is really interested in stopping it.
By amarant 2025-10-291:50 >People keep comparing _public_ schools in Europe to _private_ schools in America
Not necessarily the case. In Sweden private schools are paid for by the government, assuming they have been approved by the CSN (central agency for study-support(rough translation))
I don't know how that works in the rest of Europe, because I've never studied outside of Sweden. But in Sweden it doesn't really matter if the school is private or public. The only instance you have to pay yourself is if the school isn't sufficiently good to pass muster.
Also, again in Sweden at least, but possibly other parts of Europe as well, the tuition isn't effectively $0. The government will pay any student enrolled in higher education a monthly support. Back in my day it was 10k SEK per month (roughly 1000usd), no strings attached. Not sure how it currently stands but I imagine it hasn't changed much.
This money is meant to ease the burden on students, so that they can put more focus on studies.
"Working your way through collage" over here means you'll have a 20% job to pay for your cost of living minus the 10k SEK mentioned above.
The difference in cost of study is quite real, even taking your comment into account
One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $200K hospital bills. US hospitals charge on a sliding scale based on the applicants' families' ability to pay.
(I don’t mean to belittle your comment about universities which is factual and helpful. I’m just pointing out that US education system is just as fucked up as the US healthcare system the OP is talking about.)
Also very true, and a good point.
Even people in the US don't understand why those $200K hospital bills aren't real.
Insurance providers (including government programs) have a fixed limit for what they pay for procedures. They pay min(billed_amount, allowed_amount) so providers don't want to risk leaving money on the table by having billed_amount < allowed_amount. To ensure this doesn't happen, they bill an arbitrarily high number with the expectation that insurance will lower it down to some much smaller number.
So every time you see posts on the internet where people talk about their "$200K hospital bill" they're always talking about that arbitrarily high value. If you have to pay cash for some reason, they will reduce the value to the cash pay amount which is in line with the insurance paid numbers.
Nobody ever pays those high hospital bill amounts.
By throwway120385 2025-10-2820:224 reply That depends a lot on your insurance. For example, our out of pocket for my son's birth was somewhere in the neighborhood of $10k after insurance. I've met tons of people who would be bankrupted by that amount. What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where the employer gets to pocket anything left in the account at the end of the year. My son was essentially unplanned, in the sense that we gave up on trying to have a kid but weren't using birth control because over the previous 3 years we had not had a successful pregnancy. So an HSA would have been no help for us.
By tptacek 2025-10-2820:32 HSA funds are meant to roll over. Your employer generally should not be pocketing whatever's left over in the account. The idea is that many (most?) people are better off with a lower premium and higher deductible given that most years (for most people) aren't characterized by high medical expenditures; HDHP+HSA is closer in nature to actual "insurance", rather than a structured financing plan for health care.
By epcoa 2025-10-2823:54 HSAs are triple tax advantaged retirement accounts. Not taxed on contribution, gains, or withdrawals for qualified expenses. In the worst case it becomes like a pretax IRA because after age 65 you will not pay a penalty on non qualified expenses - but qualified expenses tend to increase with age. For many it should be their primary retirement account. Even for people with certain chronic conditions (not in perfect health), depending on how good/expensive the PPO offered by the employer, it might still work out better to do HDHP/HSA. You can get as many basically free HSA accounts from Fidelity.
An FSA really has nothing to do with an HSA.
By phil21 2025-10-2820:47 HSA is your money like a retirement account is. It’s one of the most tax advantaged ways to save money.
More or less all high income earners who do not have a chronic health issue are better off choosing a HDHP paired with a HSA - especially if the company provides any sort of matching benefit. Keep that account as an additional retirement account and pay out of pocket for most healthcare needs.
Think of it also as actual insurance vs. a pre-paid health plan.
The math of course changes for folks who are not highly paid, or have expensive chronic health conditions that would result in maxing out the deductible each year.
You are likely thinking of a FSA which is use it or lose it.
FSA's not HSA's are use-it-or-lose-it.
If you have a FSA I strongly suggest that you get an HSA instead.
https://www.fidelity.com/learning-center/smart-money/hsa-vs-...
By maxerickson 2025-10-2821:552 reply A lot of people with FSAs will have insurance that disqualifies having an HSA.
I have the paranoid idea that they designed FSAs in such a goofy way for budget scoring and it drives me nuts.
>A lot of people with FSAs will have insurance that disqualifies having an HSA.
Which should be illegal. It should be only HSA across the board. Its nonsensical that this is a thing.
I'd love an HSA, but I can't due to my plan (can't do a high deductible plan for $reasons).
I think there may be some loophole in setting up an independent HSA but I haven't looked into it enough, only recently heard of such a scheme
By com2kid 2025-10-292:38 FSA is just a 30%-ish discount on medical expenses. It is useful for eye glasses and such. A lot of QoL services qualify for FSA, including weight loss coaches and therapy.
Heck my (prescription) meta ray bans were paid for in part with FSA funds.
By maxerickson 2025-10-291:562 reply You think it's obvious that "lesuorac" was scoping their comment to people that have an FSA with an HDHP?
Doesn't read that way to me.
By lesuorac 2025-10-3013:06 The post I was replying to originally used the word "FSA" in the locations that they currently use "HSA".
My post does seem a bit weird after their edit but at least one person learned something.
It's obvious in that they specifically referred both to HSAs (not FSAs), and to HDHPs, which depend on HSAs, not FSAs. FSAs are not a kind of HSA.
So, yeah. Little bit.
By maxerickson 2025-10-292:161 reply Which they? The comment I replied to literally says:
"If you have a FSA I strongly suggest that you get an HSA instead."
Did you mean to reply to them?
By tptacek 2025-10-292:35 You are I are both commenting on a subthread started by a comment that included "What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where [...]", none of which is true. I don't care about FSAs and am not trying to argue with anybody about them, but that preceding comment is very wrong about HSAs and HDHPs.
By TheOtherHobbes 2025-10-2822:12 If the bills aren't real, why are there half a million medical bankruptcies every year?
Why do 41% of Americans have some form of medical debt?
https://www.kff.org/health-costs/kff-health-care-debt-survey...
By mindslight 2025-10-2820:36 Note that another word that straightforwardly describes this behavior is "fraud". Medical bills aren't like a bill from a car mechanic where there is a contract (either written or at least implied because the mechanic will readily give you estimates and quotes).
In the medical context, the only contract in the picture is possibly between the medical provider and the healthcare management organization. It would be fine if providers only sent the fake bills to them as they're both willingly playing this perverse game.
But the problem is when they send their fake numbers to patients as if they're some kind of legitimate bill. Medical bills to patients are presented on a "cost reimbursement" basis - helping you cost them this much, so you are responsible for reimbursing them. By inflating the numbers 3-5x they are straight up lying about the costs they incurred. That's fraud.
>The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.
This is such a weird excuse for bad policy. Making more money[0][1] somehow means its okay to saddle students with an average debt of $30-40 thousand dollars. A downpayment on a first home would be a much better use of that money, for example.
Really, the average US citizen is nickel and dimed to death with this sort of thing, from health insurance, to dental, to lots of other required but not accounted for as required costs (like cars and associated car insurance).
Not to mention, we have little safety net in the US, you're really going to hurt if you have a bad run of luck after job loss. No qualms in allowing people to become homeless as a matter of policy.
If someone were to ask me, I would say that we in the US have it completely backwards in respect to how the average citizenry is expected to live. Its not thriving, its constantly having some kind of lingering potential disaster to plan for.
[0]: which I sincerely wonder about the true veracity of this statistic
[1]: Don't forget too, that more and more struggle to pay their student loans each year and the trend has generally been that its getting worse, not better.
What policy are you referring to? Cost-conscious students can (and most should) stay in-state, do their first year or two at a city/community college (my kids knocked out core STEM classes there --- over summers, not for cost reasons --- and found the teaching markedly better), and then transfer into a commuter university. The "average" student debt owed primarily by the top income quintile in this country and captures the cost of out-of-state selective university, which are a luxury good.
By no_wizard 2025-10-2823:35 >What policy are you referring to?
The implicit policy that student loans are an acceptable and benign form of debt for the average citizen. Everything said after is predicated on this idea.
I don't think thats good policy.
By tsimionescu 2025-10-292:191 reply It's very funny to see the US perspective here. $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA, I would bet. I paid $0 for my university, as did most of my colleagues, but even if I had had to pay the tuition, it would have amounted to $4k total for a 4-year bachelor's degree, or $6.5k total for a 6-year bachelor's + master's, at one of my country's premier state universities (and consider that private universities are a joke here, just diploma mills).
Granted, none of the top universities in my country even makes it to the top 500 in the world, so maybe this isn't a completely fair comparison? Actually, it's expensive by some other EU country standards - public schools in France and Germany, including PSL (ranked 28th in the world) and TUM (ranked 22nd), are free for all EEA applicants, with some nominal yearly registration fees (amounting to $1k in total for a 4-year degree). A more expensive school, like ETH Zurich (rank 7 in the world), is $4500 total for a 4-year degree if you're a Swiss citizen or EEA citizen with a Swiss work permit; it's triple that for an international student.
So yeah, when we say "university is crazy expensive in the USA (and probably UK too)", we're actually talking about the $30-40k numbers you're looking at. $200k and so are almost inconceivable to us.
> $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA
That's the cost over 4 years. Most people will be able to get financial assistance to help pay for that and you easily manage to make 30k (or less with grants) in 4 years to pay for school. People making below 35k per year are going to pay practically zero taxes. You can work about 15 hours a week making $10 per or full time over the summer to pay for that.
There's no need to take on any debt.
People in the US make considerably more money than those in the EU and, generally pay less taxes so there's a lot more disposable income available. I think people here prefer to be able to just get what they can pay for rather than hope the government will let them pursue the education they want (there are aptitude tests and quotas in some EU countries).
It's not really better ir worse, it's just different.
By tsimionescu 2025-10-297:191 reply There are aptitude tests of some kind and quotas for all good universities everywhere in the world. Harvard won't admit 100k students in a year if they randomly decide to join, nor will they accept a student without a stellar record (apart from legacy admissions, of course). And I would bet you whatever you want that you'll get a much better salary fresh out of college in Europe with a bachelor's from the Technical University of Munich (total cost: around $2000 if you're a citizen of an EU country), or TU Delft in the Netherlands (total cost: around $9000) than you will in the states with a degree from a random college that doesn't even have to bother with admissions tests.
Sure, if you're a brilliant young mind and can get into Harvard and qualify for assistance with your tuition, you're set for life, basically, in a way no EU university can match. But for the vast majority of the population, the outcomes are significantly better with the EU system.
Also note that the gigantic tuitions at US universities are actually a relatively recent phenomenon (and a similar thing happened in the UK). Even in the 50s and 60s, tuitions were much closer to the current EU norm.
We're not talking about private universities, we're talking about public universities that have plenty of room for whatever major you choose.
By tsimionescu 2025-10-3013:25 Any good university will have a limit to how many students it can absorb. A professor can't teach 1000 students in a class, not well. So you either have a university that can accept ~any number of students and function as mostly a diploma mill; or a university that actually cares about teaching students and thus must have a selection process.
Of course, there is some room between these extremes, especially for unpopular subjects where you hardly even get enough students to fill up a professor's time. And in those cases, you'll also see that EU systems will essentially accept anyone. Typically, for uncompetitive universities and subjects (majors), the only condition is to have passed (gotten at least 50%) for the local equivalent of the SATs - a very low bar.
By fn-mote 2025-10-2823:57 > almost nobody actually pays those mind-blowing $60K/year tuition prices
This is not true at all.()
You quote tuition at the school with the highest endowment in the country. The college cost situation is absolutely still high at the less endowed second tier, and “ordinary” (non-generational wealth, two full time earner) families are paying full price.
() Except in the sense that “almost nobody” goes to any of these schools, comparing to the 50k enrollment at large public institutions.
By com2kid 2025-10-292:34 My mom was a school bus driver and my dad was a laborer retired on disability. I got zero aid except for loans.
I went to a 2nd tier in-state school 20 years ago and even that cost 10k a year by the time housing, food, and books, were paid for.
Plenty of people who can barely avoid it end up paying a large chunk of $.
By georgeecollins 2025-10-2822:376 reply If this were true, the number of Americans I have known who moved to Europe would be roughly equal to the number of Europeans I have known who have moved to the US. That's not data, that's anecdote. But what is the European country where more people go there from the US than come to the US from there?
USAians are not exactly famous for commonly speaking most European languages at a level that would allow them to resettle to the respective European countries. This makes for a considerable barrier that essentially doesn't exist in the opposite direction.
By georgeecollins 2025-10-2823:322 reply I have never heard this term before, but to clarify what I mean (it's so weird to bring race into this!): I have worked with dozens of native born dutch, german, french people etc. and lots of latin people etc. But I know almost very few that I grew up with, went to school with, who moved from the US to another country. I am not saying this is good, the US is good etc. I am saying you have to understand the revealed preference vs what people tell you.
I wouldn't be surprised if this changes in the future, I am talking about the period of my life to date.
> I am saying you have to understand the revealed preference vs what people tell you.
And what they're saying is that this isn't just an indication of how awesome the US is compared to other places, but also of how averse Americans are to learning other languages compared to other people.
Very uncharitable way to phrase that, American second language prevalance is similar to other English dominant countries like the UK or the Australia.
Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
> Very uncharitable way to phrase that, American second language prevalance is similar to other English dominant countries like the UK or the Australia.
No. Yours is uncharitable because it has got nothing to do with how many languages you speak. This is not a multiglot competition. The only point being made is that someone with a fair amount of American exposure will have a head start emigrating to America compared to say an American to Latvia. Or France. Or Germany. Just on the language front in isolation/alone.
> Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. Or maybe they were really just embarrassed to have insufficient command of the Master Language, I don’t know, maybe your version is correct.
> If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg.
"No. Yours is uncharitable because it has got nothing to do with how many languages you speak. This is not a multiglot competition."
I was referring to this specific part of the comment I replied to: "Americans are averse to learning languages as opposed to other people". My response is a very accurate explanation of the reasons why this is a) an unfair way of looking at things, and b) not unique to Americans. What aspect of my response is uncharitable? I'm not saying things should be one way or another, just explaining how they are.
"Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. "
The situation I described has occurred to me more then once, even after I tried to communicate in the local language. English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
"For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg"
Lmao, why are you so angry? I grew up in Australia and south east asia.
> I was referring to this specific part of the comment I replied to: "Americans are averse to learning languages as opposed to other people". My response is a very accurate explanation of the reasons why this is a) an unfair way of looking at things, and b) not unique to Americans. What aspect of my response is uncharitable? I'm not saying things should be one way or another, just explaining how they are.
Okay that’s fair. I glossed over that part.
> The situation I described has occurred to me more then once, even after I tried to communicate in the local language.
Your interpretation of the chain of events perhaps.
One person goes to a country and meets kind strangers. “Wow, these people are nice to strangers”. Another person has the same experience. “Wow, these people must love me or X attribute.”
> English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
I’m very upset that I speak English fluently. It really inconveniences me. > Lmao, why are you so angry? I grew up in Australia and south east asia.
Do you know what a comparison is? I did not call you an American. There’s no reason to take offense.
No, it is not my interpretation. You can be willfully ignorant about this if you want, but you are just plain wrong. I'm talking about countries I grew up in and went to school with the locals with. I know the norms of the people I was around better then you.
If you go to a place that views western culture through a looking glass and is trying to learn English to progress to a better point in life, English is cool, speaking English is cool. Not saying that is a good way for things to be (or that literally every person you will meet will have this mindset), but that is how it is for a significant portion of people.
"Do you know what a comparison is? I did not call you an American. There’s no reason to take offense"
I'm not offended, but your remark was a) clearly intended as an insult and b) demonstrated that you were likely stereotyping me on a very particular way, which runs completely contrary to my actual experience with these matters.
By keybored 2025-10-3115:50 Okay. All fair points. :)
By keybored 2025-10-2918:25 > I have never heard this term before,
> > In Spanish, the Diccionario panhispánico de dudas (English: Pan-Hispanic Dictionary of Doubts), published by the Royal Spanish Academy and the Association of Academies of the Spanish Language, recommends the genderless term estadounidense (literally United Statesian)
https://en.wikipedia.org/wiki/Demonyms_for_the_United_States
> , but to clarify what I mean
You’re restating your point while not responding to the point that OP brought up.
The two things are not equals. The US has for a western country, relaxed standards for immigration[0], in particular if you were coming from Europe, it's quite a bit easier to establish residency here.
The reverse is not true. European nations aren't very immigration friendly by comparison. On top of that, the US government, assuming you keep your citizenship, does not make it easy to live abroad. US government tax policy for citizens who live overseas is much more aggressive than any other western country, from what I understand.
Combined with the fact its alot harder to go the other way, and the US government does a fair amount to discourage it, I'm not shocked more US citizens aren't moving to Europe.
[0]: At least before Trump returned to office, I'm unsure how much of this has changed.
By throwaway2037 2025-10-290:021 reply
My comments will only concern skilled migration, e.g., you are a computer programmer or something STEM'ish and you want to work in a different country.> The US has for a western country, relaxed standards for immigrationFirst, let's start with the "Anglo-American sphere" (my term): US/UK/CA/AU/NZ. Of those five, US is the hardest to get a working visa for skilled individuals. The rest are "points-based" system where you can apply for a working visa even before you have a job (95% sure about this -- pls correct if wrong). They are much more friendly. Also, the rules are simpler, clearer, and applied more consistently.
I know much less about other OECD-level (and G7-level) nations, but anecdotally, overall, the process is much more straight forward compared to the US. What the rules say, the rules do. Not so much in the US where they randomly delay or reject applicants without good reason. (Also: Google to find horror stories of what happens when you lose your job in US as a foreigner who does not have PR. Fucking nitemare.) You hear this much less in (to name a few): Ireland, UK, France, Germany, Belgium, Netherlands, Denmark, Norway, Sweden, Finland. (I don't hear as much about Portugal, Spain, and Italy, but quality of life looks awesome!) All of those countries are wealthy, highly developed and have excellent quality of life. All of them welcome skilled migration and have clear programmes (you can Google about them) to get a working visa. Again, strictly anecdotal: The US immigration system is much more adversarial compared to all of the other countries that I mentioned. Oh, and I forgot to add Japan: After PM Abe changed the rules, it is way easier these days to get a skilled worker visa in Japan.
Last point:
I see this over and over again on HN. I want to repeat: Europe is enormous -- like continent-sized -- with ~50 countries. It doesn't say much to say "in Europe". Are we talking about Belarus, Albania, Germany, or Italy? All of them are culturally and economically much more different than anything in the US (comparing US states / regions). Immigration/healthcare/public school/public safety/retirement all looks very different in those nations. Advice: It's better to say something like: "the Nordics" or "Benelux" or "GBR/FRA/GER/ITA" (the four economic giants of Europe). The best comments are when people comment about specific European nations, like "I lived & worked in Belgium for 7 years and this happened."> European nationsBy no_wizard 2025-10-290:21 >My comments will only concern skilled migration, e.g., you are a computer programmer or something STEM'ish and you want to work in a different country.
This circumvents the original predicate, which did not have such a limitation. I know many countries have priority / helpful pathways for STEM career individuals as well as capital investors, but that wouldn't apply to everyone.
Even the US has very different pathways to citizenship depending on various factors. Last time I looked into it as research in depth, there alot of common limiting factors across Europe. Their policies are much more strict once you dive into the nuance.
That said, the US immigration landscape is extremely lopsided, thats a fair point.
>Europe is enormous -- like continent-sized -- with ~50 countries.
I realize, though as a US citizen I also realize that when most US citizens say this, they mean a much smaller contingent of countries, rightly or wrongly. I'm sure Europeans dislike how loose we use the term, but as a US citizen, it usually means cold war boundary countries, so Germany and what was considered western Europe before the iron curtain fell. Thats been my experience. People also generally forget about Portugal and a few island nations. Its a safe bet most people mean the Nordics, France, Germany, the UK, Netherlands and Denmark most of the time, conceptually.
However to be specific, France, Germany, Switzerland, the Nordics, all have strict general requirements to have a path to citizenship. I don't think the average US citizen would be able to meet them.
By georgeecollins 2025-10-2823:341 reply That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California. But I accept that could be the true reason.
By no_wizard 2025-10-2823:37 >That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California.
That alone is enough to put most people out of grasp of doing this, for a multitude of reasons, of which not having the capital is only part of the equation, as you would also need to have a suitable investment on the other side to put said money, not a promise. I'm sure there are other nuances involved too.
Thats before the fact that the cost of a house in California would price most people out of the equation to begin with.
By keybored 2025-10-2917:51 > If this were true, the number of Americans I have known who
People only live in one unvarnished (more or less) reality at a time. Americans live in America and get told stuff about “Europe”; Europeans live in Europe (or their respective countries if we want to get anal about it) and get told stuff about America. Only a very very small number of people get to live in multiple places and for long enough stretches of time to be able to compare them pretty fairly.
In what kind of dream reality do people come to have such perfect (I’m being hyperbolic) information about other places that they then are able to base their move-or-not decisions on? This is just not reality. People know what their own place is like. They “know” other places through propaganda, mostly.
But Americans are so propagandized that you have to teach them about their own propaganda.
By alemanek 2025-10-2916:47 All the benefits OP lists are at or below mandated minimums for Western EU countries. It’s trivial to lookup and confirm for yourself.
In software the money difference you still end up ahead of where you would be on an equivalent salary in the EU. Also last time I was considering a move to the EU job market was weaker than the US. Also you still need to get all the necessary work visas which aren’t automatic. Even as a dual citizen I can’t just show up to work at a company in the EU.
High fractions of Europeans speak English, eg Poland has 50% of population speaking English (for those of working age it’s probably much higher) whereas the fractions of Americans speaking non-English European languages is much lower (0.25% for Americans speaking Polish).
If 50% of Americans spoke Polish by the shake of a wand, I bet there’d be more Americans in Poland than Poles in Poland.
By georgeecollins 2025-10-2823:401 reply OK, but by that logic lots more USA citizens should be moving to the UK, Ireland, Spain than the other way around. That's just not the case, at least until very recently.
I could see that the appeal of Ireland can be increasing and Poland sounds cool. I'm not saying that the USA is great, it has tons of problems.
Net migration US/Ireland is positive to Ireland.
UK numbers yes, though maybe gloomy weather plays a role? Just kidding. That said, Brits are slightly more likely to move to Spain than US despite it being a tiny country in comparison and not necessarily easier to move to after Brexit.
Spain, not sure. It’s tricky to compare since non immigrant Spanish speaking population in US is probably significantly lower than Spaniards speaking English. But yeah, you probably have a point on that one.
By trollbridge 2025-10-291:363 reply America has around 42 million fluent Spanish speakers (based on # that speak Spanish at home).
Spain’s entire population is 48 million.
I have never met an American that migrated to Spain.
Your wand would also need to erase the reason people speak (or don’t speak) the languages they do, otherwise what you said would already be true for the UK, Australia, etc.
Would it? People don’t exclusively learn English to migrate to the US.
What language do you think Germans and Spaniards use to do commerce with each other? There needs to be a common language, there’s no bandwidth to learn all languages, so due to historical and modern reasons, English prevailed.
Re Australia, Australians have highly preferential options to move to US which is not reciprocated.
By LastTrain 2025-10-2913:05 So you are already saying it isn't just language, your wand would also need to erase "preferential options" facilitating the direction of migration. Which is what I said but in different words.
By trollbridge 2025-10-291:36 Same for NZ, Canada, UK…
By stronglikedan 2025-10-2821:342 reply > This is why quality of life in Europe, is so superior.
That's very subjective, and I would rather have my freedoms instead of your/their liberties, thanks!
The only major differences I can think of are gun ownership and abortion. What freedoms were you referring to?
By kQq9oHeAz6wLLS 2025-10-2822:50 [flagged]
>> University is expensive as fck.
While healthcare is brought up all the time this is usually ignored. The idea of parents saving a 'college fund' for their child is something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).
> something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).
Like most things learned from movies, you're not getting the full picture. Most US universities charge on a sliding scale based on family earnings. For larger universities, tuition can actually be free depending on parental earnings. At the extreme end, some Ivy League universities like Harvard have $0 tuition for families earning less than $200K/year.
We also have community colleges and state-run universities with subsidized in-state tuition. It's still more expensive than free, but the tuition is in the range where as long as you're smart with your degree selection the ROI of getting the degree will more than make up for any loans you have to take on. That said, you can get yourself into trouble if you take out loans to study for a degree that doesn't translate to a job.
By tptacek 2025-10-2820:07 And, in fact, the median amount of college debt for adults who don't hold degrees is sharply lower than the overall median (it's around $10k). It's not nothing, but it's also not a life-changing amount of debt.
(By way of policy bona fides: I'd strongly support forgiving student debt for all for-profit schools, but would oppose forgiveness for degree-holders from universities, which would be a sharply regressive policy).
Implicit in all these stories is that "education" means "access to highly selective universities". In-state tuition at Directional State University is much more manageable.
Not really. I went to a public land grant university 20 years ago and paid about $12k a year in state. That same university is now $44k per year.
Both my kids went to UIUC and we paid about $15k/yr, and both my kids graduated within the last couple years. And UIUC isn't a Directional State University; it's the flagship of the UI system. You can just look this up: tuition numbers aren't secret.
Ok I will. This claims the cost of attendance is $36,930-$42,310 per year:
https://www.admissions.illinois.edu/invest/tuition
This claims $21k per semester:
https://cost.illinois.edu/Home/Cost/R/U/10KP0112BS/15/120258...
You just cited the out-of-state cost of the flagship state university in Illinois as if it were the in-state cost of a Directional State University in Illinois. Again: you have an argument here that depends on people not Googling list prices (the prices that nobody actually pays) and seeing what they actually are.
No I didn't, that is in state, it's right there on the page.
Directly from the page:
> Illinois Resident
> Tuition & Fees: $18,046-$23,426
> Food & Housing: $15,184
> Books & Supplies: $1,200
> Other Expenses: $2,500
> Total: $36,930-$42,310
I literally looked at the exact school you used in your example and you are just wrong
Couldn't have been clearer that I was referring to tuition, including the fact that I said that specifically upthread.
Well then as long as the kids don't need housing or books or food or to pay the other fees they'll be set. Luckily those are all optional
They in fact differ wildly between students and between colleges! UIC and NIU are commuter universities where students generally don't live on campus. Students at UIUC live in campus-provided housing for their first year, but not generally for subsequent years. Everybody, whether they're in school or not, pays for housing. So no, the cost comparison you're offering here is not very useful.
Shortly later
I also think you might have to ask around to find a student paying full price for books.
By kiitos 2025-10-2918:56 take the L, it's ok
By Forgeties79 2025-10-2819:37 I set up an education fund for my kids when they were 2 and I still can’t be sure it’ll be enough. It’s really bad.
By arwhatever 2025-10-2820:37 Perennial “What Armenians should know about life in America (2014)” from days of HN past https://news.ycombinator.com/item?id=22777745
And which today must be read via internet archive
https://web.archive.org/web/20200404172130/https://likewise....
Basically explaining to Armenians at home why their relatives who moved to America don’t send better remittances back home despite their $X pay rate. Here’s why …
> University is expensive as fck. Health care is expensive as fck.
University isn't near as big of a problem. That's not something the blindsides you like health care expenses. Nobody is making you spend $300k on university. Got my engineering degree at a public university for ~$100k in total and had it paid off 5 years after graduation. But a $195k hospital bill is something I'd never be prepared for. Nobody chooses to go to a hospital.
By tsimionescu 2025-10-292:331 reply For $100k, you could pay the tuition fees for 4-10 (depending on exact school choice) of the best universities in Europe outside the UK combined - and I'm talking of the foreign student fees, not the much lower tuitions that EU citizens get.
That's great, but you've missed my point. I get payed more in the US, so I can afford the extra cost for university. And once that university bill is paid, I can pocket the extra.
There are still reasons why high university costs can be a problem. Teachers, for example, don't get paid near enough to be able to cover university costs in a few years like I was able to. But becoming a teacher requires just as much investment.
But even then, the cost of college loans is far more manageable for even teachers than an unexpected $195k visit to the hospital. University cost is a problem in the US, but I don't think it's comparable to the problem we have with health care costs.
By tsimionescu 2025-10-3013:281 reply That's true for a handful of jobs, but not so much in general. Sure, in CS and medicine and Wall Street you get salaries that are huge compared to typical EU salaries. But this doesn't apply at all to all white collar work - certainly not at the 10x - 100x difference in college tuitions.
Not to mention, I also gave the example of the tuitions for a Swiss university, and Swiss salaries are typically at least comparable to US salaries, even in CS.
> certainly not at the 10x - 100x difference in college tuitions.
The full time tuition rate at the university I got my engineering degree from is currently $11k /yr. I can't imagine that's even 10x a typical EU university - let alone 100x.
My local community college's full time tuition is currently $5.8k /yr. Either way it's a lot of money, but lets not exaggerate things too far. We're worried about affordable access to education here - not getting everyone into Harvard.
By tsimionescu 2025-10-3019:181 reply The tuition rate for any public university in France (for EU citizens) is €250/year. So your tuition was not 100x, it was just 44x what you'd pay for those.
Let's say that's unfair, since the state pays your tuition (though this is the common experience for most French students!). In Amsterdam, one of the best universities in the world, TU Delft, charges €2k/year tuition. Your tuition was less than 10x this, true, but not that far from that. Also, for a common 4 year bachelor's degree, that's €8k in total - your $100k total is more than 10x this.
By CivBase 2025-10-311:29 My $100k total includes much more than tuition. I probably had ~$40k in actual tuition.
Again, it's too much. But it's not comparable to emergency medical bills without insurance.
By j-krieger 2025-10-2821:34 > University was cheap or free
Ha! I wish. It's not free. You will pay the same that Americans pay for Uni over your life many times over since tax rates in the EU are really high. Healthcare isn't exactly cheap either.
And everything you wrote is just the result of decades of prosperity that are now coming to an end. This will be a shock for many.
By zajio1am 2025-10-2912:41 > Healthcare is cheap
Is it? I pay 13.5% of my income as healthcare 'tax' for public healthcare. Overall, it is cheaper than US healthcare (as a percentage of GDP), but individually it is still a significant expense.
By BobbyTables2 2025-10-2823:471 reply In tech, 3-4 weeks vacation not usual for senior roles. Often “unlimited” but in practice far more than 10 days. That might be for new/inexperienced hires in crappy companies.
For comparison, 4 weeks is the absolute minimum for any full-time worker here in Australia, and that’s less than people in the UK/Europe get.
By BobbyTables2 2025-10-311:40 Wow, sounds nice. Started at 2 Weeks at beginning of career. Had even a bit less due to 3-5 days of mandatory shutdowns during Christmas time.
By uyzstvqs 2025-10-290:35 It's evident that you're saying this as a non-European, as there's no "European healthcare".
Many (most?) European countries have private healthcare systems. Switzerland has it and offers some of the best healthcare in Europe and in the world. Similar systems work great in many other European countries as well. The problems with American healthcare are not because it's market-based, it's because how that market is managed.
Some other countries have public universal healthcare. It can work well, but it requires a high-income country with both wealth in abundance and significant government efficiency. It only truly works well in Scandinavia so far. This is not "socialist healthcare" as some will dubiously claim, it's sort of the opposite, which is why it works.
By throwaway0123_5 2025-10-2819:042 reply > So like these are less serious issues if you are paid an extra $1-200k/ year
Ok but to be fair most people in the US aren't making "extra $1-200k / year" over a person in Europe. They aren't even making $100k / year to begin with.
By mothballed 2025-10-2819:064 reply Almost 40% of the USA is on medicare, medicaid, or entitled to VA benefits or military healthcare. It's only a narrow majority that depends on unsubsidized private healthcare, and those people skew in the upper income levels.
By jkartchner 2025-10-2819:422 reply You believe the top 60% of the nation skew in the upper income levels? Median pay is $61k a year for the entire country. The top 1% skews to the upper income levels. The rest are charged $30 for a dose of aspirin and can't afford it.
There are numbers on this, and their comment is probably directionally correct; the median household with private insurance earns more than 400% of household FPL (KFF). By subtracting Medicaid and fixed-income seniors from the picture, you are sharply biasing the median upwards.
I would say if you ignore the poorest 40% of the population, you've got quite the slim margin to go before you are no longer talking about "Most" Americans, which the OP was pretty explicitly talking about.
He was saying "Most people in the US" don't make 100-200k more, and that they probably don't even make 100k. This was in response to the generalization that "people from other countries ... underestimate how well paid people in the US often are".
Now there was talk of getting the political motivation to change things, so I guess everyone is assuming Medicaid/Medicare/VA recipients don't want to change the system, but that wasn't really established, nor was that really being refuted.
I don't think I could be any clearer that I am (1) talking about Americans with private health insurance and (2) not making a normative judgement about which system is better, but rather a positive claim about the political challenge of changing the system (its large group of stakeholders who are better off under it).
By gusgus01 2025-10-2821:45 Oh I'm clear about the demographic you are trying to discuss, my point was I'm not sure this all stemmed from a discussion about that specific demographic. It started at "people in US", then went to "most", then by the time you got involved in the thread you were defending a statement about people with private health insurance.
I could have made this comment at the level where it went off the rails, but I thought making it at the leaf level would help everyone involved see the deviation between what was said and what was being argued.
People in the US can't afford aspirin? Where do you live? It's just not true
They are referring to the price that hospitals charge for aspirin, which is massively inflated, not the off the shelf cost of aspirin
Where in their comment do you see them referring to hospital care?
The article, talking about a patient's hospital visit, mentions "the $31 low-dose aspirin, of which they'd given him four."
By tptacek 2025-10-2823:29 Ahh, good callout. Thanks!
By GuinansEyebrows 2025-10-2821:121 reply i think in this case, if you're at all familiar with what US hospitals charge for the small stuff, it's a safe assumption that when someone says aspirin costs $30 a dose, they're not talking about buying it at a CVS. of many folks on hacker news dot com i trust you to bridge that gap instead of nitpicking!
That's an odd argument to make in this thread, because whatever the drivers of burdensome consumer health spending are, they're not overpriced hospital aspirin.
By GuinansEyebrows 2025-10-2821:51 maybe so; it's a symptom, not a cause.
By davidcbc 2025-10-2821:59 I'm capable of understanding context.
So what about this? It is a question, not meant as a counter.
Although I have to say the rosy picture some paint here about the high incomes is counter to anything I ever heard - and saw, although I left the US in the early 2000s, after having lived there for almost a decade (still mostly paid from Germany, never ready to make a complete move).
"Medical Bankruptcies by Country 2025"
https://worldpopulationreview.com/country-rankings/medical-b...
"Healthcare Insights: How Medical Debt Is Crushing 100 Million Americans"
https://www.ilr.cornell.edu/scheinman-institute/blog/john-au...
By the way, Europeans don't quite all have a "nationalized healthcare system". Germany, for example, has "Krankenkassen" but also private insurance, and the "Krankenkassen" are private organizations.
We pay health insurance and get to choose the provider, those with higher incomes can switch to complete private insurance. We also have lots of our own problems and increasing costs because of immigration but more so aging population.
However, I personally know several people who had severe illnesses for a long time, and their normal "Krankenkassen" insurance never made any problems. One person with plenty of money, whose wife was dying, even asked US medical experts if he should come to the US with her, and those US experts said he should stay where he is, the German univ3ersity hospital right next door had some of the leading therapies in the field. She lived five more years instead of dying after less than half a year with the standard therapy, every single expense paid for with the standard insurance, additional private insurance unnecessary. Similar with my stepfather, who had soooo many severe conditions, and yet every single item down to the special medical bed brought into our house so that he could finally die at home was paid without question.
The problems are with more mundane expenses, e.g. glasses, or the dentist, where only some of the treatments are covered. The really expensive illnesses seem to be better covered than the more common and much simpler problems.
Careful there, thats a rightwing propaganda point. Immigration into an aging society does not raise healthcare costs, it lowers it. See https://archive.is/XxfTH (and note that this is a NZZ article, a right-wing publication by now, so not slanted towards being immigration friendly).
By epistasis 2025-10-2821:44 Who's not being allowed to criticize immigration? Critique of a critique is pretty much the furthest thing from "disallowing" critique.
Sure, but it helps to not misrepresent the facts while you do it
Misrepresenting???
The costs DID increase.
I did not try to make a political statement, what happened here, anyway???
I have no idea what there is to defend - even if you assume they will all get high-paying jobs some ay, for the first few years costs will increase while they either learn the language, are not allowed to work (status pending), or get minimum wage jobs (food delivery and parcel services at least in my city now is dominated by immigrants).
Even with your most positive outlook, initially there will be lots more people and the same system (number of doctors), and the numbers of payers increases slowly.
I even wrote "but more so aging population", conveniently overlooked in this strange politicized discussion.
I am NOT against immigration!!! Don't make stuff up people.
By onli 2025-10-2911:20 You are misreading this exchange. You just got a fact wrong, but thus repeated a lie that is planted often by nazis - and it's easy to get mislead. Anyway, you did not get criticized for an imagined stance on immigration, but those answers are to a comment I assume you missed, the one by nxor?
You wrote, incorrectly:
> We also have lots of our own problems and increasing costs because of immigration
As the NZZ article explained, health care / Krankenkassen are the area where it is the clearest that immigration is an economic benefit. Look at statements like the section title "Krankenkassen profitieren", followed by "Ein grosser Profiteur der Zuwanderung sind dagegen wohl die Krankenkassen." and the ending paragraph of said section:
> Laut dieser Analyse gab es in diesen sieben Jahren einen Wanderungssaldo aus dem Ausland in Höhe von 4,7 Millionen Menschen in das System der GKV. Für das Jahr 2019 ergab sich daraus eine Entlastung der GKV über etwa 8 Milliarden Euro (umgerechnet 0,6 Beitragssatzpunkte). Seit 2019 hätten sich die Rahmenbedingungen aber deutlich geändert, heisst es dazu von der TK.
So the numbers we have do not support that part of your statements. And I'm not aware of newer numbers that say the contrary - the recent cost increase sees completely different reasons for example, as in https://www.mdr.de/nachrichten/deutschland/panorama/krankenk..., the "but more so aging population" part of your comment fits there.
By 86769928329709 2025-10-292:441 reply [flagged]
> Of course, far-left demagogues like you would advocate for flooding a country with uneducated criminals
We've obviously banned this account. Please stop registering accounts just to keep breaking the guidelines. It's boring and a waste of everyone's time.
By onli 2025-10-297:46 Thanks!
By yieldcrv 2025-10-2819:31 And while European countries have various forms of nationalized welfare, their salaries are so low that they would be automatically eligible for the US' welfare too!
our blocs aren't that different
except in the US middle class and upper middle class
It's hilariously out of touch, but it's what you should expect from the HN bros. They live in a bubble.
I'm from the eu and earn far less than these American techbros do, but far more than my American friends who work normal jobs. They work at the DMV, a supermarket, or general office work. You know, normal people. The vast majority.
Yeah, just because the US has 300 billionaires that does not make the median salary anywhere near six figures.
In fact it's quite low, somehow people are expected to survive on several thousand a year, after the rent, utilities, transport costs are all paid.
https://www.fool.com/money/research/average-us-income/
These are official stats, but unofficial employment puts the number lower:
https://investorshangout.com/carlyle-group-unveils-alarming-...
By tptacek 2025-10-2821:06 It helps to understand the difference between the mean and the median.
By georgeecollins 2025-10-2823:43 I agree I am not in any way representative. But the forum is hacker news, not my day at WalMart.
By ilegitmadethisn 2025-10-2819:43 [dead]
By nawgz 2025-10-2819:35 > people know it is a problem but ideologically they really disagree about what to do about it
Can we really say this is true about individuals in the US?
I think it's pretty clear the propaganda machine has successfully privatized health care to the great detriment of the populace and have the clamps on it.
After all, if you told everyone you had a solution where insurance rates would be cheaper, their healthcare system would cost less overall, and the health outcomes would be superior, they would all be like "sounds great". Then, when you reveal this solution is the complete destruction of the insurance "industry", insurance payments are "tax", and the health provider is the government, they would balk, scream about socialized healthcare, and say how they don't trust the government.
That's a trained response, not a real thought.
Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
So when you're talking about how bad the American system is, you're really talking about a minority of its users. That doesn't make everything OK, but does highlight the political difficulty of enacting seemingly-popular changes.
> about how bad the American system is, you're really talking about a minority of its users
It sure seems that way if a wealth family with top level insurance can still get bankrupt by medical bills. Examples of that are right here in comments.
By TheOtherHobbes 2025-10-2822:251 reply No need. It's a known phenomenon.
https://www.npr.org/sections/health-shots/2022/06/16/1104969...
https://rooseveltinstitute.org/publications/medical-debt/
https://www.marketplace.org/story/2024/03/27/health-and-weal...
As for income distribution
https://worldpopulationreview.com/country-rankings/gini-coef...
State GDP figures are skewed by high earners. The US is massively and systemically unequal, with far less economic mobility than the EU.
By tptacek 2025-10-2822:30 I asked a question about the comments on this thread. This isn't responsive to that question.
By wing-_-nuts 2025-10-2820:392 reply >the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
If you had said the median tech worker? I might have believed you, but the median family? No way.
The median family of 4 with private health insurance has a household income of around $115k not counting the gross cost of their employer-provided health care. Remember: being on private insurance puts you in a cohort that:
* Excludes everybody on Medicaid
* Excludes fixed-income seniors on Medicare
* Makes it overwhelmingly likely you have subsidized employer-covered health insurance.
Figure your employer "covers" half the gross cost of your $24k/yr health insurance (they aren't, really: that's money they'd be paying you directly without the distortion of employer-provided health care). Do the take-home pay math. Put them in, like, Ohio, or Iowa, or Colorado; just not SFBA or NYC.
Now move that same family to Manchester, take the wage hit for moving to the UK labor market, and work out the take-home pay. They'll of course pay $0 for the NHS.
Are they better off or worse off?
I'm not valorizing the arrangement, I'm making a point about how political tractable changing it is.
By linehedonist 2025-10-291:24 You’re moving the goalposts. How many families have private insurance? Considering both families with and without private insurance, is the median family better off in the US?
Idk, speaking as a big Medicare-for-all supporter, this would definitely explain why MfA always polls well at first, until people start asking if they can keep their current plan. I know at this point in the debate we’re supposed to write those people off as either innumerate, a minority, or too risk-averse for their own good, but honestly if it turned out that that stat was true, that would explain a lot.
And it would be exactly the kind of political engineering minmax scheme large corps in the US are great at: petition legislators to cut regulations so you can cut costs and maximize profits, but keep juuuust enough of the right perks in the right places so that a slim majority of people in Wisconsin, Michigan and Georgia oppose shaking things up.
The people who want to keep their own plan are almost definitionally not innumerate! They would be worse off financially under M4A.
That doesn't make M4A bad policy (I think it's bad policy for other reasons), but it does take "people are being irrational" off the table in a discussion like this.
By supertrope 2025-10-2821:48 Even if you keep your plan it's getting enshittified every year.
It's that time of year again - enroll for 2026 benefits. My employer raised employee premiums by 10%, raised the deductible, added more administrative burden such as "step therapy" (the insurance company denies your claim for a drug until you've tried a cheaper but less effective drug, even if you've already done "step therapy" while on another health plan!) Your employer will change the plan premiums and structure every single year. They can lay you off, exclude expensive drugs, exclude doctors, etc. Some specialties like anesthesiology and psychiatry are usually not in network. In extreme cases an employer can change health administrators mid-year and your deductible will reset.
https://www.pwc.com/us/en/industries/health-industries/libra... https://kffhealthnews.org/news/article/workplace-health-insu...
By fredophile 2025-10-2821:231 reply Why does Medicare for all mean I can't keep private health insurance? There are countries that have systems like this in place.
There are countries that have single-payer systems and widespread supplemental insurance. But if you universalized Medicare, you'd immediately do at least two big things to the market:
(1) You'd eliminate the system of advantages and supports that cause employers to offer private insurance, which is where most people get their insurance from.
(2) You'd create a huge adverse selection problem --- the more effective/useful Medicare is, the fewer families will want to spent $24k/yr on private insurance, meaning the families left on private insurance have a reason to want it, meaning the composition of the risk pool would shift dramatically.
Like, if we ever did M4A, we'd probably end up with a widespread system of supplemental insurance; we already have it with Medicare! But that's not the same thing as keeping your existing plan.
By fredophile 2025-10-293:491 reply I don't understand the obsession some people have with keeping your existing plan. Lots of people can't keep there plan under the current system. Insurance companies update their plans regularly. Sometimes they remove plans or exit markets entirely. An existing plan will get small changes over time. If Theseus has an insurance plan for 10 years and the insurance company makes changes every year can we still call it the original plan of Theseus?
If M4A plus supplemental insurance gives me about the same coverage I have now for a reduced total cost that sounds like a win to me. Even if it ends up costing me the same amount the net improvement from everyone having access to basic health care would still be a win.
By tptacek 2025-10-294:14 Every policy is easy to enact if you just define away anybody who'd object to it. But, more importantly: it's unlikely that M4A by itself (let alone with the supplemental plan you'd likely end up with) would reduce your total cost!
By dragonwriter 2025-10-2821:141 reply > Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
The US spends nearly as much in taxpayer funds as a share of GDP as other developed countries (and vastly more on a per capita basis), with even more in private costs on top of it. It is simply dishonest to say that the "wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays", because neither the US wage premium nor any lower tax burden are attributable to differences in healthcare systems, but rather are in spite of the far greater burden of the US healthcare system.
OTOH, it is true that a major challenge is that people respond with this line to any proposed major structural changes to the US system.
Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance. That family would likely (in fact, almost certainly) be worse off in a single-payer system.
I'd appreciate if you'd avoid using language like "simply dishonest" with me in the future. It's easy to tell me I'm wrong about something without accusing me of commenting in bad faith. This is in the guidelines. Thanks in advance!
There is a middle ground here. Many European countries do not actually have single-payer, but still perform better than the US.
It's a bit out of date now but the book The Healing of America found that Germany, France, and Japan had world-leading healthcare results, measured by things like survival time after major disease diagnosis, but spent much less of a percentage of their GDP on healthcare. None of them had single-payer. Their systems were pretty close to the ACA, with private insurance companies and a mandate.
They were also different than the US in certain ways. Probably the biggest was a national price list for services. A lot of healthcare isn't really a functioning market; in many cases you're in no position to comparison shop. A result of the price lists was that doctors made a lot less money, but this didn't seem to affect quality.
Other differences included: no claim denials allowed for anything on the price list (which saves a lot of administrative staff), effective national digital records systems (ditto), and the insurance companies had to be nonprofits.
All three countries actually got better bang for the buck than Canada's single-payer system. Japan was the cheapest, spending only 5% of their GDP on healthcare, despite an aging population of heavy smokers. Germany was the most expensive at 13% (compared to US 18%) but covered things like week-long visits to the spa for stress relief.
The author did a spot check on the user experience by seeing a doctor in each country for a shoulder problem, and those three countries worked out really well for him. In Japan the doctor offered surgery the next day, at a very modest cost. They did make do with simpler equipment; the MRI machines were bare-bones but they got the job done and a scan cost $100.
By tptacek 2025-10-2823:48 I agree. I'm a fan of the non-single payer European systems, and, especially, of the Australian system. Nobody can look at the American system and say we've got it right! I do like the private->Medicare compromise we have, but we also have the original sin (a strange and I think unintended consequence of the mid-century tax code) of employer-sponsored coverage.
By dragonwriter 2025-10-2821:261 reply > Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance.
Yes, you can just do the math, and changing nothing about the US except transition to a European style universal system, the median family would face lower aggregate tax, out-of-paycheck, and out-of-pocket costs than they do now, with less health insecurity around unexpected events (either health or employment), unless the tax increases necessary were deliberately and perversely targeted to avoid that.
That’s a direct consequence of the difference in the macro-level costs: they aren’t separate, orthogonal concerns. People just have a hard time accepting that the US health care system is structurally constructed right now to waste vast hordes of money preventing people from accessing health care, but that’s exactly what it does.
Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.
I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
By dragonwriter 2025-10-2821:431 reply > Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.
Not tax penalizing non-capital income is sort of an essential reform in the era of increasing automation anyway; I'm not sure what point you are trying to make there. The average middle income family isn't making a substantial share of their income in forms taxed as long-term capital gains, so that seems...unrelated to the focus of your argument.
> I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
It does both (particularly, in the “actual care” angle, as regards low-benefit, high-cost measures near the end of life.) We have a system based on denying and economically incentivizing younger people to avoid and defer care, but then doing much less of that with (most of) the elderly.
You're contradicting yourself. You took me to task earlier for factoring in the wage penalty for working in the UK market --- fair enough, though really I'm making the simple descriptive point that people in the US are accepting of a dysfunctional status quo in part because they would be worse off in Europe.
But taxing capital gains at the level of ordinary income would be an immense change our tax code. All sorts of things the broader economy would change as a result. If you accept Sanders plan, you're not holding to your original constraint of changing only the health financing system.
I want to be clear that I'm not stipulating that families would be better off under M4A if you didn't do this: I still think your argument has the fuzzy end of this lollipop. I think it's unlikely that you will come up with a set of numbers for any proposed single-payer health system that leaves the median family with private health insurance better off on a take-home basis. I'm making a strong claim, so you should be able to knock it down straightforwardly if I'm wrong, and I'm interested to see if you can.
By TheOtherHobbes 2025-10-2822:381 reply The counterargument is simple - it works in other countries.
Other countries have healthcare systems that don't generate medical bankruptcies, and don't put a slaver's chain around the necks of employees who risk financial destruction if they have to give up an employer-funded plan.
You're essentially arguing that 500k medical bankruptcies every single year, out of a population of 340 million, is a small price to pay for an imaginary financial benefit that you're convinced exists, for some loosely defined demographic, but which you've failed to quantify.
This is, very specifically, the problem that destroys your argument.
Some people in the US are better off until they aren't.
One serious medical crisis - like an extended bout with cancer - is enough to wipe out the benefits, and leave people who used to be prosperous out on the streets.
Literally. Not as an exaggeration, not as rhetoric, but as a cold, hard reality that affects half a million people every year.
By tptacek 2025-10-2822:44 You're responding persuasively to somebody's argument, but it isn't mine. I'm talking about the large cohort of American voters who would be worse off under a single-payer system.
By teaearlgraycold 2025-10-2819:081 reply I don’t know if the median American would be worse off with a European style system. Certainly the 1% don’t need it. I’ve been on the Google health insurance before and it made me feel like I had $10 million in the bank.
By teaearlgraycold 2025-10-2822:03 I've been lucky with my health so I don't have a huge list of interactions:
* Free tele psycho-therapy. Not sure what the limit is but it's >= 2 hours per week. I even cancelled same-day once with no fee. The quality of the care was also very high.
* I developed wrist pain from typing, holding a Steam Deck, starting pull ups. I was able to see a physical therapist at the Google office (through an embedded One Medical) after 1 week. No referral needed. Saw them once per week for 5 weeks paying $20 co-pay each time. They fixed my issues permanently.
* I also occasionally used the Google One Medical locations (and public ones) for injuries from a low speed bike crash, vaccines, etc. Don't think I ever paid more than $20 for anything. On a Google income that amount is completely inconsequential.
By ilegitmadethisn 2025-10-2819:11 [flagged]
I think you are underestimating the number of Americans who make less than what Europeans make.
In both systems, the upper X% can afford it. But it makes no sense to focus on that. What matters is how many don’t have access.
That number is much larger percentage-wise here than in Europe. And it will only increase the way things are going.
By georgeecollins 2025-10-2822:34 Probably true. But if you think about who votes, professionals and home owners have much higher participation rates. I am not saying this is good.
By danpalmer 2025-10-2823:40 As with many things, in the US if you're part of the privileged minority you do well. The top 10% of earners in the US earn a lot more than the top 10% in Europe – that covers tech, high end knowledge work, that sort of stuff.
But the bottom 90% do badly. Society is very divided, and most people lack social mobility, they lack a voice on the national and international stage, they lack the security that either a social safety net or high pay would give them.
The UK is similar, although much less pronounced. I moved to Australia about 18 months ago and society here is much flatter, the difference between the top 10% and bottom 10% is much less. There are still problems here, it's not a utopia, but it's very noticeable how most people are struggling less, and how the top 10% of earners aren't living that different a life.
By banku_brougham 2025-10-2821:001 reply Wrong - sorry. The reason is that politically the US public is very skillfully managed from above via divide and conquer strategies and beaureaucratic techniques (i.e. identity politics, gerrymandering voting districts). The public polling is very clear about US citizen preferences, but US Govt policy is rarely aligned that way.
By tptacek 2025-10-2821:04 No, it's not clear at all: it's been tested in actual referenda and failed. What's actually happening is people don't intuitively grok the distinction between opinion polling, where questions are asked in the abstract (and often in the best light preferred by the org sponsoring the poll) versus actual voting, where the questions are very specific and include details like "your taxes will increase by X%" or "you will lose access to your current insurance plan".
Oddly enough the big rhetorical push against a universal system from prior decades was about "death panels" deciding what care somebody would get. And guess what's happened with insurance? Death panels!
The propaganda spin on the health care system in the US has been on overdrive ever since Hillary Clinton wanted to implement some reforms in the 1990s, leading to absolutely massive resistance to any change whatsoever. Even the changes implemented by Obama, which were a HUGE improvement in access, barely made it across the legislative line, and dismantling that access to the health care system has been a huge rallying cry for one of the major political parties. I won't say which one because mentioning that fact results in people turning off their brains and downvoting.
The US healthcare has optimized for availability and higher access to the most treatment options. This does not mean evenly distributed treatment options, but that people have the chance to get access to things more quickly.
And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.
By rkomorn 2025-10-2819:48 > And guess what's happened with insurance? Death panels!
The insurance death panels already existed at the time. It didn't even happen after.
That's what made the whole thing so ridiculous in the first place.
>>> And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.
As an individual who has lived in multiple countries in three continents, I dispute that “the care most people get is better than adequate”. Perhaps better than the world average, but certainly not better than in most first-world countries. And that’s not even counting the impact of delayed decisions and denied care, and the stress of dealing with the system overall.
And if you’re looking for more than anecdotes, there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change.
> there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
Americans aren't dying earlier of diseases that are solvable with a doctor visit, surgeries, pills, or other easy medical interventions. The medically related early deaths are primarily because of overnutrition and lack of exercise leading to pre-diabetes, diabetes, high blood pressure, and heart disease. That comes from public policy mandating car dependence throughout society and huge subsidization of empty calories in the food system. Overeating and lack of exercise are problems that have been stubbornly resistant to the medical system's efforts to change behavior. There's also other heightened early death risks like car crashes, drug overdoses, and suicide, but few of these deaths could be prevented by increased access to the medical system.
>While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change
This ignores the outsized influence of lobbyists, especially post Citizens United.
The majority (depending on which polls you cite, seems to range anywhere from 57% to over 70%) favor a universal healthcare solution for all citizens. Yet like many other majority opinions, this doesn't translate into legislative action in that direction, in large part thanks to lobbyists and dysfunctional partisanship. None the less policy is not reflecting the majority.
What lobbyists are opposed to universal healthcare?
It seems to instead be merely a wedge issue in culture war. Republicans firmly oppose it, Democratic politicians fight for it, and apparently voters don't care enough to advocate for what they say they want in polls.
Off the top of my head:
- The Partnership for America's Health Care Future
- American Hospital Association
- U.S. Chamber of Commerce
- Various lobbying organizations related to private insurance and adjacent systems, like pharmacy benefit management organizations
Politico has a great article about the Medicare For All fight[0]
The opposition spent hundreds of millions of dollars fighting it.
[0]: https://www.politico.com/news/agenda/2019/11/25/medicare-for...
By epistasis 2025-10-292:59 Thanks for this article, it's great! Back from before Politico became so one-sided partisan...
Life expectancy tells you basically nothing about the quality of health care in the US. It's dominated by car accidents, homicide, and then CVD --- but CVD varies dramatically across the United States (from states in the south with drastically worse CVD outcomes to states in the north with outcomes on par with the Nordics) despite the same health care structure across all those states.
There are plenty of other countries with car accidents, homicide and cardiovascular disease. They also do worse than the US in life expectancy.
By tptacek 2025-10-290:40 Do you need a cite to back up the analysis I just gave you? Because it will be easy to provide.
Like Ticketmaster, health insurance companies get paid to be the "bad guys". This is a reasonable function since Americans can't seem to understand that someone must decide where limited resources go. However, there's no reason their cut should be so large.
Their cut is in fact very small; it's around 6.5% of total US health care spending.
I don't know how to answer that. I think the system is pretty inefficient in a variety of ways. If you universalized Medicare, eliminating insurance entirely, you'd get costs somewhere in between Medicare's current admin overhead and the overhead of private insurance (you mechanically would not get Medicare's current overhead, because the majority of your customers would have much lower claims than Medicare's all-seniors patients do, and overhead is a ratio).
But the largest inefficiencies are all on the providers side. We simply pay practitioners too much, enforce artificial scarcity of practitioners, and prescribe too many services.
So if we're talking about "The American System" as a whole --- which is what the thread is about --- it behooves us first to consider the question "how much better would things be if we simply zeroed this category of expense out". The answer is, to a first approximation, we would get a 6.5% price break. I would not drive even a couple blocks out of my way to get a 6.5% price break on a pack of chicken breasts.
> But the largest inefficiencies are all on the providers side. We simply pay practitioners too much
I agree. The complex insurance billing system enables his by obfuscating prices and limiting ability to comparison shop.
By tptacek 2025-10-2821:43 That's true, but it's a problem single-payer doesn't fix; that's my big issue with it (it locks in rapacious rates and preferences for the health provider industry, making them palatable to consumers by hiding the payer).
By epistasis 2025-10-2821:25 The complexity is far higher than credit card processing, including extensive price negotiation with individual health care providers. Though we call it "insurance" it's just as much a "buyer's club" for health care services.
Large employers (e.g. Google) are also generally "self-insured" meaning that the "insurance" component is offloaded to the purchaser, the employer of the insured individuals. In those cases, the health care insurer processes the claims from health care providers, determines if they were justified, or if the treatment/diagnostic/drug is justified by coverage determinations of the provider, etc, but the employer (e.g. Google) just pays the claims in the end too.
By epistasis 2025-10-2821:06 Health insurance companies have had their profits capped at a percentage of revenues. That means that to grow profits, they must increase revenue. Which means incentives to increase care and increase costs.
Oddly enough, all the plots I have seen of cost increases don't show a massive skyrocketing of costs since the profit caps were introduced. If anything, they have been somewhat reduced.
However a reckoning must happen at some point, health care can not consume the entire economy's efforts.
By testing22321 2025-10-2822:52 You could offer me 10x my current salary and I wouldn’t take it if it meant I had to stress and be terrified about the life of my 6 year old daighter because a company wants to make more money.
That is the definition of not worth it.
By keybored 2025-10-2822:56 A Princeton study showed over a decade ago that the policy preferences of the vast majority of Americans have no correlation with actual policies. That you put forth these completely detached theories is quite impressive.
I don’t know if this a case of ideological delusion to go along with political impotence or just the usual upper middle class playing their part in obfuscating the on-the-ground realities. Structurally the latter is more likely.
By j-krieger 2025-10-2821:33 In fact, US Americans are paid so well, the GDP per capita of the poorest state (Missisipi) is about the GDP per capita of France. In fact, the gross average wage of Missisipi is just barely lower than the average salary in Germany. Americans are paid really, really well.
> they really disagree about what to do about it
What is there to disagree with? Are there any option other than introduction of universal healthcare?
By mothballed 2025-10-2819:15 There's already a soft alternative many people use, which is the deregulation option via geo-arbitrage, go to Mexico and get the same thing for 10 cents on the dollar.
By epistasis 2025-10-2821:59 Universal healthcare is a very different thing from controlling costs.
Obamacare attempted to make the US healthcare system into a universal system by mandating that people purchase coverage, heavily subsidized to become affordable to every income level, in addition to massive expansion of Medicaid to those with the lowest levels of income or no income at all. Automatic enrollment in health insurance exchanges, even if people did not make their own choices on the health insurance exchanges, is what would make the US system universal health care.
Universal means that everyone has coverage, that the question to the patient is "what insurance plan are you on," rather than "do you have insurance." And making coverage universal has no connection to lowering costs. We need larger structural changes in the logistics of how care is delivered and how the money flows.
Single payer is another choice to be made, but that doesn't necessarily mean that health insurance is cheap, that all the care gets delivered that people want delivered, etc. Medicare is often cited as one direction for this, but most don't realize that private health insurance costs are partially high because they help subsidize the care of those who are covered by Medicare, because Medicare reimbursement rates are far lower than any of the private insurers have been able to negotiate.
Other routes are full decoupling of insurance from employment, full price controls that normalize Medicare and private insurance rates, which either make health care more free market or less free market depending on how you define those terms.
However every year that passes makes any of these reforms more difficult because administration of the costs and billing is getting more complex each year. ICD codes, PLA codes, all that stuff grows in complexity.
HMOs, like Kaiser, may provide a route towards greater simplicity of administration of health and costs.
But implementing any large change will require political buy-in of people, and when we have our current low-trust, high-misinformation political system there's been no way to make any political traction for changing anything. Until we regain a functional democracy or turn to full dictatorship, it seems unlikely that we will see structural changes that improve anything. Hell, we had Republican states actively trying to prevent poor people from receiving coverage from federal dollars. How can we ever come to terms with a change unless that sort of attitude no longer has traction?
By nkmnz 2025-10-2821:00 > ideologically they really disagree about what to do about it
I really don't understand this sentiment. It's not like the current state of the US insurance market were based on the principles of a free market. On the other hand, not coupling your health insurance to an employment contract that can be cancelled at will has nothing to do with socialism.
The United States is a democracy, but more specifically, a representative democracy. That means citizens don’t directly vote on most laws or policies—aside from certain state or local measures—but instead elect representatives to make those decisions on our behalf. The idea is that we trust them to act in our best interests.
You can probably see where the problem comes in. Take, for example, a politician who campaigns on Medicare for All or universal healthcare. To win an election, they often need massive campaign funding—much of which comes from wealthy donors, including those in the medical or pharmaceutical industries. And once in office, they’re targeted by powerful lobbying efforts worth billions of dollars from those same industries.
In the end, the issue is that politicians can legally receive millions in donations and support from industries whose interests might directly conflict with the needs of the people they’re supposed to represent.
Ultimately though, it is known by most people irrespective of party affiliation that medical costs are out of control. One recent example of this collective understanding was when the united healthcare exec was killed. Before there was even a suspect, people generally knew why he was assassinated. Most people in the U.S. have either been directly affected by the insanity that is our healthcare system, or one of their loved ones has. Those that haven’t yet, it’s just a matter of time. It’s just so pervasive.
By supertrope 2025-10-2821:07 As Lawrence Lessig put it: before the general election and before the primary election, there is a "Lester" election where donors choose who is able to mount a campaign. Candidates are effectively pre-qualified by 0.0005% of Americans. It's probably an even smaller crowd than that as that includes Joe Nobody who gives $20. Those who "bundle" $1 million in donations or write a mega check themselves have exponentially more access.
> The United States is a democracy, but more specifically, a representative democracy.
As your following explanation makes clear, it's actually an unrepresentative democracy.
There are very few countries in the world that are not a representative democracy. Switzerland is a well-known example of a country where citizens directly vote on most legislation, but in most other countries, you have a parliament, congress, etc that represents the people.
That doesn't really have anything to do with the ways in which the US is an unrepresentative democracy.
By DaSHacka 2025-10-2913:00 No, but it does with singling them out in particular.
By stOneskull 2025-10-2819:43 unfortunately, they represent a party before representing the people
By willio58 2025-10-2819:21 As stated near the end of my comment, most Americans are not okay with the system as it is. It’s legalized corruption that perpetuates the system.
For further reading, I recommend learning about the Citizens United vs FEC case that vastly increased the amount of money going to politicians, far over individual donation limits.
By quickthrowman 2025-10-2823:22 It might be worth mentioning that a massive propaganda campaign against universal healthcare has been conducted on the American public for decades by interests that benefit from privatized healthcare.
By TranquilMarmot 2025-10-2823:27 We're not okay with it, but it's so entrenched by the wealthy that the only way out will eventually be violent revolution which nobody wants.
By svobodovic 2025-10-2819:231 reply How did you come to this conclusion from the previous answer/comment?
By willio58 2025-10-2823:57 The problems with the electoral system are just one symptom of a deeper issue: unlimited political donations. The wealthiest individuals in the world can funnel endless money to politicians through Super PACs, and that influence shapes policy more than an individual voter ever could.
Even if we magically fixed the electoral system tomorrow, the results would be superficial. Sure, we might see more Democrats in office—but if they’re still beholden to massive, uncapped donations, how can we expect them to enact real, meaningful change?
This problem with money in politics is not something that only affects one party. It's a systematic issue that needs regulation. Without real regulation on money in politics, everything else is a band-aid on an open and festering wound.
By mothballed 2025-10-2819:39 Not Americans OK with it, just that right-wing wants hypercapitalist low-regulated helathcare while left-wing wants basically "free"/communist health care.
Both of which are infinitely better than what we have now, which is bastardized worst elements of both.
But because both sides will never agree we'll get neither, only the current hellscape.
By dclowd9901 2025-10-2819:07 No one is "putting up with it." We don't have a choice.
The way our government is designed right now, the populace doesn't really have elected representatives. More accurately, they have a corporate bought-and-paid for stooge that managed to be more likeable in a political race than their opponent, so we don't actually have anyone representing our interests _as a country_ at the federal level.
Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.
It's largely a side effect of a couple things... first the ACA (ObamaCare) limited the percentage of profit that insurance and medical providers can make... so they instead just grow the pie larger by inflating everything. Second is that they are allowed to have effectively vertical monopoly investments controlling multiple layers of healthcare as a whole from insurance, providers, pharma and pharmacies.
Trust busting and multiple supply lines really need to be established in order to have a chance at restoring normalcy. Which is all but impossible as Pharma alone is the single biggest spender of advertising alone, let alone policy influence over politicians.
By lotsofpulp 2025-10-2819:511 reply > so they instead just grow the pie larger by inflating everything
So why would they deny coverage? All they have to do to earn more money is keep paying for more and more healthcare.
Because they make more by not paying than by paying... When the payouts are larger, they raise premiums, make money on both sides.
Not to mention, if they can delay payment for a month, that's a month worth of interest on the money in an interest bearing account.
How exactly do they make more money by not paying? They're required to spend 80% of their funds on provider expenses. The only obvious way to sustain the narrative that insurers are distorting the system for profit is the preceding comment's hypo that they'd be over-paying (and then driving rates up as their expenses increased). You propose the opposite fact pattern here.
(Net cost of health insurance, all expenses, is around 6.5% of total US spending, as against 51.5% of direct provider costs for doctors, nurses, and procedures, not counting prescriptions.)
They keep the 20% that they don't pay out... what they do pay out, they get the invested fraction of, which is less than than what they paid out.
Even if they only get to keep up to 20%, doesn't mean they will pay a dime of what they can get away with not paying.
By spacechild1 2025-10-2819:431 reply The problem is that the insurance is provided by private companies whose incentive is to earn as much money as possible, at cost of the people in need of medical care. In my country, I never heard of anyone going bancrupt over a hospital bill. It just isn't a thing.
Here's a fun story: my sister was living with an exchange student from the US. Some day the student was complaining about intense intestinal pain she's had for the past few days. My sister told her to go the hospital. The student asked her if she was crazy. My sister then had to explain her that hospitals are free and won't bancrupt her...
In fact many of the largest insurers are nonprofits, and insurance itself is a small faction of our total expenditure. People believe a lot of weird things about US health care economics.
By spacechild1 2025-10-2822:391 reply There's another aspect: In my country, hospitals and (public) health insurance are both operated by the state and work together. If I break my arm, I go to the hospital, show my e-card and that's it. All the financials are directly handled between hospital and the (public) insurance provider. I don't have to worry about cost of treatment because I know it will be fully covered.
By tptacek 2025-10-2823:01 Right. The mainstream progressive proposal for comprehensive health care reform in the US is single payer, so-named because it does not nationalize the providers. But the providers are where all the cost is!
By wrs 2025-10-2819:11 Ideologically, just enough voters in the right places believe that unless you’re old, or a military veteran, in which case government healthcare is just fine, your sickness should not be their problem, even if it means they pay more for their own care.
Also, if healthcare wasn’t tied to having a job, then the inherent laziness and moral degeneracy of people without jobs would be encouraged by letting them not be sick. (BTW, being self-employed does not count as “having a job” in this mindset.)
By thatfrenchguy 2025-10-2822:401 reply Add a French and American person, in the US you hear "insurance did not approve", in France it's more "you can't get an appointment / the surgery provider does not have any spots unless you go to their spots in their private hospital".
The French system is more predictable (because any vaguely sane healthcare system has a price for a code instead of negotiated rates, negotiated rates is the most inefficient way to run this market) & you can get cost estimates though. And in both countries, if you live in a small town in both systems, the healthcare you will receive will suck.
Do negotiated rates not affect quality of care? I work in contracting and negotiated rates allow me to add quality, while systems like price codes incentivize minimum effort/outcomes.
I know doctors probably take their jobs more seriously, but I'd be surprised if it doesn't bleed over into healthcare quality.
By thatfrenchguy 2025-10-3019:52 Negotiated rates are per code here though, and doctors generally aren’t the ones doing the actual coding for the visit in the US, they have folks going through your doctor’s notes and figuring out the codes. Another reason why the overhead of health care is so high in the US.
By blitz_skull 2025-10-2820:182 reply This frame assumes several things:
1. Americans are not displeased with the situation. Ironically, I think this is one place most Americans agree there is a problem. The solution is the hard part because:
2. This presumes a drop-in solution where no one loses. This is where the fight is.
3. This presumes that democracies do what is logical or beneficial for the vast majority, which is a very naive view of democracy.
By queenkjuul 2025-10-3012:371 reply Just reminding you that American citizens continue to be detained
https://www.techdirt.com/2025/10/22/more-than-170-u-s-citize...
By blitz_skull 2025-11-020:191 reply What does this have to do with my comment?
By queenkjuul 2025-11-082:341 reply You told me no American citizens were being detained by ice. I'm reminding you your wrong.
By blitz_skull 2025-11-1914:01 lol, get a life dude.
By queenkjuul 2025-11-0121:28
Great question. No one "wants" insurance. Everyone wants to be able to get covered for care. The problem is that Govt decided decades ago that Health Insurance is the only way to get care even for mundane things like a regular doctor visit. To make it worse, they tied it to Employers needing to provide insurance. Insurance companies love this bureaucracy and became too powerful over the last few decades.
It is a sad state and I have almost given up on the hope that someday it will change. I m lucky enough to afford healthcare and feel for those who can't.
> I m lucky enough to afford healthcare
Up to a point, I guess? Correct me if I'm wrong.
By codegeek 2025-10-2819:23 Yes and it still sucks because I hate wasting my hard earned money because of a random number thrown at me for the so called "Claim". Fk the entire insurance industry especially health insurance mafia.
And don't get me started on the inefficiencies and waste of time that you have to go through to fight a "claim" that is incorrect.
To the extent that U.S. voters want to maintain the status quo, which many (though not most) voters do wish to do, it's largely driven by an individualist mindset in which the worst thing that can happen is somebody else getting something that they didn't "earn".
By bobro 2025-10-2819:43 I’d love to see a poll asking Americans: “Do you want to maintain the status quo?”
By mothballed 2025-10-2819:02 In part because hospital bills are monopoly money and most people just play a game of chicken with debt collectors, and the only actually sue a small fraction of the time and mostly either settle for a small fraction, give up besides annoying phone calls, or it gets discharged in bankruptcy.
Almost no one gets a bill from the hospital and just pays it, and in most cases if you do it's totally financially illiterate.
By elif 2025-10-2819:36 We are a "binocracy", where our democratic function has been reduced to a binary choice, and unfortunately both choices have been fully captured by the healthcare industry.
By andy99 2025-10-2821:23 Edit: just saw an earlier better comment saying the same thing: https://news.ycombinator.com/item?id=45737190
Countries with “free” also healthcare ration it and don’t cover everything.
Socialized insurance is still insurance, and at least in Canada it’s the only game in town, so if you have a procedure that is denied or not available your choice is basically to go to the US and pay for it and be in the same position as an uninsured American.
By dragonwriter 2025-10-2820:54 > I have heard the US is a democracy.
It is certainly not a direct democracy where each individual policy is resolved by separate independent voting, no.
> So then insurance-based healthcare is what American people truly want?
Pretty consistently, no, but there is not any single alternative that a majority of the American people prefer recently (for a while, as far back as the 1990s, there was a clear popular majority for universal single-payer), and more importantly, it is not the only issue that factors into people’s voting decisions.
By goodluckchuck 2025-10-2820:14 I think you’re just believing whatever the author says, and not considering the fact that reasonable people can disagree and be wrong and make mistakes. For all we know the procedure was entirely unnecessary and they agreed because he pushed for it. Also, what’s the alternative? The only system where you can go get procedures that authorities think unnecessary is a free market where you self-pay. A government-run system could equally decide that the procedure isn’t recommended.
America is trapped in a cycle where political parties have discovered that fear and anger drives voters whereas contentment with status quo does not motivate turnout. This leads to a scenario where parties will actively sabotage the resolution of painpoint issues such as immigration, healthcare, gun control etc. so long as it continues to create anger and fear that they can successfully blame on the other party. This behavior extends to voting against their own proposed policies in the interest of seizing/maintaining power over problem solving. And now deliberately creating crises (both real and fictional ones) has become the game-theory dominant strategy in American politics.
By supertrope 2025-10-2821:53 Even for politicians who are not absorbed in wedge issues, meaningful reform is a long term task. It would require multiple elections in a row showing that there is a durable political coalition for universal healthcare.
By egorfine 2025-10-2819:30 So much this.
Also, this works for every people, not just American.
By BurningFrog 2025-10-292:59 In European countries the procedures that are denied or very expensive in the US are often simply not offered. There is a national health budget, and not everything fits in it. The doctors have to tell the patients that there is nothing they can do, and that's that.
The patient ends up just as dead, but there is nothing to get furious about like when the doctors could fix it, but only if someone pays for it.
By lucasban 2025-10-2823:34 One thing also to keep in mind, is that this experience is not uniform throughout the US. Many Americans like -their- employer based insurance, even if they don’t like the system. I personally pay nothing for visits and nominal fees ($1-10) for prescriptions. I have not been hospitalized while on this insurance, but my understanding is that it is relatively low cost. I also have no monthly premium. Meanwhile, my mother works at a small business, pays a significant percentage of her income for insurance from the ACA marketplaces (the public marketplaces created during the Obama administration) with the current subsidies, subsidies that are in question under the current administration. The American healthcare payment system is broken, but we aren’t all living through the worst case scenario experiences that get the attention. Add to that the amount of money and effort that went into turning healthcare reform into yet another partisan issue, and there’s a good recipe for maintaining a broken status quo for a while yet.
A lot of employed people like the status quo for the healthcare that they receive.
"In contrast to their largely negative assessments of the quality and coverage of healthcare in the U.S., broad majorities of Americans continue to rate their own healthcare’s quality and coverage positively. Currently, 71% of U.S. adults consider the quality of healthcare they receive to be excellent or good, and 65% say the same of their own coverage. There has been little deviation in these readings since 2001.
Compared with their counterparts, older adults and those with higher incomes register more positive ratings of the quality and coverage of their own healthcare."
https://news.gallup.com/poll/654044/view-healthcare-quality-...
By micromacrofoot 2025-10-2820:42 It's precisely as many have said over decades at this point: the poor in our country hate themselves to the extent that they view being poor as a personal failing, and voting for free services for everyone is therefore dishonorable. I talk to people like this every day and it's frustrating.
> I have heard the US is a democracy
It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins"). It's a constitutional republic where basically you have 50 mini countries each with different weight in the house of representatives and in the electoral college and a bazillion checks and balances that make repealing existing laws and enacting new ones very difficult. I think the majority of Americans do not like the current healthcare status quo, but getting changes that everyone is on board with through the political machinery is very difficult and Americans are polarized and tend to distrust change plans proposed by the opposite party (since parties tend to propose legislation that favors their own first).
By LeoPanthera 2025-10-2819:061 reply > It's not a simple democracy, no (i.e. "enact a national-level vote for every issue and majority vote wins").
But it's worth remembering that, if it were, Trump would still have won. He won the popular vote. So, assuming that enough votes were legitimate, a majority of Americans actually do want the current health situation in the US, in fact arguably they want even less coverage.
We don't know if that's really accurate, because you're conveniently ignoring 2016. If Trump were never initially president, would he have ever become one?
Maybe, maybe not. But 2024 surely would have looked very different.
By LeoPanthera 2025-10-2819:171 reply This only serves to reenforce the fact that the US is not a functioning democracy, if the will of the voters is not reflected.
By DaSHacka 2025-10-2913:11 Is it not? He did still win the popular vote.
By throwforfeds 2025-10-2820:001 reply > Though why do you Americans put up with all this? I have heard the US is a democracy. So then insurance-based healthcare is what American people truly want?
It's because our politicians are largely owned by our corporations and spend a ridiculous amount of money protecting their interests [1]. We almost had a public option with the original "Obamacare", but it was forced out of the bill [2].
Also, just turn on Fox News for an evening and realize it's been the number one news channel in the US for 20-something years. They've been a right wing corporate propaganda machine for a long time, all while brilliantly portraying themselves as the "underdog" fighting the mainstream media. Americans aren't very educated and take pride in their ignorance, unfortunately. [3]
[1] https://en.wikipedia.org/wiki/Citizens_United_v._FEC
[2] https://en.wikipedia.org/wiki/Public_health_insurance_option
By seanmcdirmid 2025-10-2820:021 reply FoxNews has only been the number one TV news channel for the last 20 something years because almost everyone under 40 doesn't watch TV anymore. Yes, there are a lot of conservatives in the US, but the demographics is really skewed if you just look at people who watch TV and have cable.
By throwforfeds 2025-10-290:491 reply Yes, but older people vote and young people don't. I haven't owned a TV my entire adult life (in my 40s now), so I agree with you, but it's hard to imagine Trump and the current Republican party without Fox News.
> it's hard to imagine Trump and the current Republican party without Fox News.
Not Twitter and the Internet? As a non-boomer that's been the majority of the activity I've seen from people around my age.
By seanmcdirmid 2025-10-2916:261 reply Ya, I wonder how younger Trumpers are organizing, surely not FoxNews. Twitter/X, those weird social networks popping up...they seem to be really really active in trolling facebook.
By DaSHacka 2025-10-307:52 Yeah that's pretty much it, and telegram/discord groups.
By levocardia 2025-10-2823:081 reply Why do you put up with long wait times and lower-quality care in your home country?
By janalsncm 2025-10-290:08 It is very interesting that you do not where they are from but you assume longer wait times and lower quality of care. This suggests you believe the US has the shortest wait times and highest quality of care, which is objectively not true.
By ransom1538 2025-10-2818:512 reply Medicare has a total enrollment of approximately 69 million people, while Medicaid has around 83 million people. That is 152 million people. We already have socialized medicine we just run it poorly and don't apply it to people that can pay.
Moving our system to 340 million people + letting our corporations out of paying would put the US into an economic death spiral. US corporations would love this plan. But at 340 million... I don't see doctor visits but once every 2 years -- many would just die waiting for appointments.
By tptacek 2025-10-2818:56 Medicaid is apparently 77MM including CHIP. The underlying compromise in the system that you're describing is sane: people's health care costs rise dramatically and unpredictably at retirement age, just as their ability to pay plummets, so socializing health care at that point makes a lot of sense.
By SV_BubbleTime 2025-10-2818:55 Is this a comment for or against socialized medicine?
By bko 2025-10-2823:56 US person here.
I have insurance through my employer as do most Americans. And most are happy with their insurance. I can go to the doctor often same day, I can see a specialist and pay just a co-pay of between $25-50.
I had some bills but my out of pocket max is something like $5k, which I have saved up. The benefits of living in the US is that the same kind of work (engineer) pays about 3x as much here and you pay a lot less taxes (save many multiples of my out of pocket max).
So I prefer to live in a vibrant economy and take care of my own insurance.
The same way European people put up with the insane NHS and its refusal to care for the people who support it financially and supposedly support it politically.
https://edition.cnn.com/2024/03/13/uk/england-nhs-puberty-bl...
The NHS and its bizarre political agenda is an example of what can happen when a government controls access to health care.
By pjc50 2025-10-2822:02 A good example that "public" campaigning can work, but not necessarily for the better - there's been a systematic campaign to delegitimize trans healthcare.
There's comparable examples from other places; Ireland has come a long way in getting the church out of reproductive health, but there are still problems. And of course it doesn't matter whether it's public or private, abortion care is at risk in many US states.
The UK does allow you to go private, remember.
By saghm 2025-10-2819:56 Without making a claim about whether it's what most people actually want or not, there's not much that an individual can do about this by changing their voting preference. The US doesn't have proportional representation, and the overwhelming majority of elections are "first past the post" rather than one of the more "modern" alternatives like ranked choice votes, so in practice very few elections ever swing to anyone outside of the two major political parties (neither of which have a particularly large contingent of politicians who have come out in favor of something like single-payer healthcare). Even for a purely single-issue voter who only cares about this, from a game theoretic perspective you're likely to be essentially throwing your vote away if you vote for someone outside of those two major parties because it's unlikely enough others will.
Presidential elections are even worse because they're determined by electoral college vote rather than popular vote. Even ignoring the potential for "faithless electors", all but two states allocate the entirety of their electoral votes to the candidate who wins the majority of their vote, which means that if you live in a state with a majority who reliably vote for a specific party's candidate every four years, your vote for president is effectively meaningless.
The only obvious way to fix these issues with how elections work would be to elect people who make different decisions about how to run them, which is hard to do because of the issues themselves. The system is self-reinforcing in a way that makes it extremely difficult for the average person to do anything about it, and any desire to do so gets weighed against the concerns about the policies that you might actually get to influence by voting for one of the two candidates who might actually win. At the end of the day, people who are concerned with the fundamental systemic flaws in things like elections and healthcare still likely end up picking pragmatism over principle (with the expected value of a vote for a candidate who is almost guaranteed not to win being lower than one who is might be less desirable than a third-party one but still has an actually realistic chance of winning and is preferable to the other major party candidate) or just check out of the system entirely (with people not bothering to vote at all already being a fairly common phenomenon in the US).
By fallingfrog 2025-10-2823:38 No, we all hate it, but the number of senators and members of congress who would vote to replace it could be counted with one hand. The reason is simple: the insurance companies give those senators millions and millions of dollars and nobody has the cash to beat them. And we've given up at this point.
As the song goes:
"Everybody knows that the dice are loaded
Everybody rolls with their fingers crossed
Everybody knows the war is over
Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That's how it goes
Everybody knows"
By wouldbecouldbe 2025-10-2820:26 Well there is lot of shit we Europeans put up with, for instance EU moving court every few weeks voor 200m per year. But systems are hard to change.
By somethingsome 2025-10-2821:32 Hum.. At least where I live in europe, you still need to battle with insurances for any non trivial problem.. We get a health care coverage for the common stuff, but many things are not covered, or not covered enough.. Then you need insurances.. And it's always a battle..
Same for other kind of insurances such as issues with the house, etc..
By ziofill 2025-10-2820:52 Non-US person here too. From what I understand the majority of Americans want a single-payer healthcare system, but too many people in government are paid by insurance companies and affiliates to not change how things work.
By BobbyTables2 2025-10-2823:351 reply Its too easy to convince enough of the population to actively vote against their own interests.
By DaSHacka 2025-10-2913:14 How right you are, and more than you know
By emeril 2025-10-2819:10 -Democracy in name only
-Currently a dictatorship
-Historically more of plutocracy
-Our history has effectively yielded the current healthcare situation especially since those who would be most vocal tend to have better coverage and thus are less invested especially since the high costs are largely obfuscated
Just Pharmaceuticals not even all medicine is literally over half of all advertising spend in the US. And that is just the tip of the iceberg and doesn't go into the incestuous and conflicting interest relationships between pharma, pharmacies, medical providers and insurance companies all inter-invested in each-other to simply grow the pie larger since ACA limited profit percentages.
It's the single most powerful lobbying group as a whole, and nearly every politician is bought and paid for by them. Good luck getting a majority or super majority to work against them.
Pharmaceuticals are only a (high) single-digit percentage of medical spending in the USA, and the (likely) reason for the ads is the highly competitive nature of the market. Most of healthcare spending is on labor, specifically doctors and nurses, who are protected by highly effective trade and lobby organizations.
By tracker1 2025-10-2819:39 My point stands... as a whole, they (medical industry as a whole, including pharma) are the single largest lobbying group and nothing you've said refutes that. My use of pharma ad spend was an example of how much money they put out as an indication of how much lobbying power all of medicine as a whole has.
By ponector 2025-10-2819:42 One can argue what people wants is to be ruled by old convicted felon dictator.
By thesuitonym 2025-10-2819:11 The US money machine has one of the most sophisticated propaganda networks in the history of the world working to make sure nothing ever gets better for working class people. In George Orwell's vision of a dystopian future, "The party told you to reject the evidence of your eyes and ears. It was their final, most essential command." In the US, the party didn't even have to issue the command, they just asked a few thousand talking heads to do it.
By zulban 2025-10-2822:29 You've implied the answer to your own question. The USA is not a democracy. The opinions of almost all Americans have no impact on policy. It's a well researched fact.
Having an election day where people vote doesn't mean you live in a democracy.
By baby 2025-10-2821:06 As soon as someone introduce these ideas people think they're a communist. See Mamdani in NY right now.
By bluesounddirect 2025-10-2822:39 Then what sort of feel good stories about AI would we have . The US needs to adopt a single flat income / corp tax, government provided healthcare, and move on to the rest of life.
The US is gigantic. Imagine if every EU member, however rich, poor, or corrupt from Bulgaria to Germany had to enact one healthcare system.
Decades of right-wing propaganda, unfortunately. They tend to have an emotional reaction against any sort of socialized anything, including healthcare.
By LeoPanthera 2025-10-2819:001 reply The US is only ostensibly a democracy. It's not a functioning one, due to widespread voter disenfranchisement.
Voter ID laws, voter roll purges, registration barriers, polling place accessibility, early and mail-in voting restrictions, and perhaps most importantly gerrymandering, misinformation, and intimidation all serve to reduce the power of the ballot box.
And that's before we even get to US citizens in Puerto Rico, Guam, the US Virgin Islands, and American Samoa being unable to vote in Presidential elections at all.
Most other countries have voter ID, and the controversy surrounding it is puzzling to most foreigners. Additionally, parliamentary systems which result in majority governments are much more ‘dictatorship-like’ than the US system where individual representatives retain some autonomy.
By hydrogen7800 2025-10-2820:261 reply A large number of Americans do not have ID's, which is strange to many people. If the need for voter ID and risk of fraud were so great, the efforts would be to make it trivial for these folks to get one, rather than preventing them from voting.
not sure why you're getting downmodded. People will say M4A ("medicare for all") polls at super high levels, and they're right, it does. But poll those same people telling them "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on, and that poll turns right upside down.
By Projectiboga 2025-10-2819:131 reply Every actuarial study about the switch projects total cost savings even during the first year. This scarsity of providers is artificial there haven't been enough medical student slots ever in America. American life expectancy isnt in the top 25 nations, while having the largest percapita GDP.
By Aurornis 2025-10-2819:34 > Every actuarial study about the switch projects total cost savings even during the first year.
This is missing the point about why people don't like the past M4A proposals: It's not about cost savings, it's about losing access to their existing health care with scarce details about what would change.
The surprising reality about American health insurance is that many people's plans cover a lot of things, procedures, and medications that would be harder for them to obtain under Medicare or even in other socialized medicine systems like the NHS.
If politicians would lay out a Medicare buy-in option and let everyone opt-in to it, it would be far more popular. The past proposals that involved shutting down the private insurance industry and handing it all over to the government is resoundingly unpopular.
> "would you favor that your employer-based healthcare would be rescinded and you would instead get healthcare from a new government controlled plan, where there would be no other options", which is the assumption M4A's viability is based on
No, that's just the condition for one proposal for Medicare For All.
As much as Americans complain about healthcare in general, most people don't want to give up their own health insurance once they have it. This is a known political trap that the previous M4A proposals walked right into, before crashing and burning.
When you say "Medicare for All" to people without details, they assume it means a Medicare option for all. When they start reading the details and realize they have to give up their current insurance, they don't like it.
By zzzeek 2025-10-2820:37 what are the other proposals? I like everyone else would love the option.
though at the moment I'm super happy DJT does not control my healthcare.
The alternative is no surgery and no choice, which is what happens with government-run healthcare.
By Freedom2 2025-10-2823:51 I doubt this comment is true, given that other countries with government run healthcare have surgeries and choice. Do you happen to have any evidence that every country with government run healthcare has no choice or surgeries at all? Your comment seems to imply as such.
I don't think this has much to do with being a democracy. I, for one, wouldn't trust our federal government to competently run an efficient, most uncorrupted healthcare system for all.
The incentive structures that have built up around US politicians simply doesn't leave any room for it to realistically happen. Until the incentives are changed I'd vote against nearly any major government program.
By wing-_-nuts 2025-10-2820:491 reply I hope you refuse Medicare at 65 under those same principles
That would entirely depend on the coverage I could get and how it compared to private. If Medicare is changed over the next few decades to look more like Medicare Advantage, aka Plan C, you couldn't pay me to deal with that.
Edit: its worth noting that your question for whether I'd take medicare is a separate issue from my original point. If the existence of Medicare as it is today was on the ballot, I would vote to get rid or drastically change it. If the program exists regardless of my opinions of it, my choice to take benefits from it is entirely a question of means and comparative benefits of all the options.
By wing-_-nuts 2025-10-3114:44 >If Medicare is changed over the next few decades to look more like Medicare Advantage, aka Plan C, you couldn't pay me to deal with that.
Ironic, considering that MCA is the more 'free market' of the two. Almost as if medical care shouldn't be for profit.
By galangalalgol 2025-10-293:031 reply Well it was a democratic republic. Now it is an electoral autocracy. He fixed it so good those christians will never have (or be able) to vote again. Just like he said he would. A Republic where the representatives are chosen by a popular vote are still democracies.
The representatives are chosen by the Electoral College, not the popular vote. The U.S. is not a democracy.
By galangalalgol 2025-10-303:311 reply Representatives are chosen directly by the voters of their districts and senators directly by the voters of their state. Electors are selected however their state decides, so yeah, the president isn't necessarily democratically chosen. Neither are judges. In practice though the electors are chosen based on the state vote. Saying the us wasn't a democracy is narrowing the definition of democracy quite a bit.
By tboyd47 2025-10-3118:02 It's a constitutional republic. Democracy is optional. We'll either discover it now or discover it later.
By frogperson 2025-10-2821:56 The are advertised as a democracy, but ever since Citizens United was passed we became an Oligarchy. Money now takes the place of votes since the rich can donate unlimited funds to a candidate. Candidates have zero incentive to serve the public.
By FpUser 2025-10-2821:36 Non US as well. Life saving saving surgeries get denied, delayed and otherwise screwed all the time. Not sure where exactly it is worse since absolutely atrocious cases can be found in every G7 country never mind the rest
By qgin 2025-10-2822:26 We have a lot of people being constantly brainwashed that we have the most amazing system in the world and that any attempt to change it is communism.
By fukka42 2025-10-2819:19 Yes, it is what they want.
In the end there are more of them who want to "own the libs", or "not pay for freeloaders" than those who want to contribute to another's child surviving.
By ab_testing 2025-10-293:12 I think the root cause of the problem is not insurance companies but they definitely do play a part. The real reasons are multiple but can be listed as below.
1 A very high cost of drugs due to no intervention by the government as part of free market philosophy. This means that the same insulin that costs $25 in Canada can be sold for up to $1000 per month. New introduced drugs for Alzheimer's or other diseases can cost up to 50k per year - again because no price controls.
2. Insanely high prices of services due to a captive market - example a ten minute ambulance ride can cost up from $1000 to $5000. The private ambulance companies know they can charge a high base rate because they are connected to a city or municipality via contracts. Bribes as campaign funds are popular here. E.g. a new York based ambulance operator paid 45k in campaign funds to NY's governor elect and got a contract worth one billion dollars
https://www.wkbw.com/news/state-news/report-nysdoh-awards-mu...
3. Overcharging by hospitals for medicines and services again due to a captive audience. The hospitals are free to maintain various price books and you are not told what each service will cost at the time of administration of service. lately the hospitals have been forced to open up their price books but they are so convoluted that no normal human can decipher those prices.
Thus a ten cent aspirin would cost you $25 in the hospital and a MRI can run up to 15k.
4. Very high charges for doctors due to strict control on the number of MD positions and no increase in colleges or D seats over multiple years.
https://www.aamc.org/news/press-releases/new-aamc-report-sho...
5. Insurance companies have a for profit motive and need to extract their profits from premiums paid. Thus they fight tooth and nail to deny procedures and medications and set up convoluted processes for appeals.
6. Extensive fraud on Medicare and other government run health programs especially in durable medical goods and fake billing. In fact one of sitting US senators medical care company was involved in the largest Medicare fraud fines in the US and he still holds his seat.
https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....
Infact fraud billing Medicare for services not rendered is so popular that even Insurance companies do it
https://oig.hhs.gov/fraud/enforcement/united-states-interven...
Combine all the above factors and you will see why the US consumer gets so little while paying so much for his healthcare.
By ajkjk 2025-10-2820:11 We fucking hate it don't worry
By nine_zeros 2025-10-2821:14 [dead]
By stronglikedan 2025-10-2821:322 reply Yes, but we also want universal healthcare. What we don't want is only universal healthcare with death panels like the UK and Canada has. Give us universal health care where we can also get insurance if we want, and we'll vote it in. That's never what comes up though. I firmly believe we could gut medicare/medicaid and the savings from the bureaucratic administration costs alone could pay for universal healthcare.
By trollbridge 2025-10-292:06 Note that Massachusetts and San Francisco have universal healthcare. Mass. is also home to one of the best healthcare systems and children’s hospital in the word.
UK/CA healthcare sounds like hell. Every doctor is under the government, so even if you have money for a procedure the government doesn't want to cover, you can't get it done. And of course because there is no rationing by price there is rationing by time, so you end up with 13mo waits for an MRI.
By dragonwriter 2025-10-2823:38 Leaving aside the subjective impressions, the objective parts of that description are only accurate for CA, not UK, healthcare; the UK has optional add-on private insurance and care on top of the universal public system.
By nmz 2025-10-2821:55 > incompetence
No, that's the goal. Denying coverage is how insurance companies make money. The less money they give, the more money they keep.
By horns4lyfe 2025-10-2823:40 Insurance companies have become cartoonishly evil. It’s going to get really nasty out there at some point.
By game_the0ry 2025-10-2819:52 Happy to hear this all worked out. Have you thought about reaching out to local news to get the word out? That insurance company should be called out.
By IlikeKitties 2025-10-294:06 I'm glad you were able to use these tools to help your family though such tough times!
> The hopeful part of me is that many others can use similar techniques to win.
And the realistic part in me says that these tools will be used to deny appeals without a human ever looking into them and making sure you will never get to talk to a human or get approval for anything ever again.
A few of the sentences don't make sense to me. Who is "they" and "their" in the last two paragraphs?
Seems like GP is trying to refer to the child without reference to sex.
By chrisgeleven 2025-10-2918:35 Bingo. It's not important.
By lotsofpulp 2025-10-2818:484 reply I was under the impression that if you were to go to an emergency room, life saving surgery would be scheduled regardless of who is paying (or not paying), due to EMTALA. I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.
Is this incorrect?
By evan_ 2025-10-2819:24 if the kid has a steel spike through his abdomen then they will perform that surgery. If he's having seizures because of a brain tumor all they're required to do is stabilize and release.
By chrisgeleven 2025-10-2918:39 This wasn't an immediate ER situation, at least directly (yet). More of a if this procedure doesn't get done now, at some point in the relatively near future, there will be multiple ER situations, almost certainly multiple hospitalizations, and one of those might go past the point of no return.
And the insurance still played games. Like, it's in your best interest to pay once and get this situation resolved in a scheduled/controlled manner than wait for multiple emergency hospitalizations AND have to pay for this in an emergency situation...you're probably talking at least 2x cost if not more.
By kiitos 2025-10-2919:02 > Is this incorrect?
yep
because "life-saving" isn't a single well-defined boolean condition that can be determined by ER staff as part of triage
> I can't imagine a hospital waiting for an insurance company's approval to pay for a procedure to schedule a child's life saving surgery.
then I guess you've never dealt with major health issues like cancer, blood disease, etc. etc. because what you're describing here happens all the time
By tptacek 2025-10-2819:04 Good reminder that "life saving" and "elective" are orthogonal.
By heavyset_go 2025-10-295:131 reply The other side of this is that your LLM interaction can be leveraged to train adversarial models that find ways to still deny or delay your claim despite your LLM-advised actions.
Insurance companies, or the companies they pay to launder their involvement, would pay a lot more for that than the public would be able to.
By chrisgeleven 2025-10-2918:54 I know, that is a worry I have.
By lanfeust6 2025-10-2818:56 Great story, and encapsulates what I find most powerful about LLMs.
By phyzix5761 2025-10-294:372 reply I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.
By heavyset_go 2025-10-295:38 There's a difference between immediate stabilization, required by law, and life saving surgery in general, not required by law.
If you come in with a gaping head wound and can't pay, by law, hospitals are required to treat you.
If you come in with brain cancer, no one is compelled to give you the radiation, chemotherapy or surgeries you may require, even though it is literally life saving. You are stable, albeit slowly dying, so too bad.
By lelanthran 2025-10-294:572 reply > I'm curious, where do you live that denies a child a life saving surgery just because insurance won't cover it? Because in the US there's laws against that.
Maybe I'm just too skeptical, but
a) This is a very new account with exactly 1 other posting 3 months ago, and
b) They don't refer to their child with any sort of gender. They even used slightly awkward sentence construction just to avoid gender. Few parents think of their child as an "it".
So either this is a sleeper bot, or the surgery in question was gender reassignment.
Or this poster routinely refers to their child as an "it", not a "he" or a "her".
Or they value privacy? Especially regarding their children?
Many people nondescriptly don’t gender themselves in online discussions.
By lelanthran 2025-10-2914:16 > Or they value privacy? Especially regarding their children?
Could be, but they made only a single other posting and are effectively not even pseudo-anonymous, but completely anonymous.
By chrisgeleven 2025-10-2918:47 I usually read Hacker News, not comment...this story just grabbed my attention because of my kid's situation and wanting to maybe give others hope fighting a similar battle.
You know, when you deal with the past 18 months where your kid has 6 hospitalizations due to illness, 2 minor surgeries, 3 major surgeries (this last one was spine related, others heart), countless appointments, multiple feeding tube feedings a day to sustain nutrition, nearly $2 million lifetime billed do insurance (as a 6 year old)...who the fuck cares about what gender I decide to write about or the reason I might not share it?
By Cub3 2025-10-3011:55 Man that’s terrifying. I can’t imagine going through that due to admin incompetence
The US healthcare system sounds horrific
By ethbr1 2025-10-2819:59 Amazingly happy to hear you were able to drive the process! FWIW, surgical centers usually have to do the exact same thing for their patients (typical role: coordinator), and they do it the same way you did (plus knowing a few counterparties because they work together regularly).
The lack of data standardization in health insurance is atrocious. (In the US, CMS/Congress pushing what it can, but at a glacial pace)
The strongest argument for single payer is that a diverse marketplace has demonstrated a fundamental inability to interoperate.
By miki123211 2025-10-2822:091 reply This is why AI is an equalizing force.
Eventually, we'll just have a free (or at least much cheaper) psychiatrist in our pocket.
Sure, AI advice is workse than the advice of a competent professional, but it's very often better no advice, and that's what you get if you can't afford the professional.
By ASalazarMX 2025-10-2822:391 reply I shudder to think when insurance companies use AI to counteract customers using AI to navigate through their system. They'll eventually catch up, and people who don't use any kind of AI will be disadvantaged.
That is, until someone sells them a turnkey AI service to do insurance claims... and decides to play both teams so resolutions come back at pre-AI levels, and the free market(TM) is happy because a new equilibrium has been reached.
Maybe I just need more sleep.
By itissid 2025-10-294:05 I am not sure it's that simple. Thing is many costs are due to information assymetry: you not knowing something that they do.
For example them counting on you to big hire a lawyer for collecting medical debt or mortgage debt your spouse or parent owes. As a general rule you aren't responsible for it. There are exceptions. e.g. Filial laws(children responsible for parent's debts) exist in many states, but are difficult to invoke. Community property laws https://www.irs.gov/publications/p555#en_US_202502_publink10... in 9 states that can link your income to your partner, when the state you were domiciled in with your partner in a home/condo you bought together.
So in general, adverserial use of AI cannot bring claims "back to pre-AI" levels. Much more likely is the fact is reduced debt collection activity and illegal billing will reduce to a new baseline.
By Sincere6066 2025-10-293:30 (this thread paid for by OpenAI)
The American Medical Association owns copyright to all the codes and their descriptions. They have an extremely restrictive and expensive licensing options and they strictly forbid training models with the codes.
This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.
The AMA (a nonprofit!) clears ~$300M/year revenue from the codes, which is the direct cost passed through to consumers, but the indirect costs are the byzantine nightmare of OP.
A code is not an artistic expression and so can't be copyrightable. The layout of a book of codes, for sure, but the information in it... might be protectable with other IPR but not copyright.
Does not stop people threatening you though.
This is my opinion only, not legal advice, and does not relate to my employment.
>A code is not an artistic expression and so can't be copyrightable.
that was changed
https://www.bitlaw.com/copyright/database.html
Databases are generally protected by copyright law as compilations. Under the Copyright Act, a compilation is defined as a "collection and assembling of preexisting materials or of data that are selected in such a way that the resulting work as a whole constitutes an original work of authorship." 17. U.S.C. § 101. The preexisting materials or data may be protected by copyright, or may be unprotectable facts or ideas (see the BitLaw discussion on unprotected ideas for more information).
(I did not use AI, but this appeared at the top of my search and I think the search engine used AI to generate it):
In the European Union, databases are protected under the Database Directive, which provides legal protection based on the originality of the selection or arrangement of their contents...Some countries offer additional protections for databases that do not meet the originality requirement, often through sui generis rights.
By marcosdumay 2025-10-2819:162 reply That means the organization and selection of data is copyrightable, and only if they are creative. If you write your own tags for the codes, and makes a compilation of them all, none of that will cover your database.
Also, I think the bitlaw interpretation is incorrect. “Sweat of the brow” doesn’t magically produce copyright protection, and they don’t mention that.
Taking their example, if you had a collections from quotes from presidents, and I got a bunch of similar collections, then made my own ultimate definitive collection based partially on your list, then there’s very little chance I’d be liable for violating your copyright. If I copied the list and typesetting verbatim, you’d have a better case.
Also, modern rulings about LLM training (the topic of this thread) certainly mean copyrights on compilations of facts don’t survive training + inference cycles.
By fsckboy 2025-10-3018:32 >“Sweat of the brow” doesn’t magically produce copyright protection
...then you go on to make the "sweat of the brow" argument
"typesetting" doesn't enter into it, "database" is meant to include the computerized version
By fsckboy 2025-10-312:16 creation of a database is a creative act
Judging by Judge Alsup's ruling even if the codes were copyrighted it would most likely not be copyright infringement to train on them either, and as such even if they are copyrightable and they do own copyright on them it remains beyond their abilities to forbid training on them. (Also opinion, also not legal advice, I'm also not a lawyer and sort of doubt the person I'm responding to is).
By themafia 2025-10-2818:45 > not be copyright infringement to train on them either
Copyright is about reproduction. It does not cover uses. Once you bought it, it's yours, as long as you don't reproduce it outside of fair use.
The problem with most language models is they will often uncritically reproduce significant portions of copyrighted works.
By MostlyStable 2025-10-2818:55 If you buy the codes, yes. If you only license them (which is what the original comment claims is the only way to get them legally), and that license explicitly forbids training, that seems to be less clear-cut. I have no idea if such restrictions are legal or would hold up to challenge, but it's less clear than the case where you buy a book and can then do whatever you want with it.
By pbhjpbhj 2025-10-2817:53 IANAL, you're right.
Software I write at work is not artistic expression yet is covered by copyright.
This isn't a counter argument, just pointing out how absurd copyright is.
Your software is definitely artistic expression. You signed over the rights to those expressions to your employer.
(IANAL)
By Zambyte 2025-10-2819:14 My software is definitely not artistic expression. I signed over the rights to the software to my employer. These statements are not codependent in any way.
By hamdingers 2025-10-291:23 Always disappointing to hear creative writers denigrate their craft just because their main audience happens to be computers.
By kemitchell 2025-10-2823:49 Copyright under US law does not require "artistic expression". One of the requirements is called "creativity", but it's very easy to meet. The key phrase is literally "some minimal degree of creativity".
The fundamental policy choice was to protect computer software under intellectual property law, with exclusive rights and market compensation. There were a number of ways that could have been done. Other jurisdictions toyed with new, software-specific laws. But in the end the call in the US was to bring it under existing copyright law with some tweaks to definitions and a small handful of software-specific rules.
By fluoridation 2025-10-2817:591 reply A code in this sense is something different. It's a shorthand for a longer description of an object. It'd be like a hotel copyrighting the relationship between a room number and its physical location within the building, or copyrighting resistor colors.
I understand. The different meanings of "code" in this conversation is why I said "software" in my comment instead of code.
Copyrighting software is as absurd the other things you listed.
By papercrane 2025-10-2818:25 In the US copyright just requires a level of originality. The bar isn't very high, but for example simple logos, like IBMs blue lines logo is not copyrightable.
There are examples of software code that is probably not copyrightable, but that's limited to very simple code that has only obvious implementations.
By fluoridation 2025-10-2820:05 >Copyrighting software is as absurd the other things you listed.
I don't really agree, and for context I think copyright in general is nonsense.
Consider these thoughts: https://wiki.c2.com/?SoftwareIsArt
Our role as programmers being closer to artists than engineers does not make code closer to paintings than bridges. We do have highly repeatable patterns. Nearly every program can be essentially boiled down to some subset of CRUD + tranformation.
Even if it is art (I'm not convinced), the recent artificial scarcity on art is absurd. Some other thoughts to consider:
- https://drewdevault.com/2020/08/24/Alice-in-Wonderland.html
- https://drewdevault.com/2021/12/23/Sustainable-creativity-po...
By hamdingers 2025-10-291:24 I've never seen a bridge I wouldn't consider a work of art either.
By embedding-shape 2025-10-2817:55 Also the collection of essays carrying the name "Hackers & Painters" is of relevance.
By maxerickson 2025-10-2822:16 Artistic expression isn't the standard in US law.
By philipallstar 2025-10-2817:502 reply > The layout of a book of codes, for sure, but the information in it
Are you talking about copyright here? It sounds more like design protection.
Wouldn't the book be as copyrightable as any other non-fiction work?
By pbhjpbhj 2025-10-2818:22 The work I know of, I'm not in USA only have an interest in copyright laws in general, is Feist v Rural Telephone (1991) -- which appears to mirror codes for health procedures quite closely; but not exactly.
There's old but more recent law from Practice Management v AMA (1997) supporting that AMA's codes can't be copyrightable as they're part of legislation.
Berne's Art 2(8), to which USA are signed, related to non-copyright of facts.
I'm afraid I'm not appraised of the full situation, however.
By adriand 2025-10-2818:16
By onionisafruit 2025-10-2817:411 reply And yet people are collectively paying $300M licensing these non-copyrightable codes? With that kind of money somebody must have looked into not paying for licensing
I’m sure it’s crossed the mind of many people in the industry. But it’s a comprehensive taxonomy of all diseases, medical conditions, causes, procedures and treatments. Starting from scratch would be much more expensive than just paying the licensing.
By sowbug 2025-10-291:42 Here in California, Senate Bill 478 bans many junk fees, such as the mandatory "service fee" to buy a concert ticket. It's a stretch, but I could see an argument that if hospitals use a billing system that's incomprehensible without licensing an expensive codex, then the hospital is on the hook to provide the codex to you.
Fight fire with fire.
By onionisafruit 2025-10-2821:401 reply What I mean is using it without paying the license, because if GP is accurate there is no copyright preventing it.
By mr_toad 2025-10-2822:11 In that case its probably cheaper for most organisations just to pay the license fees than risk paying legal fees which would probably be more, even if they won.
By BurningFrog 2025-10-2818:002 reply It's important to understand that a "nonprofit" can be just as greedy as any other organization.
It can't pay out profits to shareholders, but it can hire its owners as employees and pay them any number of millions.
Doesn't the AMA serve the medical industry? They don't have to make profits themselves. If a byzantine coding process raises medical treatment costs, they'll do it. Just like how they intentionally cap med school admissions to keep doctors in demand and inflate their salaries.
By BurningFrog 2025-10-2916:06 The AMA is functionally the trade union for doctors. They work to maximize the income of their members. Maintaining a shortage of doctors is one of their primary tools.
If this also helps the medical industry, it's an accidental side effect.
By antisthenes 2025-10-2818:49 Any non-profit can always claim to inflate their expenditures up to (and above) their expenses and pay lavish bonuses to their employees, like you said.
Doesn't change what it basically is - aka Scamming the Public, and privatising the gains.
By GrinningFool 2025-10-2817:121 reply Reading between the lines, it seems like this is a threat made to bring AMA in line with the administration's policies around medically supporting transgender people.
I would expect that if (when) the AMA folds on the matter, concerns around the codes will be somehow forgotten
By ecosystem 2025-10-2913:39 Probably, but it wouldn't be the first time an axe grinding broke a sponsored monopoly.
By tw04 2025-10-2818:00 >This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.
So you think the same Senate that is planning on gutting healthcare for millions of Americans is going to go after the AMA billing codes? Is this real life? They MIGHT demand some donations to the ballroom, but I doubt they care enough to even do that.
Ahh, here's the correct link and as I suspected, this has absolutely nothing to do with reducing healthcare costs for the average american. It is a direct attack on the AMA for advocating for supportive care for transgender citizens.
https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...
With opinions like this, you can rest assured Cassidy is concerned with healthcare costs for the average citizen:
>This comes after Cassidy denounced the AMA for defying President Trump’s Executive Order by promoting gender mutilation and castration of children.
By like_any_other 2025-10-2818:246 reply So what you're saying is the AMA is openly hostile to Americans.
By antisthenes 2025-10-2818:501 reply Anything related to healthcare (except some genuine minority of doctors and staff) is almost openly hostile to Americans.
I used to think American healthcare was in part expensive because Americans have poor health (e.g. high obesity).
Now I am beginning to think that Americans have poor health by design for the healthcare industry to be able to maximize their profits. Making some Americans healthy just seems to be a side product.
By kldg 2025-10-296:23 I will throw a story out here because I don't know where else to put it and want it off my chest (I will leave a lot out of this):
Daughter tried suicide a few weeks ago. "It was not a serious attempt," but obviously it is. We go to only local hospital; they don't have a pediatric unit, so ER basically just looks at her and aren't sure what to do because it's not like she's bleeding out. They clean the cuts and ask if I want county behavioral health involved. I'm in over my head and need help, so I say yes.
Behavioral health mobile response person comes out -- good guy, made me see something I hadn't prior -- because I've had her in therapy for half a year prior but we weren't really making much progress on anxiety/depression issues -- but he says we weren't going to get anywhere with therapy before drugs, that she was too far out, and in retrospect that was absolutely the right call. Anyway, he puts her on 72-hours mandatory hold. Here, this means the child must be transferred to a pediatric health facility with suicide watch and psychiatric services. This became a big problem.
Cincinnati Childrens Hospital had no beds (and I have ill will toward them anyway). Dayton had no beds. Charge nurse was calling people for hours and hours, and I joined in calling places (we stayed at hospital the whole time without sleeping), and it wasn't until 24 hours after admission we're finally transferred. My mom was/is a social worker for those with developmental disabilities, and spent about a decade working at long-term facilities for juveniles, where it was almost always court-ordered. I spent a fair bit of my time there for economic/childcare reasons while she was working -- awful place for the kids (not for me; I hung out in staff rooms and watched movies). Doors, by law, could not be locked, and they were terribly understaffed; violence and rape was expected. We had a second person from county behavioral come out, and once I realized the only kinds of places open to us, started pleading and insisting to have the hold lifted, but they refused. I wind up with one out-of-state option, and one in-state; both about an hour and a half away, and both the kinds of facilities I was terrified of. I later talked to other parents and was surprised to find time to find a facility, lack of beds, and travel time were all common issues between us. I went for visitation every day, and at least one adult would almost always come out of visitation crying, not realizing these places are poorly-staffed, unsafe prisons until they first visit and talk with their kid.
Anyway, so the 72-hour clock starts only once daughter's transferred to this pediatric psych facility (she wound up staying for 5 days; this is a whole other issue where they had no social worker available to provide AMA paperwork, they claimed). -And this place is a long-term juvenile psych facility, so it tends to have a lot of kids who were sentenced by courts to be there; violent offenders, but it was a mix (daughter has a story about playing Uno with a kid experiencing "weed psychosis", which'd I'd never heard of before; interesting stuff). You know, so I'm going to bed every night, and I've got some wild nightmares I could share -- BUT everything turned out mostly fine. At one point, daughter witnessed staff slam a kid against the wall hard enough for him to bleed from the head, and didn't clean the blood off the wall; the toilet in her room didn't work and the room smelled like feces; they couldn't lock doors, and the facility was severely understaffed. A recipe for disaster, but it could have been a LOT worse than it was, though trauma is there nonetheless from the experience.
Now, the reason the county insisted on sending her to this hellhole is because it's the only way to unlock county behavioral services. You must first have committed an attempt to harm yourself or someone else, or be ordered by courts. I wrote at the beginning I was able to get a counselor before all this, but this took a lot of emails and phone calls, and the place I found with help required 2 hours on the road per visit. The person I got was new in the field and didn't specialize in pediatric; he was not a licensed psychologist nor psychiatrist, but he was the only person I could get and I was grateful for any assist. There were/are no available pediatric psychiatrists or psychologists EXCEPT through county behavioral; they have them all locked away from the market, basically.
The total bill for all this, by the way (uninsured, cash, including the ambulance) was $8,709.45. I didn't negotiate; I've planned for this, I took out $20k from broker on the first day I got to go home. Money isn't the issue; it's the non-availability of service which's the real problem here, for us. I was surprised to walk into county behavioral and be told while registering at front desk they don't accept self-pay; that they aren't set up for it. I've never run into this before, and it got a morbid chuckle out of me because this's been a heck of a roll of the dice up to now, specifically to get in county services, and now I'm told they don't offer anything for us.
I ask for the people who insisted on the 72-hour hold (and btw, the facility which held daughter prescribed nothing but an antihistamine, with trauma inflicted, though minor; worthless experience except to unlock services) to speak with me, and I get one of them. She talks to supervisor, and apparently nobody knows their own policies because they do, in fact, accept self-pay. I had to fill out a Medicaid form, which we don't qualify for. Now, the strange part about this is if you have insurance (and this is why they have you apply for Medicaid), they charge you on a sliding scale, but if you don't have any insurance and get rejected by Medicaid, they really don't have any system set up to bill you, so everything's free. The psychiatrist and counselor both are free; it's crazy, so I'll kick some money to food pantries while SNAP's cut off in the state due to federal shutdown, but it's like nobody's ever really thought through the systems we have for healthcare; it's inefficient and brittle from every angle, not just the providers/insurers screwing people over for capitalism angle; like a proof-of-concept someone slapped together over a weekend where everyone's spinning their wheels without a clue what to do, except it's something we've had for centuries and are spending $trillions/year on. -And every time the government provides new weapons or issues new mandates, it somehow seems to get worse.
(Things are going well now, btw; we got a real psychologist scheduled same-day, and first appointment with psychiatrist was 2-3 days after intake. She's doing better, but the journey here was straight Hell.)
By almosthere 2025-10-2818:39 It has been forever, what planet are you on? Their official policy would be to make any native american cure (upon which many of the medications we use from big pharma, are based on in origin) to be illegal. They would want all profit going through them, whether that is good for you or not.
By aqme28 2025-10-297:17 It’s quite literally a cartel and it acts like one. They heavily restrict the supply of doctors, which means our medical costs are higher in favor of higher doctor salaries.
By DesiLurker 2025-11-0416:53 and imagine doing that to earn just $300M thats like a dollar per citizen.
By red-iron-pine 2025-10-2913:50 take a look at the Fortune 100 list and notice how many healthcare companies are in the top 20
the AMA is their homie and is sponsored by them
By iAMkenough 2025-10-2820:52 You could argue the lawmakers that granted copyright protections are openly hostile to Americans. Many fine people are saying that Congress values profits over people.
By newZWhoDis 2025-10-2821:01 Insurance companies get a lot of (deserved) hate, but the doctor cartel seems to skate on by in the eyes of the public.
The white coats are far from blameless here.
By RandallBrown 2025-10-2818:111 reply Google tells me that the AMA made about 468 million last year in revenue. If they made that much from the codes it seems like they wouldn't necessarily pass the IRS Public Support test. (Unless somehow this licensing counts as "public support."
I seem to remember this test is why the Mozilla Foundation and the Mozilla Corporation exist, but I could be mistaken.
Edit: Seems that the AMA is a 501c6, which is a different kind of non profit.
By ecosystem 2025-10-2913:05 Right, it seems a lot like the public support test fails for the AMA -- their purpose and actions are highly misaligned on CPTs, but IANAL.
> extremely restrictive and expensive licensing options
The license is meaningless if training AI is considered fair use, and if you never agreed to the license.
They might be able to lean heavily on medical researchers and the like (who probably need a license for other uses), but when push comes to shove I suspect Google and OpenAI would win.
By ecosystem 2025-10-2913:09 The bigger issue is software development, imo. eg the IT team at a hospital or the medical office can't build a tool to help coding efficiency or accuracy. Further, public resources/websites with code-related information get DMCA takedowns. It's a stranglehold on innovation/progress.
By almosthere 2025-10-2818:37 A subscriber of the code can use it agentically by using snomed,icd,cpt etc.. in their official capacity to look up meanings.
It would also be permissible to search existing records and prices (if an actor has them) to cross check average prices for some procedure.
$300M/year is less than $1 per person. This is not why healthcare is expensive.
By paulryanrogers 2025-10-2821:44 The opaque costs add up. If nothing else all the layers make things slow, when time is the difference between life/health and death/illness.
By ecosystem 2025-10-2913:15 It's ~$1/person direct, but how much indirect cost? Things become inexpensive when automation and technological progress makes them so, and the code copyright and restriction is a major barrier to do that.
By Danjoe4 2025-10-2911:47 Quick guys someone make an MCP server with the codes. Fuck em!
By bnjms 2025-10-2818:04 I have heard this also how some state law works. That it’s difficult to directly reference state law or relevant information which define the meaning of state law.
By datavirtue 2025-10-2818:11 The codes are data. The restrictions are empty threats.
It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.
I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.
It's pretty clear that even access to a potentially buggy and unreliable expert is very helpful. Whatever else AI does I hope it chips away at how institutions use lengthy standards and expertise barriers to make it difficult for people to contest unfair charges.
By sidewndr46 2025-10-2816:481 reply having hired an expert in this field, I can tell you they aren't really that sophisticated. I found myself with an absolute mountain of cash after an accident as part of a settlement. My medical insurance won't pay claims until I've exhausted that cash. The claims I had were much higher than even the mountain of cash. The lawyer I hired use a pretty effective strategy: he contacted all of the claims against me and told them we could engage in N-way negotiations amongst all the parties until we came to a settlement so everyone got their nibble of the pie. Or they could get X today, where X was some amount that was a bit less than the rate the industry actually gets paid for those services. They all accepted.
The discounts he negotiated left me with tons of cash & were in excess of the fee he charged me.
By robertritz 2025-10-291:30 He literally did a prisoner's dilemma on them. Love it.
The thing is the prices are all made up anyway. The hospital hallucinates prices, so they don’t blink an eye when an llm does the same.
Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)
For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k. His response was, "lol I'm uninsured and don't give a fuck about my credit score, so, fuck you basically." The bill was revised to $500, which he paid just to not have that debt on his record.
>The wider implications of this are left to the reader.
IMHO, it's actually worse than we realize. The Medical Loss Ratio requirement is good because it requires insurance companies to spend 80% or 85% of premiums on health care. It's bad because one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums so they can get 80% of a bigger pie. It also gives them incentives to provide care themselves so they can capture some of that 80% spend.
> For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k.
I experienced this personally with my own insurance. My bill was over $20k, and it took a year to convince the insurance company that removing a few feet of my intestines was actually emergency surgery. I ended up paying $800. My roommate in the hospital had no insurance and ended up not paying anything (which I did not begrudge them at all, since the reason for no insurance was debilitating back pain that led to unemployment)
> one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums
This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.
The truth is though, healthcare providers are ultimately responsible for prices.
By swiftcoder 2025-10-2818:061 reply > This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.
This assumes the competitors are not all colluding to raise prices across the board
By lotsofpulp 2025-10-2818:412 reply Then they must suck at collusion, given they can't even beat a risk-less broad market index.
SP500 10 year annual return: 14.6%
UNH: 13.59% Elevance: 10.79% Cigna 9.42% Humana: 6.1% CVS: 0.55% Molina: 9.42% Centene: 0.9%
Or, the likelier explanation, is that health insurance prices are highly regulated and have to get their prices approved by a government official(s), and B) they don't have a lot of pricing power due to the competition and they are not colluding.
By datadrivenangel 2025-10-2819:241 reply Executives earn more based on revenues and thus prices and not stock returns.
By lotsofpulp 2025-10-2820:21 See almost any of the proxy filings and you will see much of the compensation is based on hitting targets other than just revenue, and most of the compensation itself is equity:
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...
https://s202.q4cdn.com/665319960/files/doc_financials/2025/a...
The executives seem to have a heavy interest in equity returns.
By Me001 2025-10-2823:52 [dead]
By BobbyTables2 2025-10-2823:53 Insurance companies are required to spend something like 80% of premiums on claims.
This sounds like a really good thing, almost everything coming in has to go back out…
What it really means is they love high “allowed” prices. They live on the 20% and want to see the pie as large as possible.
Healthcare costs go up? They raise premiums — win-win.
The road to hell is only paved with good intentions.
> since another insurance company would just steal their customers by having lower
LOL. Meanwhile, in real-life America, there are only four or five major carriers that control the market, and none of them are incentivized to do this "competition" thing you speak of by engaging in damaging price wars. Why would they when continuing to be part of the problem makes them more and more profits each year? See also: military contracting. Do you see them constantly undercutting each other? No, they buy each other, reducing the number of bidders on every contract.
By lotsofpulp 2025-10-2818:441 reply >Why would they when continuing to be part of the problem makes them more and more profits each year?
In real-life America, they don't even earn enough profit to earn their shareholders a better return than SP500:
https://news.ycombinator.com/item?id=45736978
And in real-life America, the only people health insurance companies engage in price wars with is the state insurance regulator who gets to deny requested price increases.
By xp84 2025-10-290:05 Fascinating observation, thanks for challenging my assumptions here. Just seems to further point out how useless health insurers are, even to their shareholders.
My most sincere wish is that all insurers would be nationalized, every last employee summarily fired, and their HQs all imploded and replaced with memorials to all the people whose lives they have cut short over the years. Not a thing of value would be lost IMO. Worse than paying people to dig holes and fill them in again.
By astrange 2025-10-2818:34 The military encourages them to buy each other because it's much easier to regulate an industry with fewer companies in it.
Four or five competitors is plenty for a healthy market.
Where I live, they do compete on price - prices vary by about 30% for similar coverage. They can't engage in the kind of price war you're thinking of since insurance companies, by law, have to maintain a fund able to cover costs, have to get rate changes approved by regulators and are largely banned from price discrimination.
I understand the desire to shift blame entirely onto insurance companies rather than providers. After all, one is all about money and the other is seemingly all about healing.
Heck, when a provider does bill people directly because an insurance company refused to pay, we blame insurance companies - even when the charges on those bills are highway robbery - like those in the article itself.
The fact is, the net cost of health insurance was about $279 billion in 2022. Meanwhile, $3.7 trillion went to healthcare providers, pharmacies and the like for care. The ones who stand the most to gain from higher prices are providers.
Frankly, decades of lobbying from the healthcare provider lobby to enrich themselves should have made it this obvious, but sadly, people see doctors as selfless angels and it blinds them.
By BobbyTables2 2025-10-2823:56 Providers have certainly gotten greedy but still can’t compete against hospitals when it comes to ridiculous billing.
I practically damn feel sorry for surgeons when I see what they get from insurance versus the hospital for providing the operating room or bed.
By Izikiel43 2025-10-2818:55 Aren't they doing some kind of turf non compete agreement like isps do?
I had read that comcast won't go into century link territory and viceversa, and something along those lines for the major isps, in order be local monopolies and set prices as they like.
By f1shy 2025-10-2817:58 Fuck those assholes!!! From 20k to 500… how do you name that?
By Izikiel43 2025-10-2818:52 > to justify increasing premiums so they can get 80% of a bigger pie.
Wouldn't it be 20% of a bigger pile?
By sidewndr46 2025-10-2816:55 I used to live with a guy from Guatemala, who at some point or another wound up at the ER. At the time his insurance apparently had some huge deductible for ER visits so he got the whole bill in excess of $1000. He was going to pay it, so I suggested he just call and tell them he was planning to leave the country and not come back. I told him to tell them there was no way he could pay the full amount, but didn't want to leave a debt out there like this. They lowered the bill to $150 after a few minutes on the phone.
Many years ago, I managed to stab my face with a screwdriver (not my proudest moment), and had to go to the ER. After the stitches, I was asked whether I wanted to pay with insurance. If I did, it was something like $2,000. If I didn't, there was a 75% discount off MSRP. My deductible was like 25%, so it ended up basically being the same out of pocket either way.
The fact that there seems to be a 4x markup means makes me think insurance companies are in bed with these hospitals. If you can mark up prices arbitrarily high, the insurance "discount" is fake.
By amenhotep 2025-10-2818:24 There's all kinds of shenanigans that these prices enable: https://archive.is/jPE3n
By xeonmc 2025-10-2818:37 From what I heard, doctors’ bonuses rates per unit of work are entirely calculated based on the specific hospital’s revenue from medical insurance claims; smaller hospitals can’t get as many patient payouts so their rates are lower and so are not as attractive to doctors compared to hospitals that can scalp well. So the prices do relate somewhat to what the hospital must spend on personnel, even if it’s arbitrarily engineered in the first place.
There are cases with prescriptions where its actually better to claim to be uninsured
By supertrope 2025-10-2823:42 At Costco Pharmacy I stopped using my insurance plan as the co-pay was more than the no claim cash price. I learned later that my health insurance company owns its own pharmacy and they design the claims process to bias you toward their own pharmacy. Since medical loss ratio must exceed 85% on employer health plans they realize their excess profits by jacking up prices at their pharmacy subsidiary and using their pharmacy benefit manager subsidiary and insurance product to steer you toward overpaying if you just take their suggestion (e.g. $100 if you use OptumRX mail order Pharmacy for the "savings" versus $20 cash price from Costco).
By drdec 2025-10-2817:53 > Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)
Don't leave out the part where the consumer doesn't even shop (or sometimes pay) for the insurance policy either, it is determined by their place of work.
So the consumer of healthcare is doubly shielded from any price signals the market might supply.
By potato3732842 2025-10-2817:39 I know a couple that avoided marriage so she could negotiate the childbirth bill on the basis that she was an uninsured single mom who didn't own property, etc, etc.
By intrasight 2025-10-2818:171 reply Health Care Sharing Ministries (HCSMs) are an interesting loophole in healthcare regulations that excepts uninsured people that participate in an HCSM from paying the tax penalty.
HCSMs are membership organizations in which people with common religious or ethical beliefs share medical expenses with one another. They are not the same as traditional health insurance.
Because patients are considered "self-pay", they negotiate their own prices with providers and they are likely to get an 80% or more discount on "list price" for the service. They are reimbursed by the HCSM if the HCSM approves the reimbursement.
As of 2025, approximately 1.7 million Americans participate in Health Care Sharing Ministries (HCSMs), which amounts to about 0.5% of the U.S. population. In Colorado alone, HCSM enrollment (at least 68k) is equivalent to 30 percent of Obamacare enrollment.
Because HCSMs often exclude essential health services and are therefore more attractive to people who are relatively healthy, enrollment of this size, relative to marketplace enrollment, may increase premiums for marketplace plans.
I am not promoting HCSMs but I did research it when I lost my COBRA coverage a few years ago. I do find it an interesting alternative approach to paying for healthcare. We really do need to explore options in this country.
I can definitely see AI being applied in the HCSM context.
https://www.commonwealthfund.org/publications/fund-reports/2...
By supertrope 2025-10-2823:541 reply Warning! As grotesque as health insurance companies are, in theory they are obligated to pay valid claims under your policy. Health sharing ministries can exercise discretion to deny payment because they disagree with your lifestyle choices. Or for any reason or no reason given at all. They are subject to far fewer regulations and audits and in some extreme cases the administrators just pocketed the money.
By intrasight 2025-10-290:12 More and more states are auditing them. But yes it's a faith thing. And definitely not insurance. Works better for tight-knit communities where there is trust.
By gwbas1c 2025-10-2817:33 > Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged.
Not quite: US hospital billing is based on the idea that the insurance company does the haggling for you.
Insurance companies negotiate (cough) "the best rate that the hospital has to offer," therefore: What the insurance company pays is confidential, and the official unnegotiated price is highly inflated. That's why hospitals will always negotiate with uninsured patients, because they're deliberately inflating their fees.
---
In 2011 I had surgery. The first bill was for $100,000, which was sent to the insurance company. Then the insurance company got a letter (cough) "reminding" the hospital of the negotiated rates. The next bill was $20,000. On a follow-up visit, they did an X-ray, and sent me the bill. I sat on it, and then called my insurance company. The insurance company called the hospital to (cough) "remind" them that the negotiated rate for that kind of X-ray was $0.
By almosthere 2025-10-2818:41 So you're saying one solution is to get rid of all insurance and make hospitals charge a reasonable price. Sounds good to me. You sound conservative!
A large portion of the US economy is based on this entire grift pipeline (settling before getting to court). And it's very costly and pushes up insurance costs and costs in general for everyone else.
When people talk about government inefficiency, I always think of how prevalent these kinds of shenanigans really are. I think they are more costly than inefficient government.
By otikik 2025-10-2818:12 The private sector is more efficient at extracting a profit. That doesn't mean they will be better at providing a service, however.
By morleytj 2025-10-2817:08 It's incredibly costly, and I think it's also incredibly costly in difficult to measure ways. The main method that the average American (read as: not incredibly wealthy person who has lawyers retained) uses to deal with the early stages of this pipeline is engaging in interminably long phone calls, going back and forth between multiple stakeholders, and trying to negotiate as to what actually needs to be paid or done individually. The incentives are aligned for various members of this process to make it a complicated and frustrating experience for customers, because they often benefit from increasing friction for the insured party. I think if you measured working hours lost or impacted by this it would be startlingly high.
By potato3732842 2025-10-2817:42 The government does it too.
Pretty much every 4+ figure civil violation, fine, etc, etc, is assessed on the basis of "what's the most we can get away with that won't have them taking us to court where it'll get knocked down or cause a public outcry if they tell the news"
By lotsofpulp 2025-10-2817:112 reply Having to settle because court cases take too long to resolve is due to inefficient government.
Not only does the actual court case and appeals process take years, but even after you “win”, the collection process takes years after it has already been determined who owes what.
See Alex Jones for a ridiculous example. He should have been homeless and shirtless a long time ago.
By Terr_ 2025-10-2817:30 While you're not wrong that most "justice" processes are expensive, I think the parent-poster is referring to a different kind of "government inefficiency", things like:
1. Single-payer health insurance.
2. Laws that insurance-companies must actually use X% of their premiums on payouts.
3. Laws requiring disclosure of negotiated prices, to encourage competition via free-market forces.
this looks like shopping in Moroccan bazaar with no price labels. But here you bargaining not for couple fruits but for your health and price range is in thousands. WTF :)
By bonoboTP 2025-10-2818:42 Yeah at this point this is more like a cultural ritual. You know like howin some cultures you have to refuse a gift 5 times with increasingly stubborn facial expressions, and the gift giver has to insist through it all, and then accept and say thanks. As the default.
Or where you as a guest announce that you now go home, and the hosts have to insist you stay for some more tea or whatever and then you have to again and again say you're now going really and they insist you stay so you chat more in the hallway etc. And it's just how it always is and it would be super rude to just leave or if the host didn't demand that you stay.
Similarly the US developed this traditional ritual that the first bill is outrageously expensive and everyone knows that everyone know, but the ritual protocol say you gotta start with that, we are civilized people, we say hello, so in Healthcare the hello is the huge price, and the interaction always ends in a lowered rate, because that's also part of the protocol.
It's just a cultural difference.
By kasey_junk 2025-10-2818:212 reply It’s worse than that. In a bazaar there are only 2 participants and they are looking out for their own interests. Most Americans don’t choose their own insurance their _employers_ do.
The insurance company has no reason to make the health recipient happy and the health recipient has little agency in pricing.
By supertrope 2025-10-290:00 In a bazaar you can examine the fruit or rug yourself.
An average person cannot call up $750K in a year to pay for cancer treatment. But for-profit businesses (and any organization for that matter) treat you much better if keep the carrot of another payment in front of their face. If you've forked over the whole wad of cash upfront they immediately de-prioritize keeping you satisfied.
By mgkimsal 2025-10-2818:31 > Most Americans don’t choose their own insurance their _employers_ do.
I don't have an employer, but I still only have one company selling health insurance in my county, so... that's all I can buy.
By gowld 2025-10-2818:55 It's even weirder than that, because in healthcare you consume the product&service before anyone even starts to talk about negotiating the price!
We are self-employed in the US and buy our own high deductible plan on our state's marketplace. One of my family members needed a fairly routine planned surgery, so I went through the effort to try to determine in advance how much I would be billed. What a waste of time. My favorite was the hospital who told me the fee for a one night stay would be 73k. But, good news! Your insurance has a contracted discount that brings it down to 13k. So what does the 73k price even mean? At this point I shelved the effort as I correctly concluded we would hit our household max out of pocket for the year, so anything above that would not affect us.
And hey! Silver lining: in a year when we max the out of pocket limit, no more cost-sharing on any other services for that calendar year! Time to pack in some care we have been deferring mostly due to cost. Except the care providers and insurance company are well aware of this, so they don't bill you for up to a year from the date of service, so you can't be sure you "hit your max" until the subsequent year.
It is enough to induce strong negative emotions.
By BurningFrog 2025-10-2818:11 The Surgery Center of Oklahoma publishes all their prices, and do not take insurance:
https://surgerycenterok.com/surgery-prices/
They're the pioneer, but there are other clinics like that.
By JCM9 2025-10-2818:34 The “full” prices are basically just made up. If this was like the insurance company negotiates a 15% discount than OK. But the reality is crazy stuff like the “full price” is $7,623 but “your insurance company paid” $34.12. It’s totally bonkers and should be illegal.
By lokar 2025-10-2915:42 But that’s expected. Even in a restaurant it’s not like each dish is priced as cost to make plus a markup. It varies widely, what matters is that the prices make sense in the market and over a week/month the overall numbers work out.
A hospital is vastly more complex. They have huge costs (for things they must have) that can’t be recovered 1:1 with services.
By atourgates 2025-10-2817:124 reply What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.
If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).
The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."
That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.
Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)
Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.
That's basically the way all medical billing to private and government insurance providers in this country works.
"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.
I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.
By woadwarrior01 2025-10-2817:582 reply > What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.
Interestingly enough, the FBI considers double billing and phantom billing by medical providers, to be fraud.
https://www.fbi.gov/investigate/white-collar-crime/health-ca...
By atourgates 2025-10-2819:03 Yes. Though I think technically none of that happened here.
If I sound like I'm defending the morality of the hospital for billing a private individual $190k for services they'd expect to be paid $37k for, please know that I'm not. But it helps to understand WHY the hospital billed that much, and whether it's legal for the hospital to bill that much.
The biggest semantic "mistake" the author makes in their thread is saying, "Claude figured out that the biggest rule for Medicare was that one of the codes meant all other procedures and supplies during the encounter were unbillable."
The Medicare rule does not make those codes "unbillable" - it makes them unreimburseable.
The hospital can both bill Medicare for a bigger procedure code, and the individual components of that procedure, but Medicare is gonna say, "Thanks for the bill, you're only entitled to be paid for the bigger procedure code, not the stuff in there."
Neither the FBI nor Medicare is gonna go after the hospital for submitting covered procedure codes and individual codes that are unreimbursable under those procedure codes. That's not crime, that's just medical billing.
Actual double billing would occur if, say, your insurnace paid the hospital for a procedure, and then they came after you for more money, or billed a secondary insurance for the same procedure. Or if they'd said, "Oh no, the OP's brother in law wasn't here for just 4-hours, they were here overnight so now we're billing for that as well."
NOW - a much better way for the hospital to handle this scenario would be to see that the patient is cash-pay, and then have separate cash-pay rates that they get billed that essentially mirror Medicare reimbursement. That's essentially what the author got them to do, and it absolutely sucks that's what he had to do.
By gowld 2025-10-2818:56 And yet Florida elected a Senator who earned over $100M doing just that.
By SkyPuncher 2025-10-2822:55 I briefly worked in adjacent space. While I hate the way it works, it makes a lot more sense when you understand that the billed amount is essentially just a negotiation tactic that represents a price well above what they ever expect to be paid (and a bit added to that for safety).
Then, they negotiate with all of the in-network providers for some number that’s well below the billed amount. That number varies a bit based on how effective various negotiations are.
Realistically, OP simply found the number that insurance was going to pay out anyways.
I think the argument is that it’s criminal to take advantage of the patient without insurance and ask them to ruin their life trying to come up with 195k when your system is setup to reasonably profit off the 37k you get from the insured patients. I firmly believe that even in a capitalist society the idea of profiting off of anything let alone healthcare in the thousands of percentage points is criminal.
I think he meant literally criminal.
The hospital double billed for over $100k worth of services on the original invoice.
At a certain point a pattern of issuing inaccurate invoices crosses the line into negligence.
If a business just have a habit of blasting out invoices that bill for services never received, and they know that they keep doing this, and only correct it when the customer points it out, at a certain point it turns into a crime.
By MattyRad 2025-10-290:03 From a quick Google query, it says that ~%90 of Americans have health insurance (which seems higher to me than I'd expected). I'd be very interested in knowing the number of uninsured, negligent/nefarious, and exorbitant invoices that are issued as a percentage of all invoices, for the purpose of determining the scale of criminality with respect to your description.
By itsthecourier 2025-10-2817:45 double charging on purpose systematically sounds slightly criminal to me
By potato3732842 2025-10-2816:252 reply Exactly. You can do this with anything where the racket is based around the layman not being able to take in the amount of arcane subject matter info they'd need to argue their case, not just medical.
Tons of institutions that specialize in screwing people are built this way because it's pretty hard to "overtly" build an institution to screw people.
This! People underestimate the extent to which lawyers are negotiable also. “I’m not paying that” is a surprisingly effective method; they’re often willing to compromise on payment terms, work at-risk subject to a successful outcome, significantly reduce their rates, etc.
By kemitchell 2025-10-290:05 In my experience, most people underestimate what's negotiable across the board. Especially those making enough to do most of their business with mass-market operations, like big-box stores and retail service providers, that profit by doing many, many standardized transactions every day, with minimal discretion or even personal involvement.
Below that, lots of haggling and informal trade often help people get by. The costs of that process can be another burden on the poor. At the high end, it's worth involving people with discretion on the sell side. Additionally, sales are often one-off and customized. They may also bundle a bunch of different items and benefits without clear line-item breakdowns.
When hiring a lawyer, I'd nearly always recommend getting terms down in a written and signed engagement letter before work starts. That is very much a negotiation, but it's fine to ask questions and comparison shop.
If you're starting with a call, it's perfectly normal to start by asking whether initial consultation will be billed or not. If it will be, ask the rate. If it won't be, expect some limits on what can be discussed. The best lawyers I know aren't cheap or easily tricked into giving free advice on consultation calls with speedrunners, but they are up-front about what they charge for and how.
Disclosure: Am lawyer. Negotiate professionally.
By alistairSH 2025-10-2817:131 reply Not just arcane subject matter, but numbers so high any sane person panics.
Hospital: "Here's your bill for $1,000,000." (a figure which is 100% fictional) Patient: <panic> "Oh shit, I don't have $1,000,000!" Hospital: "Oh, we'll reduce it to $30,000. Aren't we nice!" Patient: <slightly less panic> "I don't have $30,000 either, but it might not bankrupt me immediately, so I guess that'll do..."
Never mind that the same procedure in most of the EU was either "free" (to consumer at time of care) or a fraction of the cost.
The whole system is fucked.
By macrolime 2025-10-2818:56 In the EU you can also generally look up the cost, even in cases where the patient doesn't pay, there is a bill and fixed costs. The costs are what the government pays or what a foreigner with no medical coverage and insurance would pay. It's also generally a tiny fraction of the cost in the US.
By nonethewiser 2025-10-2817:022 reply > it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.
Im increasingly of the opinion that AI gives people more confidence than insight. The author probably could have just thought of the same or similar things to assert to the hospital and gotten the same result. However, he wouldn't have necessarily though his assertions would be convincing, since he has no idea whats going on. AI doesn't either, but it seems like it does.
By embedding-shape 2025-10-2817:061 reply I've found LLMs helpful for figuring out what I don't know, then I can go and look up how those things work, again together with an LLM.
But in the past, once I got to the point where I know I could maybe do something about it, but not exactly what, and I don't know any of the domain words used, you got pretty much stuck unless you asked other people, either locally or on the internet.
At least now I can explore what I don't know, and decide if it's relevant or not. It's really helpful when diving into new topics, because it gives you a starting point.
I would never send something to a real human that a LLM composed without me, I still want to write and decide everything 100% myself, but I use more LLMs as a powerful search engine where you can put synonyms or questions and get somewhat fine answers from it.
By nonethewiser 2025-10-2817:45 Absolutely. It's cheap (as far as the user is concerned) to just fire off a question. And it can even be really fuzzy/ambiguous/ill-defined sometimes. It's a great starting point.
By tclancy 2025-10-2819:26 "But fight with knowledge. My $20/month subscription to Claude more than paid for itself. Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right. I also had ChatGPT, to which I subscribed for one month just to do this, read the letter and fact check it. No notes."
By pavel_lishin 2025-10-2817:16 > The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.
This will always happen, especially if you don't have health insurance. I had to have surgery without insurance in the early 2000s, and I was able to knock off a large percentage of the bill (don't remember how much, it's been decades) by literally just writing back to the hospital and asking them to double check and verify the line items I was being charged.
(edit: more stories along similar lines in this thread: https://news.ycombinator.com/item?id=45735136)
Totally agree that even this buggy expert can empower patients.
But you better believe that hospitals all over the place are also using AI to find ways around Medicare/Insurance rules to maximize their profit too.
The rules are probably going to get WAY more complex because they will rely less on a few humans, and more on very powerful AIs.
Old poker adage: "The more wild cards and crazy rules, the greater the expert's advantage."
Poker has nothing on Commercial Lawfare.
By SilasX 2025-10-2915:58 Oh wow, I had independently formulated that as the duality/parallel between corruption and cheat codes: "The more out-of-band information you need in order to be treated normally/fairly, the more corrupt the system is."
By thaumasiotes 2025-10-2816:572 reply This reflects a common complaint in social engineering.
People keep trying to enact rules to stick it to the elites and make the downtrodden better off.
And as the rules get more and more complex, the position of the elites gets more and more solid.
By photonthug 2025-10-2817:51 Adding complexity is just one aspect. Everywhere there is someone whose job is to ensure the bottom line never changes and status quo for the powerful is preserved. Insurance, taxes, rents.. in the absence of effective regulation, the average number of successful appeals will simply get factored in and average costs go up so that profit stays the same and grows at the same rate as before. Similar to how chains factor in losses due to spoilage or theft.. of course they don't actually take a profit loss, they just price it in.
I really don't get people who see this kind of thing as empowering because in the end your (now strictly necessary) appeal with lawyers or AI to get a more fair deal just becomes a new tax on your time/money; you are worse off than before. A good capitalist will notice these dynamics, and invest in AI once it's as required for life as healthcare is, and then work on driving up the costs of AI. Big win for someone but not the downtrodden.
Exactly. The elites hire experts to do it for them, while everybody else has to deal with the complex rules themselves.
It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.
By mrguyorama 2025-10-2818:29 >It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.
The IRS disagrees every single year.
They say they can easily recover significant revenue from tax cheats if they were staffed and funded enough, to the point that every dollar you fund the IRS recovers 1.6 dollars.
The rich people who say they are just getting their fair deductions then refuse to fund the IRS.
If they weren't cheating, they wouldn't have to kneecap the IRS.
I suppose a saving grace there is that Medicare is incentivized to help people or at least not incentivized to provide the minimum amount of value for maximum profit.
By SoftTalker 2025-10-2816:391 reply Lol. Who do you think makes the Medicare rules?
By hooverd 2025-10-2816:54 CMS?
By ToucanLoucan 2025-10-2816:26 So what you're saying is we've injected a whole smorgasbord of electrical dumbasses into a system already rife with corruption, greed and exploitation that provides services no person can do without and is frustrating to use at every juncture.
Yaaaaaaaaaaaaaaaay.
> Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right.
By enraged_camel 2025-10-2816:50 The funniest bit about all this is that this is all just laziness all the way down. People complain about AI-written articles. When the article is written about a human, they fall over themselves to point out potential flaws, like "well it looks like AI hallucinated" and it gets voted to the top. Then it turns out that they themselves did not read the article. Just a damning indictment of the quality of online discourse in year 2025.
By awillen 2025-10-2817:11 Often with these kinds of things it's not even as much about being specifically accurate as it is about presenting yourself in a way that makes the other party believe that have sufficient understanding of the issue at hand and the escalation paths available that you won't just go away if they don't play ball. That is, make yourself credibly as a Dangerous Professional, in patio11 parlance.
I just did this with a pet insurance bill, and ChatGPT was very helpful. They denied based on the pre-existing condition exclusion even where it was obviously not valid (my dog chipped her tooth severely enough to need a root canal, and they denied because years before when she wasn't covered under the policy, she had chipped the same tooth in a minor, completely cosmetic way).
I was sure they were in the wrong and would've written a demand letter even in the pre-AI days, but ChatGPT helped me articulate it in a way that made me sound vastly more competent than the average consumer threatening a lawsuit. It helped make my language as legally formal as possible, and it gave me specific statutes around what comprises a pre-existing condition in CA as well as case law that placed very high standards on insurers seeking to decline coverage by invoking an exclusion (yes I checked, and they were real cases that said what it thought they said).
Gave them fourteen days to reverse the denial before I filed in small claims court, and on day fourteen got a letter informing me that the claim would be paid in full. It's of basically no cost to them to deny even remotely borderline cases, so you have to make them believe that you will use the court system or whatever other escalation paths there are to impose costs, and LLMs are great for that.
By CGMthrowaway 2025-10-2817:042 reply >It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.
What exactly do you think negotiating is? Real negotiation in business transactions is more often based on agreements around certain facts than emotional manipulation.
By aeturnum 2025-10-2818:47 I guess I would think that negotiating at least involves communicating with your counter-party. Its role here feels more similar to being a billing consultant. There are plenty of people (and systems) that pass messaging over to the actual AI - which was my expectation from the title and why I noted it didn't happen.
By kenjackson 2025-10-2818:36 People want so badly that AI won't be useful that I feel like they will diminish everything they do. I also get that they probably feel like it's all hype, but there are plenty of examples of real value that AI brings to the table.
By themafia 2025-10-2818:47 > the hospital came back with a much lower offer.
Yes, because, there is an entire department _dedicated_ to this function. You just call them and say "I can't pay this" and you'll get the same result.
By itissid 2025-10-2817:40 The author mentioned in a reply in threads that most of the fees was Facility Fees. That might be just wrapped up in a code for cardiology sure, but its just profit chasing hospitals because that practice can wildly inflate the cost and billing and that can be fought.
> I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.
I'm a cofounder of Turquoise Health and this is all we do, all day. Our purpose is to make it really easy to know the entire, all-in, upfront cost of a complex healthcare encounter under any insurance plan. You can see upfront bills for many procedures paid by various healthcare plans on our website.
The information posted in the thread is generally correct. Hospitals have fictional list prices and they on average only expect to collect ~30% of that list price from commercial insurance plans. For Medicare patients, they collect around 15%. The amount the user finally settled for was ~15% of the billed amount, so it all checks out.
The reason for fictional list prices (like everything in US healthcare) is historical, but that doesn't make it any more logical. Many hospital insurance contracts are written as "insurer will pay X% of hospital's billed charges for Y treatment" where X% is a number like 30. No one is 'supposed' to pay anywhere near the list price. Yes, this is a terrible way to do things. Yes, there are shenanigans with logging expected price reductions are 'charity' for tax purposes. But there isn't a single bad guy here. The whole system that is a mess on all sides.
Part of the problem is that the US healthcare billing system is incredibly complex. Billing is as granular as possible. It's like paying for a burger at a restaurant by paying for separate line items like the sesame seeds on the bun, the flour in the bun, the employee time to set the bun on the burger, the level of experience of the bun-setter (was it a Dr. Bun Setter or an RN bun setter?), etc. But like the user said, some of these granular charges get rolled up into a fixed rate for the main service.
However, the roll-up rules are different for every insurance contract. So saying the hospital 'billed them twice' is only maybe true. The answer would be different based on the patient's specific insurance plan and how that insurance company negotiated it. Hospitals often have little idea how much they will get paid to do X service before it happens. They just bill the insurance company and see what comes back. When a patient comes in without insurance, they don't know how to estimate the bill since there is no insurance agreement to follow. So they start from the imaginary list prices and send the patient an astronomically high bill, expecting it to be negotiated down. In some areas, there are now laws like 'you can't charge an uninsured patient more than your highest negotiated insurance rate' but these are not universal.
If you find yourself in this situation, there are good charities like 'Dollar For' that can help patients negotiate this bill down for you. We are trying to address this complexity with software and have made a lot of progress, but there is much more to do. The government has legislation (the No Surprises Act) that requires hospitals to provide upfront estimates and enter mediation if the bill varies more than $400 from that amount. But some parts of the law don't have an enforcement date set yet, which we hope changes soon.
By antisthenes 2025-10-2818:53 > even access to a potentially buggy and unreliable expert is very helpful
Which is a great description of the American health care industry, even before its involvement with AI in any capacity.
