Why does nobody look at the medical profession as the racket it is? You don't need to be an MD to handle %80 of hospital visits, and you can train trades people to handle most emergencies.
Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.
Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as the root cause that every health policy expert in the country can tell you is not the root cause, and that doesn't hold up to even slight scrutiny by comparison with other, similar, countries.
Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?
So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas.
Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority.
That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude.
As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen.
As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers.
Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?
I ama surgeon in MA. I get less than $800 for a hernia repair. That includes all the face time with the patient, explaining everything, doing the procedure and taking care of him after. The hospital gets $8000 and lets me use a 'special' room for an hour and another 'special' place for a few hours for the patient to 'sleep off' the anaesthesia. The doctor who provides anaesthesia gets <200$ for every 15 minutes. The gases and his machines cost a multiple of that. Hospitals inflate their costs by running red budgets (basically up spending for everything so they can justify higher budgets). A urologist in my facility who does robot surgery gets $1500 to remove a prostate for cancer. The hospital bills $80,000 for the procedure. And cancer surgery is being permitted even though a few weeks' delay will make little difference in the outcome for most cases. The hospital, who rents me my office by the way, is not giving me any breaks on the rent even though my business is down 50% . Even comcast gave me a $100 rebate because my volume is down. Can you imagine hospitals as corporations worse than Comcast?
The concept of 'efficiency of scale' does not translate to service industries. The only efficiency that happens is efficiency of funneling more money to higher salaries of higher executives. Hospitals are driven by profit and their incentives do not align with the precepts that led to their formation.
Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it.
By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage.
If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure."
Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1]
We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them.
[1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.
can I say 'bullshit' here without being rude? Hospitals ONLY provide services they can profit from. They could have a doc in an office to do the stitching you refer to. And save a crap ton on overhead. By offering a 'luxury pathway' not only do they up their profit, they make everyone else who is trying to save money for the system look bad. Hospitals CHOOSE not to offer cost effective care because there is less profit in it. And then they hide behind Stark regulations - 'we cannot help private practitioners, sorry'.
The primary issues - root cause - of our systemic faults lie in approximately three places:
1. We are fractured. There is no "healthcare system." That's a singular noun. We have a marketplace: that means things like three top-tier specialty centers in walking distance of each other in some areas, and nothing at all in others. About 90% of our problems derive from this. As do a number of our strengths (if you're in Boston, you should never have to wait more than two weeks for a colonoscopy. Ever.)
1a. The healthcare "system" is not equivalent to hospitals. Hospitals are a single strain of profit-seeking enterprise (non-profit hospitals are the same shit.) People keep confusing the two, resulting in advocacy for policies that just concentrate power harder into the hands of a few, massive, corporations.
2. We are bipolar. A huge, huge proportion of our healthcare dollars flows from medicare. A large portion of our people are uninsured or underinsured. The result is that healthcare operations are built (generally) around Medicare's billing practices and needs - that's what you optimize on to stay afloat. This means when someone uninsured comes in, though, they're thrown into an operational flow for which they're barely an after-thought. Prices set as a negotiation point with private insurers are brought to bear against uninsured people - and they get nailed with ridiculous, unpredictable prices that have nothing to do with... almost anything. These people either need to be brought under the umbrella of contracted rates (Medicare For All), or I don't know what. You're not going to convince an organization with operating margins <2% to launch a massive operational restructuring to accommodate people that generate <<1% of its profits. And don't think there isn't legislative collusion in this - in places like CA, hospitals are obligated to go to collections for all patients. They used to say, fuck it, that guy was poor as fuck, write it off as uncollectible and deduct it as charity care. The state didn't want to lose the tax dollars the hospital didn't bother collecting, so now hospitals are required to send those indigent patients to collections, or else the hospital has to eat the entirety of the cost - not even a tax deduction to soften the hit. That adds up to a lot of dollars.
3. Unfunded Mandates. Every policy change pushed through our healthcare system is perceived as targeting "those wealthy doctors" (doctor != hospital != healthcare system). Most docs I know drive a Nissan Altima or a Camry - they're middle-class cogs buried under debt. But the stereotype makes a good excuse for pushing policy changes and then not allocating money to accomplishing them. Which means every policy change fractures the system further apart socioeconomically - you have wealthy-client practices that can afford to stop taking insurance, opt-out of Medicare, and thus avoid all these unfunded mandates... and then you have everyone else. Which puts basically everyone but hospitals out of business, because only hospitals have the capital and the scale to be able to meet the new requirements. You think FB likes privacy regs because it builds a moat? Hospitals don't just get moats, they basically get to buy up every small practice in the area at cost. Your local PCP is small and nimble enough to say "oh, you're uninsured? Fuck it, $40." It's the hospital that says, "Oh, we'll send you a bill later," and then ho boy, get ready. This also includes getting docs who are super-bought into the status quo: "We profited off charging you hundreds of thousands in tuition. We sold the idea that you'd be set afterwards, and could just be a good doctor. Turns out that while paying off your loans, you're just middle-middle-class, after having been impoverished into your 30s. And now, for the good of society, we'd like to cut your income by another 20%, while asking you to continue working like a madman. No, we will not offer you one penny of federal loan forgiveness, even though it is the federal government that is gutting your income. In fact, we won't even let you declare bankruptcy - that's cause for revoking your license." Yeah, docs are going to buck really hard against most changes in hc reimbursement. Even so, look at organizations like Doctors For America - a shit ton of docs still agitate for reform, for the good of their nation, if not the good of their own pocket. A related point is the "shortage" of docs: training positions in hospitals are funded by the federal government. Funding which barely crawls. "We have a doctor shortage!" "Will you open new training positions?" "No." "Then..." "No worries, we'll have nurses take some night classes, skip the entirety of actual residency training, and then we can call them doctors, too! We'll just confuse people by telling them they're going to see 'providers', and that way we can avoid paying doctors for doctoring."
There's a lot of other headline bullet points, but most issues in American healthcare boil down to an interaction of the above three.
edit: I should add, big picture, that healthcare isn't magically divorced from the rest of our social ills. As wealth inequality grows, bear in mind two things: (1) wealth correlates to health, and disease burden to correlates to poverty, (2) people can still vote themselves healthcare allocation (i.e., medicaid). The result is that increasingly more disease is concentrated among the increasingly impoverished, which means they're legislatively allocating themselves healthcare ... without the resources to pay for it. Whether or not you like or dislike any of the above, a lot of our issues with hc reimbursement are linked - directly or indirectly - to questions of wealth inequality. Adjusted for inflation, most docs have seen their real income stagnating, hard, for decades - and that's specifically as a result of trying to cheapen them, because they're increasingly paid for with redistributed tax dollars rather than anyone actually buying healthcare.
The healthcare system in the US isn't a marketplace either. For markets to function you have to know how much something will cost before you buy it, and you have to be able to make decisions based on cost. For most Americans, health pricing is a black box indirected by hospitals and insurance companies. And good luck getting an ambulance to take you to a cheaper hospital in an emergency.
So does the developers. Anyone can code and do %90 of what a developer can do with a very little training.
Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one.
Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option.
US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition.
I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.
There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!)
If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that.
(Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)
> There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!)
The vast majority of developers cannot kill you if they screw up. In the cases where that isn't true, e.g. software for medical equipment, I'd expect to find some significantly higher hurdles to get past before you can release that software.
We don't generally require developers to have certain qualifications, but their output can be measured in other standardised ways nonetheless.
> their output can be measured in other standardised ways nonetheless.
What are these standardised ways to measure developer output? I've never seen any, beyond "burndown charts" and "LOC", which I don't believe pass the sniff test.
One example of a standard software might comply with is MISRA C [1]. For that, you ignore a large chunk of the C language to something much less prone to bugs. Others might be HIPAA compliance, how you handle personal information to be compliant with GDPR or the VW diesel emissions scandal a few years ago.
That’s only because of the size if the impact if things go wrong. You need a license too to build a house or drive a truck because it’s actually very easy to do it %99 of the time well but you can’t afford that %1.
I would argue that bus drivers have a much larger impact in terms of lives lost if things go wrong, yet they have significantly lower wages and require less training. The same goes for pilots and air traffic controllers.
How is it decided how many regulations are "enough" for a given field? It seems they are on an ever-increasing ratchet mechanism, often driven by mass hysteria.
A sibling of mine is a very highly paid medical specialist. She studied, worked and studied more doing exams into her early thirties. Combined with having to travel a lot to get experience meant she wasn't able to settle till her mid thirties. Prior to that she earned good money but worked insane hours not including study time. I know because I stayed with her sometimes. I work in a pretty stressful job but I couldn't handle the stress her job entails on a daily basis where she sees extremely ill people in theatre and whose lives are literally in her hands both there and later in the ICU. She's well into her fifties now but still one week a month had to be available to work in the middle of the night if called on a rota. She earns a good multiple of what I do but I think she earns every penny.
The current system restricts the supply of medics and results in overwork, often sleep-deprived stressed people in a rush to make decisions. It would be better to allow more people in who can take more time and consideration of each case.
Yeah, it's definitely not the insurance companies that extort everyone for outrageous fees under threat of death thus creating most profitable industry in the world, yet producing nothing of value whatsoever who are the problem, it's all the doctors fault.
This. Insurance companies want medical procedures to cost more so that they can charge higher fees and punish those who don’t choose to participate in their industry.
Exactly, it's the same for car insurance where (industry-wide) high repair costs mean the insurance industry has more turnover from which to extract a percentage profit margin. Exactly the same forces apply for medical insurance.
This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN.
I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds.
There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries.
The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.
LOL. I agree with you- healthcare should be way more accessible and affordable. But I suspect that if you looked at what it costs to train and deploy a field medic in today's military, you would find that it is a lot. And the many reasons for that very high expense probably echo some of the issues that also exist in healthcare. Hint: the MD isn't getting anywhere near $3000 to do your stitches.
If you were to drop the arms training and all that stuff from a “civilian field medic’s” training surely the cost would come down. Not to mention that the Airfoce purchasing $10k toilet seats and related financially irresponsible decisions would probably be less likely to happen in any non governmental org
I think that there are certainly some issues with an artificial scarcity of doctors as well as overly restrictive regulations requiring MDs for certain procedures that don't require MD training, but the evidence shows that this is not the main driver of high costs. Physician salaries are only about 8% of healthcare spending[1] and according to my own research, only about 20% is due to all healthcare worker salaries (including physicians, nurses, physician assistants, etc. The remaining 80% is medicine, medical supplies, capital costs (MRI machines, hospitals) and administrative costs. Unfortunately there's no single cost that could instantly solve everything if eliminated; there's just a lot of middlemen each taking a tiny portion that add up to a huge total cost.
There are plenty of ways it could be made cheaper, hugely cheaper, but the regulatory system protects the established players / methods and prevents competition.
"Of course" says everyone because it seems like an easy answer.
"Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted...
This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%
My sister is a veterinarian. Honestly, I think I’d rather have her give me stitches than most doctors. She’s had to give so many more than most doctors.
I am a veterinarian too. It's ridiculous how stitches are so impossible to have access to (at least where I live). Last time I had a coworker fix me up after a bicycle fall (was on the elbow sadly, could hardly do it solo), not because of cost where I live, gladly, but because a MD can't stitch me, so it's either the emergency department, or MD and then only referal (so yet another appointment and all the trouble that is) to a surgeon.
I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.
Because it's not. If you actually look at the numbers doctors only get about 1/3 of the money. Furthermore with the kind of money you have to loan it would make no financial sense to become a doctor.
Noone is having a good time with this system. Doctors want the insane amounts of work and stress coming from the lack of personnel that justify the salaries just so they can pay the student loans.
In the 19th and early 20th centuries there was in the US a proliferation of medical schools -
many unaffiliated with Universities - with very few entrance requirements, extremely uneven quality of education and little standardization in curriculum. In fact many people became doctors through apprenticeship right up through the turn of the 20th century. Many states had extremely lax or nonexistent licensing requirements. It was quite chaotic and unregulated.
In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations.
The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day.
The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues.
Targeted reform of the system is the best solution for American healthcare.
The number of physicians per capita in the U.S. is greater than Canada or Japan, both of which have cheaper healthcare. Yes, apparently most European countries have a significantly higher ratio. But, interestingly, all the Anglo countries (UK/GB, US, AU, IE) seem to cluster together.
The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes.
EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.
The regulatory restrictions don't just apply to the doctors themselves, but have expanded to stifle innovation in every part of the system, from hospitals to equipment to drugs to administration. Each takes its toll.
“fully trained” has a different meaning in other countries. In the US the number of doctors that can be “fully trained” is artificially limited. Furthermore, many countries with cheaper healthcare have abbreviated training for doctors.
I mean do doctors really need to spend 4 years getting a bachelor's degree in "pre-med"? If you know you're going to be a doctor why not just start off with biology, anatomy, physiology, chemistry in year one and go on to cutting up bodies in year 2? It seems utterly ridiculous to spend 4 years majoring in humanities, or calculus[1] only to seek entrance to med school.
You are speaking from a place of ignorance. The prerequisites needed to take the courses that you mention alone are >1 year, yet alone all of the material needed to become a doctor.
Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other. If you don't know what a nucleophile is then you simply can't pass biochem, and that's how it should be.
Granted, you could theoretically shorten the program by removing all the humanities courses; but shouldn't doctors-to-be take ethics courses?
You're right, I hold my hands up. I don't have any medical training.
> Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other.
You obviously know what you're talking about and I won't debate you on how this works. But again, does a prospective doctor need to spend 4 years on this? How does every country other than the US and Canada manage to train their doctors without making them get a Bachelor's along the way in something non-medical? Why can't doctors study 5 or 6 years and graduate with a medical degree, ready to become a general practitioner? That's how they do it in the UK. Are you saying their docs didn't pass biochem or don't know what a nucleophile is?
> shouldn't doctors-to-be take ethics courses?
Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.
My apologies, I didn't mean to come off harshly, it's approx 3 am here so I'm not exactly a ball of sunshine.
Do doc's need to spend 4 years doing an undergrad before med school? Maybe. There are a lot of things that you need to learn before you can learn what you need to be a doctor. Do you need to know physics? Eh, only kind of.
I'm not terribly familiar with the system in the UK, but at least where I went to school, most of the folks who were planning on going to med school studied either Chem, Biochem or straight Biology. In fact, it was something of an issue because the Chemistry courses tended to be weed out courses, i.e. you had to pass Organic chem 1 & 2 with a (3.0+)/4.0, or you didn't have a ghost of a chance of getting in to med school. I, personally, didn't know anyone who was planning on going to med school who was studying anything outside the STEM umbrella.
>Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.
Reasonably. I was really only picking on this point because of, what I had thought was, a dismissal to the usage of the humanities as a doc.
Things you need to learn, not an inclusive list, before med school: Chemistry, drug interactions, A&P, Ethics, Statistics, Maths, and Biology.
That's (6, 2, 1, 2, 3, 4) 18 courses minimum. Remembering that they have to be done sequentially rather than concurrently and you're looking at, bare minimum, 2 years rather than 2 semesters.
This is as it should be. To bring it back to your CS example, if you are making a web app and you fail to secure your attack surface, the worst that happens is that folks get their info stolen. If you fail to do your drug interaction math correctly, people die.
In other countries banks don't make five+ figures on every doctor's education, and their doctors certainly don't make enough to service six figures in education debt.
Finance capitalists keep the vicious cycle going. Doctors' unions scratch and claw for high comp because without it their new entrants are screwed.
The 250k+/year US salary of the fully trained doctor setting bones could be a problem. Many doctors are paid significantly less in many of those other countries.
Why do I need to see a doctor to get a mole or skin lesion checked? Why is it necessary for someone to go through 4 years of undergrad, med school, etc etc just to examine a mole and remove it with a scalpel?
Are you trolling? Are you legitimately asking why you need a doctor to check something that might be, amongst the million other possible complications, Cancer?
Go back a step further. Why do they need a big income? Because they took on lots of education debt. Why did they take on so much? Why is it so expensive? Because the usurers extend that much credit.
The free market in shampoo is okay, sort of. For a lot of other stuff "free market" + fiat looks like a mess.
We don’t have a free market in healthcare. We have a highly regulated one. Free market healthcare is lasik and boob jobs. Both have come down in price because they are not part of the insurance system. They’ve also gone up in quality due to competition and demand.
It's covered by most employer health plans, so patients don't see the true cost and don't shop around much. That's not the case for lasik or elective plastic surgery.
Of course since the latter are elective, customers have the luxury of shopping around and taking their time.
I'm not sure where you've been employed, but dental plans have always been separate from the actual health plans and generally cover nothing beyond giving a pittance per year that hardly rolls over. Once that's gone, you get to pay the full cost.
I've had to deal with the true cost of dental work and I can guarantee you anyone that's needed to deal with significant dental issues has had the same experience. So why hasn't the free market dropped down prices? Why are we still paying more for basic dental work compared to other countries?
Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.
The US has nurses and PAs for this stuff. A doctor is only needed as a staff supervisor, much like an engineering project only needs one licensed engineer to sign off.
It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.
Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed.
I'll suggest you model something like a team conducting surgery at a mid size hospital.
You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes.
The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors.
Add to that external services such as labs.
Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals.
Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise.
If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure.
Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.
Logically this may make sense, but in reality it does not. Other countries with more sane healthcare systems have costs that are fractional compared to ours despite having the exact same costs you mention.
If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.
Costs, regulatory overhead, education and taxes are different everywhere.
My wife pays tens of thousands of dollars per year in malpractice insurance...and she isn't even at the top of the scale in terms of these costs. The cost of education? An MD can graduate with anywhere from $300K and more in debt.
And lawsuits? Show me a place on earth where attorneys will go after anyone, medical industry or not, as quickly, easily and violently as they do in the US?
Show me a place on earth where the government guarantees student loans to the extent that university costs are bloated to the point of creating financial slavery for graduates.
Show me a place on earth where doctors have to order a pile of unnecessary tests in order to protect themselves from being sued.
Show me a place on earth where developing the simplest medical device costs tens of millions of dollars in regulatory fees alone (if you are lucky).
Show me a place on earth where bringing a drug to market comes with potentially billions of dollars in regulatory costs.
Show me a place on earth where a manufacturer of N95 masks and gowns is not allowed to supply them to hospitals during an emergency due to regulatory burdens, the fear of lawsuits and has to demand immunity from the president of the country before they are able to do so.
I tried to develop a relatively simple hearing device to help people who suffer from SSD (Single Side Deafness). We have someone in the family with this condition. I designed and built a device for her. She loved it. I then looked into going to market with it. The costs would run into the tens of millions of dollars (or more). There was no way to take that leap. And that doesn't include protecting from or fighting the inevitable lawsuits.
No, nothing is "the exact same". And that's my point. Unless you pull-up a spreadsheet and analyze the cost structure you will never understand why healthcare costs what it does in the US. It has nothing to do with insurance, or profit, or greed or any of the nonsense ideas being floated around --particularly by politicians who just want to manipulate the audience for votes.
This is a simple equation: If you want to lower consumer costs you have to lower the cost structure driving the process and resources necessary to deliver the goods and services they receive.
I would urge you not to form opinions as you have until and unless you have taken the time to truly understand the details of the matter, which is to say: Analyze the cost structure tree down to a good level of granularity and then see what you would change in order to reduce consumer costs. Insurance will not be on that list.
There's a parallel here, between the medical field requiring 8+ years of schooling to put in stitches, and the days (not so distant) when most software companies wouldn't hire you to write an online mortgage interest calculator unless you had passed classes in compiler design and calculus.
edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?
Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.