We really need to switch to a National Health Service style of administration of health costs. Right now we have Medicare which makes unilateral cost determinations, and doctors and hospitals end up accepting below-cost reimbursement that because how could they turn away all the retired people, but they end up subsidizing these unilateral decisions with money from private insurance payors (namely everybody who's working).
Medicare might not technically be a monopsony, but it acts like one, and all the rest of us working folks end up paying the gap that rounds out the rest of the costs.
We have a few generations that have had easy lives, where they had easy access to homes, to higher education, to wealth building, and decided to cut off access to the same as soon as they got it, while still living off the labor of current working people that are not even allowed to build new apartments next to these wealthy people while they pay for all their health care.
The economy is a massive multiple player rpg with a point system economy that's fixed by federal and state laws, and it's been rigged both at the health care level and at every level to extract wealth for those that had it easy in the past.
The dirty little not-so-secret is that we pay doctors too much in the US. To the tune of several times as much as other large developed countries, like Germany, France and England. Medical care in the US will never ever be as cheap as those countries as long as the providers here earn 2x or 3x.
That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Another part of the problem is the bloated administrative bureaucracy of hospitals in the US, we well as the fact that you aren't allowed to build a new hospital (and yes, this is actually true) unless you can prove that a hospital is needed in a particular community.
With no competitive market for healthcare providers, nor a competitive market for places where they work, why shouldn't they extract as much as they can from the rest of us?
They get away with it, too, because "medical doctor" is one of the highest trusted and most reputable professions. It's badthink to discuss these things in polite company.
Until we fix those things, it simply doesn't matter how the insurance/payment system works. Every time I hear that we need to get rid of private insurers, nobody can seem to explain how doing that will save more than 10-15% despite the fact that insurance companies have a statutorily-limited profit margin.
The shortage of physicians has nothing to do with medical schools. The immediate bottleneck is a shortage of residency slots. Every year, students graduate from medical schools but are unable to practice medicine because they don't get matched to a residency program. (Some do get matched the following year.) This is primarily due to limited funding from Medicare, although some residency slots are funded from other sources.
I agree that certificate of need laws should be repealed to increase competition between healthcare facilities. That only impacts some states, not the whole country.
While many specialties are fully filled, we need pediatricians, family medicine, and internal medicine docs. They're generalists and where the largest shortage is. There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
My statement above was correct. There are students who graduate from accredited medical schools with MD/DO degrees but don't get matched. Part of that is because some of them simply don't apply to programs that have extra openings. Medicare / Medicaid pay primary care physicians below market rates so students are naturally reluctant to pursue those specialties.
Doctor salaries alone do not account for the hundreds of billions in profit that health insurance companies extract from us. You are right there is not a competitive market place because the US government cannot provide a universal plan for anyone. We all know the insurance companies would fold overnight as government welfare programs are extremely popular (just look at how much corporations love government welfare).
Odd how the most popular programs in the US, social security + medicare, are the ones with zero means testing.
Maybe let's not blame one of the few only noble professions left in our greed fueled world.
Blame the hospital administrators or pharmaceutical reps before you start blaming doctors.
It’s a red flag whenever someone talks about healthcare and they focus on health insurance companies and hospital administrators. It’s a sign that they’re working backwards from some ideological beef rather than looking at where the costs actually are.
Health insurance companies have profit margins around 5% or less. Hospitals are half that. A Subway franchise has a higher profit margin. That’s just not where your healthcare dollars are going.
The issue is not that health insurance companies make too much money (ok, it's not the only issue)They, along with the system they put in place introduce immense amounts of friction into every medical interaction and prevent doctors from practicing good medicine.
The insurance companies are not stopping the government from paying for everyone's healthcare. It's the other way around, governments are using insurance companies (better referred to as managed care organizations since they don't really sell insurance) to add the friction so that some people get more healthcare and some people get less.
Who gets more and who gets less depends on who has political power (that's why the old and non working get subsidized by the young and working), and in a democracy, this question ultimately comes back to the voters.
That is no longer true. What we have historically referred to as “health insurance” companies responded to ACA margin limits by becoming sprawling behemoths whose rampant self-dealing makes such profit margin calculations meaningless.
If you have a fixed profit margin, the way to make more absolute money is to allow your costs to increase. Insurance companies have zero reason to negotiate prices down.
The above obviously does not include the many millions of Americans covered by non profit insurers, such as Kaiser Permanence, Providence, Cambia, and the various Blue Cross plans.
Here are the 5 year returns for the above businesses compared to SP500:
No, they are not paid too much. There's a lot of incorrect assertions here, so it'll take a lot to work through them.
Physician pay depends on specialty, but it can range from the low $100kish mark for pediatricians to $500-750k for certain kinds of surgeons. Family medicine tends to be around $200k. However, this amount ranges vastly by market and top pay often goes to those willing to work in more rural hospitals because no one wants to. For example, pay in NYC for physicians is appalling low compared to the rest of the U.S. market. In addition, certain systems have hard caps. For example, the VA hospitals cap physician pay inclusive of bonus at $400k. This is documented and you can in fact just look up a random doc at the VA with one of the many federal pay search tools.
While some doctors can make more, it typically because they own a practice and that increased pay comes from good old fashioned capitalism. Meaning, they tax the amount their nurses, NPs, medical assistants, etc. make just like all businesses make money per head on their employees. Whether you believe this is right or wrong is up to you. However, this is not any different that someone who runs, for example, a yard care business. More accurate pay can be found by those who work directly for large hospitals.
Next, the cost of medical education in the United States is vastly higher than other countries. Right now, medical school will cost you somewhere from $400-600k. This is in addition to whatever debt accrued during undergraduate. Further, medical school applications are highly competitive, so students often accrue additional debt by completing a masters in something like public health prior to entry to medical school. This means that someone may have upwards of $750k of debt when they finish medical school, but they still have somewhere between 3-10 years of residency and fellowship before they make attending money. During this time, the debt accrues interest and balloons.
Now, once you become an attending, you're still not good and expenses are vast. Shift work can vary from something like 7 12-hour shifts in a row for intensivists to 14 shifts in a row for hospitalists. Note, just because it says its a 12-hour shift doesn't mean you work 12 hours. They still need to chart and bill and if it's busy, that may be another few hours after the shift is over. In some remote clinics, an ER physican may work 7 24-hour shifts in a row. That may sound absurd and unsafe and it likely is, but it's the reality of the work. If someone is working that schedule, they have increased expenses to just, frankly, live. On the low end, it's very difficult to cook in that environment, so you have to buy a lot of premade food. On a more expensive end, having children on this schedule is extremely difficult. You either require a spouse that doesn't work or you need something like a night nanny. If you're working 12 hour shifts, you must sleep at night and you can't be up to take care of a baby otherwise you run the risk of killing someone the next day. Unless you're paying someone under the table, current nanny rates in large markets are about $20-25/hour. Insurance rates are also high. I don't mean malpractice either. Generally speaking, one needs to carry disability insurance because if one gets into a car accident and breaks their magic hands, there's no way to pay back that debt otherwise. These policies are thousands a year. That's just the start. They pay a large amount of money to buy their time back because they don't have it.
Next, there's a myth about limiting residency slots in order to increase pay, at least recently. I will not defend the AMA and some of they took, especially in the 1990s. Here's the 2025 residency match data:
The number of offered and filled slots is on page 2 (or 13 depending on how you count). Some specialties filled all of their slots. Where the U.S. vastly lacks is pediatricians, family medicine, internal medicine (who can work like family medicine if need be.) Pediatricians had 147 unfilled slots. Family medicine had 805 unfilled spots. Internal medicine had 357 unfilled spots. These spots can be filled by people who graduated from U.S. medical schools, island medical schools, Mexican medical schools, or a vast array of other foreign medical schools. However, they're not filled because they don't have the applicants. That's not medical school collusion. That's the hard reality that medical school is extremely expensive and the training is extremely long.
Now, how do other countries handle things? One, their medical school is not as crushingly expensive. Two, places like Europe cap the number of hours a physican can work. If you want to pay American physicians less, you'd need to blow out their medical school debt, reduce their hours, and offer better benefits. Until then, no, really, they're not overpaid.
If you want to start pointing fingers, try the vertical integration of insurance companies, pharmacy benefit managers, and hospitals. I don't have the numbers readily available, so I'll stop here. But, really, it's not the docs.
Yes, and that national administration has to include national standards of care. The government should set cost-effective standards of care for various scenarios. Then doctors should have immunity to lawsuits as long as they followed the standard of care. You shouldn’t be able to sue a doctor and get some expert up there saying he should have run these additional tests or tried this additional treatment.
Potentially. The issue is how do you manage solvency.
State Medicaid and Workers Compensation funds were already insolvent before the 2024 election, and as such most states lack the fiscal overhead needed to fully support a fully funded single payer program today.
It would end up the same way the NHS has in the UK.
Vast swathes of the US are deeply fiscally troubled due to the impact of the COVID pandemic, and if that is not solved then we cannot even start to contemplate single payer.
This should not be used to justify austerity which is not the answer and does more harm than good, but points out that a reckoning is needed. From my personal experience dealing with the current crop of state and local politicos, it's looking dicey in portions of the US.
Edit: can't reply
> Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever
Yes. But you need capital to build an insurance fund. And a large portion of that is going to service existing liabilities.
Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever.
The core issue is it suddenly destroys a large number of companies and removes millions of unnecessary jobs from the economy. That’s a great deal of wealth and a great number of voters who don’t want you to save hundreds per month by making them redundant.
That makes sense for the "utilities" bucket, and to a small degree for the health insurance bucket, which are the biggest buckets linked.
Utilities have had complete regulatory capture of most states' Public Utilities Commissions. It's blatant and obvious in places like Arizona that have open corruption in their elections and commission decisions. But in places like California it's far more hidden: the massive increase in cost of utilities is mostly from increased costs for the transmission and distribution grid, but CPUC has basically zero information for the public to understand why they keep on handing over more money to the big utilities. There definitely seems to be massive corruption but where is it and what is the actual mechanism? It's so well hidden and sophisticated that if there is corruption nobody understands what the F is going on.
How do you replace a state-sponsored monopoly like a utility into something competitive? I don't know, when I learned econ 101 utilities were given as the example of a "natural" monopoly. But clearly that's not working out... maybe it just needs to be "state" rather than "state sponsored monopoly." The only other state sponsored monopoly we really have is the state itself. What does the public gain by allowing monopoly utilities that giving away the public's money to investors? The incentives are all off.
The problem with the health insurance bucket is not the number of players, it's that you're buying a pig in a poke.
Between ghost networks, death panels that deny you treatment, and the nature of deductibles, you have no fucking idea what you're buying, and whether or not you're getting ripped off.
The ammount of shrinkflation in the last year is just stunning. Sometimes they bother to make the bottle/box/can incrementally imperceptibly smaller. Sometimes they just put less in. I track macros so I'm always looking at weights, and they're generically down 20%, while prices are up.
From TFA (becuase apparently HNers can't read): "Sharp Increases in the Cost of Insurance and Utilities"
> "The largest increase by a wide margin was for employee health insurance, which saw an average increase of 14.2 percent among manufacturers and 12.9 percent for service firms"
> "The next largest cost increase was for utilities, which climbed by 8.5 percent over the past year for both types of firms, with about 15 percent of all respondents reporting increases of 20 percent or more"
> "Business insurance—which includes liability, property, auto, and workers’ compensation, among other things—climbed by about 7 percent, on average, for service firms and by 7.5 percent for manufacturers"
I alluded to this before on HN [0] - much of the insurance woes faced are the legacy of the COVID pandemic, as a large portion of workers compensation funds are insolvent and healthcare pools are heavily stressed, leading to perverse incentives.
Here in the Pacific Northwest, the catch-and-release of car thieves drove up costs for everyone. If I change my address away from the craziness, my policy drops by half.
Yep! Both private and public insurance funds are nickel and diming wherever possible to make up for losses during the COVID pandemic which went on for 3 years.
Edit: can't reply
> This started decades before COVID, and has been summarily ignored for the entire time. We’re still insuring properties in areas we known sea level rise and climate change make uninsurable
It's not property insurance that's causing the issue as I as well as the article pointed out.
This started decades before COVID, and has been summarily ignored for the entire time. We’re still insuring properties in areas we known sea level rise and climate change make uninsurable, we still refuse to let the government negotiate with or dictate rates, we still tie healthcare to employment, and we still let manufacturers sell top-tier/unrepairable vehicles while constantly discontinuing anything remotely affordable or repairable.
The market isn’t going to correct itself now that we have enough data to know where to squeeze next, and how hard it can go. The only way to unwind this disaster is meaningful regulations and wholesale reforms.
It’s a vicious cycle, but something needs to pump the brakes before the metaphorical engine explodes.
* Stop tying healthcare to private insurers and employers. State-level single-payer models by default via fixed payroll deductions per employee, and let the government dictate or negotiate costs.
* Re-work incentives for efficient utility usage. Incentivize self-generation for power through lower electric rates if a certain percentage of your consumption is generated on-site, for instance. Also, stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
* Those insurance rates keep going up because healthcare continues rising and repair costs are increasingly more expensive or on par with replacement costs. Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
* Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher (along with costs to replace those wages from injury or loss via insurance schemes) until and unless we actually address the underlying crises. This means lowering housing costs, lowering rent, lowering transit costs (either through cheaper cars or expanded public transport, ideally both), lowering food costs, lowering utility costs, lowering healthcare costs, lowering childcare costs (universal childcare or incentives for more single-earner/single-income households), etc.
This report hits the highlights, but this is a huge issue that’s only going to get worse if we don’t start seriously addressing the myriad of root causes.
> Stop tying healthcare to private insurers and employers. State-level single-payer models by default via fixed payroll deductions per employee, and let the government dictate or negotiate costs.
Most state-run workers compensation and Medicaid funds are already insolvent. Until that gets resolved, no attempt at creating a single payer fund is possible.
> stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
Most DC projects in the US have already integrated renewable and battery storage systems thanks to Biden-era subsidizes and capacity building.
Utilities are using data centers as a scapegoat - the reality is most are stuck with fiscal liabilities due to COVID along with insurance and raising prices as a result.
> Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
I support right-to-repair at a personal level as a tinkerer, but that wouldn't move the needle for the insurance problem.
The big issue is the COVID pandemic era liabilities that continue to require to be paid out to this day.
It's the same for workers comp as most workers comp funds are already insolvent.
> Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher...
Becuase that's not something that dramatically impacts the bottom line in most industries - most businesses can afford increasing salaries a couple dollars an hour by reducing capex next year, reducing hours for existing employees, or moving employees to the salaried bucket.
But if my insurance premiums are constantly increase by 7-20% YoY it becomes difficult to manage.
Edit: can't reply
> What do you (sic) proscribe as a solution then?
F#ck if I know.
This is a polycrisis, and each state will have to solve stuff individually because of the federal nature of the US. The pandemic was brutal and we're still facing feeling it's reverberations to this day.
Enshitification and the weird desire to please modern audience, are the only reasons.
Until the early 2000s, things were built to last, solid build, simple.
Now, even fridge has AI in it like what the actual f!!!
Cars are tablets on wheels, Tesla and others, rather than just being cars.
And this weird desire to please modern audience costing movies, products, videos games billions of dollars, closing studios thousands of jobs lost unable to make the investment back as consequences and yet, companies seem to do not read the room.
It's worth noting that at least a lot of the (non-health) insurance rises are driven by the reinsurance market responding to ever higher dollar amounts of claims annually due to disasters.
This underestimates the SUI premium hikes following the COVID layoffs. Most states charge businesses a risk premium when employees are terminated, and given that most states UI and Workers Compensation funds are now insolvent [0] they fight tooth and nail to increase premiums.
Financialization and the diffusion, across the economy, of the risk of dozens of major bad-bet nuclear detonations in the securities and commodities markets. The bets were never closed - not really - because the losses would have lead to immediate collapse. You're still paying for 2008 (and earlier debacles, and later ones, too). The economic output of the next few decades is already spoken for.
This hits TFA's culprits, rising insurance and utilities costs. They're just the symptoms, not the source.
Let us not worry about "the whole economy". Yes, we know there is massive Executive overreach with tariffs and immigration. Yes, we know Congress is deadlocked to the point of being worse than useless. Yes, the SCOTUS also has its own problems with a majority of the public no longer having any faith in the judiciary. Lets start with things the FEDeral Reserve can fix, right here, right now.
Narrow banking now.
This is something the Federal Reserve can actually fix. Give every single US person (I am not a lawyer and I can't define what counts as a US person) a fee-free bank account with the Federal Reserve. Cut out the middle men of commercial banks. I think that alone will go a long way to drive down business costs.
If we had a functioning Federal Government, we need this like yesterday. I know the EU and the China Mainland are showing ridiculous incompetence today but they won't be incompetent forever. Digital Euro and Digital RMB are coming, perhaps as soon as within a decade. We are essentially playing catch up with the US Dollar at this point. Fed Now is a good start but it really is not enough.
What you said, fee free banking + KYC + free instant transacting is something we definitely need, even if it hurts JP Morgan Chase a little bit.
Right, also turns out the regional banks of the FED are de facto owned by commercial banks. Why would they vote against their own interest if they can get money from the Federal Reserve at about three percent interest and then turn around and lend it at six percent?
We really need to switch to a National Health Service style of administration of health costs. Right now we have Medicare which makes unilateral cost determinations, and doctors and hospitals end up accepting below-cost reimbursement that because how could they turn away all the retired people, but they end up subsidizing these unilateral decisions with money from private insurance payors (namely everybody who's working).
Medicare might not technically be a monopsony, but it acts like one, and all the rest of us working folks end up paying the gap that rounds out the rest of the costs.
We have a few generations that have had easy lives, where they had easy access to homes, to higher education, to wealth building, and decided to cut off access to the same as soon as they got it, while still living off the labor of current working people that are not even allowed to build new apartments next to these wealthy people while they pay for all their health care.
The economy is a massive multiple player rpg with a point system economy that's fixed by federal and state laws, and it's been rigged both at the health care level and at every level to extract wealth for those that had it easy in the past.
The dirty little not-so-secret is that we pay doctors too much in the US. To the tune of several times as much as other large developed countries, like Germany, France and England. Medical care in the US will never ever be as cheap as those countries as long as the providers here earn 2x or 3x.
That's partly because we have a doctor shortage here (medical schools collude to limit the number of new doctors created each year).
Another part of the problem is the bloated administrative bureaucracy of hospitals in the US, we well as the fact that you aren't allowed to build a new hospital (and yes, this is actually true) unless you can prove that a hospital is needed in a particular community.
With no competitive market for healthcare providers, nor a competitive market for places where they work, why shouldn't they extract as much as they can from the rest of us?
They get away with it, too, because "medical doctor" is one of the highest trusted and most reputable professions. It's badthink to discuss these things in polite company.
Until we fix those things, it simply doesn't matter how the insurance/payment system works. Every time I hear that we need to get rid of private insurers, nobody can seem to explain how doing that will save more than 10-15% despite the fact that insurance companies have a statutorily-limited profit margin.
The shortage of physicians has nothing to do with medical schools. The immediate bottleneck is a shortage of residency slots. Every year, students graduate from medical schools but are unable to practice medicine because they don't get matched to a residency program. (Some do get matched the following year.) This is primarily due to limited funding from Medicare, although some residency slots are funded from other sources.
https://savegme.org/
I agree that certificate of need laws should be repealed to increase competition between healthcare facilities. That only impacts some states, not the whole country.
https://nashp.org/state-tracker/50-state-scan-of-state-certi...
That's not true. You can look at the residency match for 2025 here:
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
While many specialties are fully filled, we need pediatricians, family medicine, and internal medicine docs. They're generalists and where the largest shortage is. There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
My statement above was correct. There are students who graduate from accredited medical schools with MD/DO degrees but don't get matched. Part of that is because some of them simply don't apply to programs that have extra openings. Medicare / Medicaid pay primary care physicians below market rates so students are naturally reluctant to pursue those specialties.
But aren’t the specialities where the highest salaries are? So to reduce costs, shouldn’t those have more slots?
Doctor salaries alone do not account for the hundreds of billions in profit that health insurance companies extract from us. You are right there is not a competitive market place because the US government cannot provide a universal plan for anyone. We all know the insurance companies would fold overnight as government welfare programs are extremely popular (just look at how much corporations love government welfare).
Odd how the most popular programs in the US, social security + medicare, are the ones with zero means testing.
Maybe let's not blame one of the few only noble professions left in our greed fueled world.
Blame the hospital administrators or pharmaceutical reps before you start blaming doctors.
It’s a red flag whenever someone talks about healthcare and they focus on health insurance companies and hospital administrators. It’s a sign that they’re working backwards from some ideological beef rather than looking at where the costs actually are.
Health insurance companies have profit margins around 5% or less. Hospitals are half that. A Subway franchise has a higher profit margin. That’s just not where your healthcare dollars are going.
The issue is not that health insurance companies make too much money (ok, it's not the only issue)They, along with the system they put in place introduce immense amounts of friction into every medical interaction and prevent doctors from practicing good medicine.
The insurance companies are not stopping the government from paying for everyone's healthcare. It's the other way around, governments are using insurance companies (better referred to as managed care organizations since they don't really sell insurance) to add the friction so that some people get more healthcare and some people get less.
Who gets more and who gets less depends on who has political power (that's why the old and non working get subsidized by the young and working), and in a democracy, this question ultimately comes back to the voters.
That is no longer true. What we have historically referred to as “health insurance” companies responded to ACA margin limits by becoming sprawling behemoths whose rampant self-dealing makes such profit margin calculations meaningless.
If you have a fixed profit margin, the way to make more absolute money is to allow your costs to increase. Insurance companies have zero reason to negotiate prices down.
Show us the data. You want to make the claim, bring the evidence.
shimman claimed
>hundreds of billions in profit that health insurance companies extract
yet no claim for evidence?
Here's data for medical loss ratios:
https://www.kff.org/private-insurance/medical-loss-ratio-reb...
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
Here are the sub 5% profit margins for the publicly listed insurers:
https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...
https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...
https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro...
https://www.macrotrends.net/stocks/charts/ELV/elevance-healt...
https://www.macrotrends.net/stocks/charts/HUM/humana/profit-...
https://www.macrotrends.net/stocks/charts/CNC/centene/profit...
https://www.macrotrends.net/stocks/charts/MOH/molina-healthc...
The above obviously does not include the many millions of Americans covered by non profit insurers, such as Kaiser Permanence, Providence, Cambia, and the various Blue Cross plans.
Here are the 5 year returns for the above businesses compared to SP500:
https://i.imgur.com/S8bNSM2.png
Suffice to say, you would not want to be a shareholder of a health insurer.
No, they are not paid too much. There's a lot of incorrect assertions here, so it'll take a lot to work through them.
Physician pay depends on specialty, but it can range from the low $100kish mark for pediatricians to $500-750k for certain kinds of surgeons. Family medicine tends to be around $200k. However, this amount ranges vastly by market and top pay often goes to those willing to work in more rural hospitals because no one wants to. For example, pay in NYC for physicians is appalling low compared to the rest of the U.S. market. In addition, certain systems have hard caps. For example, the VA hospitals cap physician pay inclusive of bonus at $400k. This is documented and you can in fact just look up a random doc at the VA with one of the many federal pay search tools.
While some doctors can make more, it typically because they own a practice and that increased pay comes from good old fashioned capitalism. Meaning, they tax the amount their nurses, NPs, medical assistants, etc. make just like all businesses make money per head on their employees. Whether you believe this is right or wrong is up to you. However, this is not any different that someone who runs, for example, a yard care business. More accurate pay can be found by those who work directly for large hospitals.
Next, the cost of medical education in the United States is vastly higher than other countries. Right now, medical school will cost you somewhere from $400-600k. This is in addition to whatever debt accrued during undergraduate. Further, medical school applications are highly competitive, so students often accrue additional debt by completing a masters in something like public health prior to entry to medical school. This means that someone may have upwards of $750k of debt when they finish medical school, but they still have somewhere between 3-10 years of residency and fellowship before they make attending money. During this time, the debt accrues interest and balloons.
Now, once you become an attending, you're still not good and expenses are vast. Shift work can vary from something like 7 12-hour shifts in a row for intensivists to 14 shifts in a row for hospitalists. Note, just because it says its a 12-hour shift doesn't mean you work 12 hours. They still need to chart and bill and if it's busy, that may be another few hours after the shift is over. In some remote clinics, an ER physican may work 7 24-hour shifts in a row. That may sound absurd and unsafe and it likely is, but it's the reality of the work. If someone is working that schedule, they have increased expenses to just, frankly, live. On the low end, it's very difficult to cook in that environment, so you have to buy a lot of premade food. On a more expensive end, having children on this schedule is extremely difficult. You either require a spouse that doesn't work or you need something like a night nanny. If you're working 12 hour shifts, you must sleep at night and you can't be up to take care of a baby otherwise you run the risk of killing someone the next day. Unless you're paying someone under the table, current nanny rates in large markets are about $20-25/hour. Insurance rates are also high. I don't mean malpractice either. Generally speaking, one needs to carry disability insurance because if one gets into a car accident and breaks their magic hands, there's no way to pay back that debt otherwise. These policies are thousands a year. That's just the start. They pay a large amount of money to buy their time back because they don't have it.
Next, there's a myth about limiting residency slots in order to increase pay, at least recently. I will not defend the AMA and some of they took, especially in the 1990s. Here's the 2025 residency match data:
https://www.nrmp.org/match-data/2025/05/results-and-data-202...
The number of offered and filled slots is on page 2 (or 13 depending on how you count). Some specialties filled all of their slots. Where the U.S. vastly lacks is pediatricians, family medicine, internal medicine (who can work like family medicine if need be.) Pediatricians had 147 unfilled slots. Family medicine had 805 unfilled spots. Internal medicine had 357 unfilled spots. These spots can be filled by people who graduated from U.S. medical schools, island medical schools, Mexican medical schools, or a vast array of other foreign medical schools. However, they're not filled because they don't have the applicants. That's not medical school collusion. That's the hard reality that medical school is extremely expensive and the training is extremely long.
Now, how do other countries handle things? One, their medical school is not as crushingly expensive. Two, places like Europe cap the number of hours a physican can work. If you want to pay American physicians less, you'd need to blow out their medical school debt, reduce their hours, and offer better benefits. Until then, no, really, they're not overpaid.
If you want to start pointing fingers, try the vertical integration of insurance companies, pharmacy benefit managers, and hospitals. I don't have the numbers readily available, so I'll stop here. But, really, it's not the docs.
Yes, and that national administration has to include national standards of care. The government should set cost-effective standards of care for various scenarios. Then doctors should have immunity to lawsuits as long as they followed the standard of care. You shouldn’t be able to sue a doctor and get some expert up there saying he should have run these additional tests or tried this additional treatment.
Potentially. The issue is how do you manage solvency.
State Medicaid and Workers Compensation funds were already insolvent before the 2024 election, and as such most states lack the fiscal overhead needed to fully support a fully funded single payer program today.
It would end up the same way the NHS has in the UK.
Vast swathes of the US are deeply fiscally troubled due to the impact of the COVID pandemic, and if that is not solved then we cannot even start to contemplate single payer.
This should not be used to justify austerity which is not the answer and does more harm than good, but points out that a reckoning is needed. From my personal experience dealing with the current crop of state and local politicos, it's looking dicey in portions of the US.
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> Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever
Yes. But you need capital to build an insurance fund. And a large portion of that is going to service existing liabilities.
Gong single payer is a drastic drop in the cost of healthcare as a percentage of GDP. There’s no fiscal advantage to the current system whatsoever.
The core issue is it suddenly destroys a large number of companies and removes millions of unnecessary jobs from the economy. That’s a great deal of wealth and a great number of voters who don’t want you to save hundreds per month by making them redundant.
State sponsored monopolies is my vote. It's a failure of government to have fewer than ten players (non-Trusting) in any industry.
That makes sense for the "utilities" bucket, and to a small degree for the health insurance bucket, which are the biggest buckets linked.
Utilities have had complete regulatory capture of most states' Public Utilities Commissions. It's blatant and obvious in places like Arizona that have open corruption in their elections and commission decisions. But in places like California it's far more hidden: the massive increase in cost of utilities is mostly from increased costs for the transmission and distribution grid, but CPUC has basically zero information for the public to understand why they keep on handing over more money to the big utilities. There definitely seems to be massive corruption but where is it and what is the actual mechanism? It's so well hidden and sophisticated that if there is corruption nobody understands what the F is going on.
How do you replace a state-sponsored monopoly like a utility into something competitive? I don't know, when I learned econ 101 utilities were given as the example of a "natural" monopoly. But clearly that's not working out... maybe it just needs to be "state" rather than "state sponsored monopoly." The only other state sponsored monopoly we really have is the state itself. What does the public gain by allowing monopoly utilities that giving away the public's money to investors? The incentives are all off.
The problem with the health insurance bucket is not the number of players, it's that you're buying a pig in a poke.
Between ghost networks, death panels that deny you treatment, and the nature of deductibles, you have no fucking idea what you're buying, and whether or not you're getting ripped off.
Our economy is an oroborous of middlemen all using tariffs and inflation as excuses to raise their prices
The ammount of shrinkflation in the last year is just stunning. Sometimes they bother to make the bottle/box/can incrementally imperceptibly smaller. Sometimes they just put less in. I track macros so I'm always looking at weights, and they're generically down 20%, while prices are up.
From TFA (becuase apparently HNers can't read): "Sharp Increases in the Cost of Insurance and Utilities"
> "The largest increase by a wide margin was for employee health insurance, which saw an average increase of 14.2 percent among manufacturers and 12.9 percent for service firms"
> "The next largest cost increase was for utilities, which climbed by 8.5 percent over the past year for both types of firms, with about 15 percent of all respondents reporting increases of 20 percent or more"
> "Business insurance—which includes liability, property, auto, and workers’ compensation, among other things—climbed by about 7 percent, on average, for service firms and by 7.5 percent for manufacturers"
I alluded to this before on HN [0] - much of the insurance woes faced are the legacy of the COVID pandemic, as a large portion of workers compensation funds are insolvent and healthcare pools are heavily stressed, leading to perverse incentives.
[0] - https://news.ycombinator.com/item?id=47047646
No accident. No move. No new vehicle.
My car insurance went up 30%, in one year. Tried pricing around and it's not much better. Took an online "safety class" and got an 8% discount.
Here in the Pacific Northwest, the catch-and-release of car thieves drove up costs for everyone. If I change my address away from the craziness, my policy drops by half.
Yep! Both private and public insurance funds are nickel and diming wherever possible to make up for losses during the COVID pandemic which went on for 3 years.
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> This started decades before COVID, and has been summarily ignored for the entire time. We’re still insuring properties in areas we known sea level rise and climate change make uninsurable
It's not property insurance that's causing the issue as I as well as the article pointed out.
This started decades before COVID, and has been summarily ignored for the entire time. We’re still insuring properties in areas we known sea level rise and climate change make uninsurable, we still refuse to let the government negotiate with or dictate rates, we still tie healthcare to employment, and we still let manufacturers sell top-tier/unrepairable vehicles while constantly discontinuing anything remotely affordable or repairable.
The market isn’t going to correct itself now that we have enough data to know where to squeeze next, and how hard it can go. The only way to unwind this disaster is meaningful regulations and wholesale reforms.
It’s a vicious cycle, but something needs to pump the brakes before the metaphorical engine explodes.
* Stop tying healthcare to private insurers and employers. State-level single-payer models by default via fixed payroll deductions per employee, and let the government dictate or negotiate costs.
* Re-work incentives for efficient utility usage. Incentivize self-generation for power through lower electric rates if a certain percentage of your consumption is generated on-site, for instance. Also, stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
* Those insurance rates keep going up because healthcare continues rising and repair costs are increasingly more expensive or on par with replacement costs. Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
* Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher (along with costs to replace those wages from injury or loss via insurance schemes) until and unless we actually address the underlying crises. This means lowering housing costs, lowering rent, lowering transit costs (either through cheaper cars or expanded public transport, ideally both), lowering food costs, lowering utility costs, lowering healthcare costs, lowering childcare costs (universal childcare or incentives for more single-earner/single-income households), etc.
This report hits the highlights, but this is a huge issue that’s only going to get worse if we don’t start seriously addressing the myriad of root causes.
> Stop tying healthcare to private insurers and employers. State-level single-payer models by default via fixed payroll deductions per employee, and let the government dictate or negotiate costs.
Most state-run workers compensation and Medicaid funds are already insolvent. Until that gets resolved, no attempt at creating a single payer fund is possible.
> stop subsidizing huge consumers (like data centers) by raising customer rates, and keep expanding renewables and battery storage to depress costs in the long haul
Most DC projects in the US have already integrated renewable and battery storage systems thanks to Biden-era subsidizes and capacity building.
Utilities are using data centers as a scapegoat - the reality is most are stuck with fiscal liabilities due to COVID along with insurance and raising prices as a result.
> Right to repair can lower auto/property insurance rates over time by making shit repairable, and liability/workers comp can begin coming down once healthcare is meaningfully addressed
I support right-to-repair at a personal level as a tinkerer, but that wouldn't move the needle for the insurance problem.
The big issue is the COVID pandemic era liabilities that continue to require to be paid out to this day.
It's the same for workers comp as most workers comp funds are already insolvent.
> Not being mentioned in the report (but raised by other commenters) is the general cost of living will continue driving wages higher...
Becuase that's not something that dramatically impacts the bottom line in most industries - most businesses can afford increasing salaries a couple dollars an hour by reducing capex next year, reducing hours for existing employees, or moving employees to the salaried bucket.
But if my insurance premiums are constantly increase by 7-20% YoY it becomes difficult to manage.
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> What do you (sic) proscribe as a solution then?
F#ck if I know.
This is a polycrisis, and each state will have to solve stuff individually because of the federal nature of the US. The pandemic was brutal and we're still facing feeling it's reverberations to this day.
What do you proscribe as a solution then?
Enshitification and the weird desire to please modern audience, are the only reasons.
Until the early 2000s, things were built to last, solid build, simple.
Now, even fridge has AI in it like what the actual f!!! Cars are tablets on wheels, Tesla and others, rather than just being cars.
And this weird desire to please modern audience costing movies, products, videos games billions of dollars, closing studios thousands of jobs lost unable to make the investment back as consequences and yet, companies seem to do not read the room.
Insurance
It's worth noting that at least a lot of the (non-health) insurance rises are driven by the reinsurance market responding to ever higher dollar amounts of claims annually due to disasters.
This underestimates the SUI premium hikes following the COVID layoffs. Most states charge businesses a risk premium when employees are terminated, and given that most states UI and Workers Compensation funds are now insolvent [0] they fight tooth and nail to increase premiums.
[0] - https://oui.doleta.gov/unemploy/docs/trustFundSolvReport2025...
Unhinged greed
Financialization and the diffusion, across the economy, of the risk of dozens of major bad-bet nuclear detonations in the securities and commodities markets. The bets were never closed - not really - because the losses would have lead to immediate collapse. You're still paying for 2008 (and earlier debacles, and later ones, too). The economic output of the next few decades is already spoken for.
This hits TFA's culprits, rising insurance and utilities costs. They're just the symptoms, not the source.
That's us actually. It's pretty much all busy work at this point.
Let us not worry about "the whole economy". Yes, we know there is massive Executive overreach with tariffs and immigration. Yes, we know Congress is deadlocked to the point of being worse than useless. Yes, the SCOTUS also has its own problems with a majority of the public no longer having any faith in the judiciary. Lets start with things the FEDeral Reserve can fix, right here, right now.
Narrow banking now.
This is something the Federal Reserve can actually fix. Give every single US person (I am not a lawyer and I can't define what counts as a US person) a fee-free bank account with the Federal Reserve. Cut out the middle men of commercial banks. I think that alone will go a long way to drive down business costs.
fee free banking + KYC + free instant transacting = ooo eee modern banking infra
If we had a functioning Federal Government, we need this like yesterday. I know the EU and the China Mainland are showing ridiculous incompetence today but they won't be incompetent forever. Digital Euro and Digital RMB are coming, perhaps as soon as within a decade. We are essentially playing catch up with the US Dollar at this point. Fed Now is a good start but it really is not enough.
What you said, fee free banking + KYC + free instant transacting is something we definitely need, even if it hurts JP Morgan Chase a little bit.
And in the process make every member of congress less more rich tomorrow.
Never, ever going to happen.
Right, also turns out the regional banks of the FED are de facto owned by commercial banks. Why would they vote against their own interest if they can get money from the Federal Reserve at about three percent interest and then turn around and lend it at six percent?