Framing it this way is probably inaccurate, and if inaccurate, unhelpful.
From decades of observing the system, it seems extremely unlikely to me that it was deliberately engineered to be this way. Rather, different parts of it grew and changed organically and the parts and changes that benefitted moneyed interests in power stayed, while those that did not were discarded.
It does not take a deliberate will behind something for it to be pulled toward this sort of inequality, and presenting it as if that's what's happened suggests that if we could only defeat the Evil People who "engineered" it this way, we could make it better. It's a very compelling idea, and it makes for a nice dramatic narrative, and humans love good stories.
Unfortunately, it's not the case. In order to make it better, we need to take a good, comprehensive look at many aspects of our systems of economics and government, and redesign them deliberately and with a strong intention to inhibit the flow of money upward from the 99% to the 1%. It's hard, it will take a long time, the people with the most wealth and power will fight us every step of the way, and there's no silver bullet, but there's also very little that's more worth doing.
Agree in part — but there has been some engineering due to the moneyed interests. Few other industries have the perverse incentive structure where you cannot “shop around” to keep costs low. Also, the tax code was most assuredly engineered: tax code, as insurance that pays for medical procedures is tax-free to workers. But if they want to pay for the same procedure out of pocket, they have to pay tax on it. This leads to more insurance coverage and less consumer control.
It does seem like it’s engineered towards making profits in extremely unethical ways?
I get they need to make money, but many times it seems like hospitals/doctors sent out bills just hoping people will pay.
Me, and my father used to have great union insurance (Cadillac plans). For years their were no problems. That started to change in the late 90’s.
1. I once got a $900 lab test from a hospital. They knew I had insurance. I called multiple times, and told don’t worry about it, but I still got the bills. Lather I saw what the the hospital charged my insurance company, and it was $90 for the test. I paid $9 for my premium. Isn’t in the hospitals interest to send out bills just hoping I might pay $900?
2. My mom is sent so many bills even though she has the same plan.
My point is there are no laws against sending out bills. Hospitals/doctors might not have it written down anywhere, but just send out a bill, and let the patient clean up the mess with their insurance company seems like a good strategy—for the heathens?
My mom had a bad tooth a few years ago. Went to her dentist, and he demanded cash upfront—conveniently on a Friday, and he knew she had great insurance. She paid because of the pain. She called up a few weeks later, and asked for a refund. She gave $2500, and insurance (Delta Dental) paid 90% of the bill. She kept calling the dr’s office, but always was told we need to contact the insurance company. I finally got on to a Delta Dental worker, and started to explain the situation. The work seemed to know exactly what I was trying to say. In thirty minutes, after Delta called the doctor, a highly apologetic money manger said we are sending off your check today. (I won’t publicly saw what the representative implied here of the doctor here.)
3. My father once went to Marin General for a routine hernia surgery. My father was beyond a hardened man. I saw him close to crying once, and it over taxes. Well he woke up after the surgery, and their was a Teddy Bear, and bouquet of flowers waiting for him. It wasn’t me, I told him. Anyways it was a mystery until he got his bill. Beyond the typical $12 Tylenol’s, there was a $330 psychological enrichment fee. Yes—that was the hospital charging my father, and insurance for the unasked for gift.
So it is it seems like it’s in their best financial interest to overcharge, do unethical things, and hope people just pay?
No one argues that the California or Texas power grids were geared to be unreliable and fail, but they were deliberately engineered over the years in specific ways for specific reasons.
Our medical system is no different. Insurers developed byzantine claims departments and custom plans as a way to make medical coding complicated and error prone for the purpose of denying claims due to error. They setup private panels and doctors to reviews claims and treatment plans with the explicit purpose of denying claims as not medically necessary.
The system is designed to intimidate, overwhelm, and confuse and it's stacked against both the customer and the medical provider.
There are three heads to this beast: hospitals, insurance companies, and drug companies. Each swears it is innocent and points to the other two and calls them the problem, but they are all guilty.
You've covered the evil tactics of insurers, but providers absolutely engage in intentional opaqueness, overbilling, and as much screwball behavior as the market will bear. No, the insurance company did not force them to charge $500 for an aspirin and "accidentally" bill in full for a procedure that was discussed as a hypothetical but never actually happened. "Look over there!" isn't going to cut it as an excuse forever.
Over billing is a result of the complexity of the system. Care providers have to hire full-time staff trained to deal with insurance and file claims. Insurers negotiate rates with care providers that put them in a position of having no customers or ones they're paid poorly for. They have responded by playing games with billing and insurance to make ends meet.
Is it fair or honest? No but if they suddenly became fair and honest it would solve nothing because they're a symptom of the problem, not a source.
Same goes for insurance companies: just letting providers overbill would not solve the problem.
I'm sure the overbilling and weaponized opaqueness are plausibly deniable, but I'm just as sure that providers don't mind one bit when they work, just as an insurance company doesn't mind when they discover an excuse to deny coverage. Providers are not "making ends meet," they are testing the limits of how far they can exploit the blank checks they have been written. They are not solely responsible for this mess, but they have a full share of moral and systemic culpability.
Sure, nobody sat down 50 years ago and said this is how we want things to happen, but each individual part was created and the direct interactions are intentional.
For example insurance pays for procedures not the process of doctors filling out insurance forms. That’s by design and ends up having horrifying implications for the healthcare system as doctors often spend more time dealing with insurance than the patient actually needing treatment.
The intent is to maintain status-quo despite evidence that it's a broken system for medical users. Profits are being made based on the system we have. It's boards & c-suite executives keeping their fiduciary responsibility to their investors by lobbying against structural change. The intent is clearly there.
The intent is socially entrenched though - it's not just c-level executives calling for keeping the government out of healthcare. America has a real problem with anything that even smells like socialism or egalitarianism.
> It does not take a deliberate will behind something for it to be pulled toward this sort of inequality, and presenting it as if that's what's happened suggests that if we could only defeat the Evil People who "engineered" it this way, we could make it better.
...but then also this:
> ...to inhibit the flow of money upward from the 99% to the 1%. It's hard, it will take a long time, the people with the most wealth and power will fight us every step of the way...
So maybe there are "evil" people and deliberation at work, and it's not just emergent complexity?
There can be "evil" people who will work to prevent the dismantling of a system, even if those people did not deliberately design and build that system. All that is required is that they recognize that the status quo benefits them, and that's a very common situation for those among the elite.
The Social Transformation of American Medicine is an illuminating read. Much of how we got here came in the form of, essentially, patches on top of patches, some of which were for good reasons, some of which were not.
Non for profit is a nice smokescreen. Nonprofit status is a nice little windfall fir the permanent bureaucrat class at payors and hospitals.
Starting from cancer children's hospitals that do all kinds of tricks to energize fundraisers and draw donations.. which amount to a paltry 30% of their CEO's salary....
Is it any surprise that admins then balk at putting prices online, with an argument that can be summed up as "OMG, you make us put online the price from 2000 contracts!! Its too hard! "
Here is a little nugget. Nonprofit designation for hospital is a recent development. It didn't exist before 1900. The designation was effectively "compensation" by the government to hospitals, so the latter would agree to admit patients regardless of ability to pay. Quid pro quo.
Dont feel bad for hospitals and their "curse" of nonpaying patients. They got their pound of flesh.
Nonprofit status its not just federal exemption.. its ALL Taxes (state, local, real estate, commercial, etc).
Imagine your life if you didn't have to pay sale tax? Property tax? State tax ? FICA, FUTA SDI?
I've come to the conclusion the past couple years is we need to get rid of non-profit status. There is too much room for grift and I'm afraid narrowing requirements would just make more loop holes and continue the process. I don't think that would be a popular opinion but I really don't see another solution to the problems caused by non profits.
The executives, board members, and middle management at all of these companies. I've worked with some of the companies you named, they have lavish offices and gravy train jobs for everyone and their crony friends. Yes, they're "not for profit", but that doesn't mean no one gets (insane) bonuses. Checkout their 990s sometime to get an idea at the excess of cash being pocketed.
Employers and owners of practices, hospitals, clinics etc. Shareholders of pharmaceutical and medical device companies. Executives and administrative roles are paid well, too.
