The problem with American healthcare is the attempt to compromise between healthcare as a universally available public utility and healthcare as a commodity on the private market. (Arguably this is a legacy of pre-modern healthcare, where hospitals were operated by charities run by nuns and funded by aristocrats and royal families, hence all the “Saint” names in hospitals nowadays).
There’s a variety of weird examples of this mixed system:
>Poor people use ERs for every day healthcare, usually they get away with paying nothing, no insurance
>Working people with insurance pay more to enable this access for the destitute (or criminal) portion of the population
>Old people are sort of entitled to free healthcare. They get medicare, but if they want everything, they have to pay for “supplements.”
>Young people pay for the old people’s healthcare twice, on their payroll taxes and in the form of higher premiums. A 25 year old male should absolutely not have a $300/mo health premium. But he does, because his premium is paying for other’s care.
This is a system pretending to be private, but it’s actually just inefficiently public. It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily.
Alternatively, abolish health insurance altogether—a notoriously inefficient and exploitative industry that does not suit the classic purpose of insurance (boat accidents and fires)—and see what happens. This is obviously a rather unpalatable option due to the chaos that would ensue, but it’s probably the best option.
> It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily.
I don't think this is true. Some countries with public healthcare are far more efficient than our system.
But there are countries that have systems similar to ours that are far more efficient as well.
We just have a really shitty system, and who pays for it isn't going to change that. It's a hard technocratic problem that doesn't have any easy answers. (Besides increasing the number of residency slots, removing the bachelor degree requirements and allowing foreign physicians to practice which are basically freebies.)
> But there are countries that have systems similar to ours that are far more efficient as well
Typically, those countries have BOTH a public system and a private sector. This means the private sector actually has to be really competitive, because they're competing with "free" (or close to it). This isn't the case in the US, there's no competition.
There is the idea of elite over production. We have private health insurance in order to create a couple thousand upper class jobs. With a half dozen billionaires running things.
I live in north Texas, and the situation here is pretty much on par with the article.
Urgent Care & Emergency Room combos are here on every corner. It’s a lucrative business, so it makes sense that private equity firms are gobbling it up. But I think the more interesting problem here is one level up. Why are there so many of them? I see two possible reasons:
1. Anytime one of my family members gets sick, it’s rather hard to make an appointment with the primary care provider. They are usually booked, and it takes a day or two to get in.
2. Bills from the primary care providers tend to be significantly higher than a bill from urgent care. Anytime I go to a doctor, it’s around $300 for a basic consultation visit. Any problem easily adds $50-100 to it. My typical bill from an urgent care visit for sickness is around $150.
Both places are in-network. Anyway, that’s my experience.
The next "one level up" might explore how much is because the community is quite morbid and unwell, because modern culture has displaced traditional home/self care with consumerized services, or because of other things.
There are people I know who are largely healthy and who consult paid medical services many times per year for everyday disturbances, and others who take decades to overcome procrastination to even get a physical. The demand for commercialized health services is very much a cultural thing, especially for everyday wellness, and that culture has been evolving quite dramatically.
Meanwhile, there's no ignoring that obesity and sedentary living are rampant, that a recent pandemic spooked people about infectious disease and its possible consequences, etc.
You're thinking about the pocketbook economics, here, but looking at it through these other lenses might provide further perspective too.
Not sure what you mean by this? If I have a broken bone, I'm not going to set it myself at home and take a few aspirin. Same if I'm puking my guts out.
If you just mean getting exercise and eating healthy then I fully agree with you. But, when you're actually sick, and need to see a professional, that is the right time for "consumerized services".
I suppose I’m guilty of the demand for immediate care too. Not because I go to the doctor immediately after I get a symptom, but because I try to get better on my own until I reach a point where I think I need help, and at that point, I no longer want to wait.
I cannot just schedule an appointment for 3 days ahead because “late” cancellation costs $$ too.
It's a shame that we have not preserved more local, "community medicine" that you mention. Unfortunately, the reason is that we have destroyed the community by moving to a model where advanced technology is our primary aid instead of other human beings.
You also have Insta-clinic in chains like CVS. Not sure it's a bad thing. Came back from a trip with minor but persistent cough symptoms that were a LOT like the time I had COVID even though I tested negative. Got an appointment the next day at a clinic with a nurse practitioner who prescribed me an inhaler and said it was a "virus" after listening to my chest, etc. I think I maybe had a $40 bill.
Told my primary care at my next appointment and she basically said she'd have done the exact same thing.
For some reason these all seem to be closing down. I don't think there any of the CVS Minute Clinics left in California. They used to be in every third CVS or so.
It's funny, my first job out of college was machine learning for a company processing medical bills to detect fraud on the part of hospitals. It was a very eye-opening process for me as to how American health care is perhaps the worst designed system conceivable by man -- as in, it's genuinely difficult to imagine how the various regulations, incentives etc could be made worse from any perspective (left or right) or measure (human care, cost, equality, whatever). Medical diagnoses are systematized in a rigorous manner through a series of codes (ICD9s, CPTs, DRGs etc), but there is no real set or expected pricing for each code apart from Medicare and these strange agreements between particular insurance providers and particular hospitals (i.e. what defines "in-network" or "out-of-network", where pricing is more or less random). Bills also have an explicit location type (Inpatient, Outpatient, Emergency room, Ambulance etc) and Urgent/Emergency Room care is significantly and consistently the most expensive to the insurer (most American insurance is, after all, high deductible emergency insurance) and thus one of the major vectors of fraud was passing bills off as such. One of the real aspects of madness in the whole system is the pricing disconnect and lack of transparency between all participants: hospitals ask an agreed upon price to insurers who pay it with few questions asked, as hospital pricing drifts up insurers raise premium prices, employers keep paying premiums, and individuals either pay something contractually determined by their insurance company or an essentially random price if uninsured.
TLDR; it isn't at all surprising to me that yet another vulture on American health care expenditure has discovered how profitable emergency rooms can be and that we see such a mad proliferation of urgent care facilities on every corner.
The FTC really should put a stop to labeling community ERs as Urgent Care when they aren't subject to the same billing regulations and are just an excuse for a predatory money grab.
From what I see around me, they advertise that they are both Urgent Care and Emergency Room. UC hours of operation end in the evening, and coming in past the COB automatically puts you to ER billing and pricing.
But if you come in during UC hours and the procedures are outside of UC, you can still end up being billed as an ER customer. The difference is usually in thousands.
> high-deductible plans designed to discourage people from seeking any healthcare
This is in fact not the purpose of those plans.
They try to actually be insurance (ie, in case of unexpected high expenses) rather than a combination of insurance plus pre-payment of typical expenses.
High deductible plans are great. They are designed to allow you to take pretax money out and use it to either invest like an IRA or spend it on healthcare.
In other words they are actually insurance. Not a prepaid healthcare plan. No one should be using “insurance” to cover every day expected expenses like random doctor visits for the flu.
They are a small fight against the massive principal agent problem which is the sole issue anyone should be focusing on if they care about healthcare costs.
When I was covered by an employer plan, a lot of people seemed to gravitate towards high deductible plans because they were cheaper so long as you didn't consume a lot of healthcare. (Personally, I never did but a lot of people were adamant that you saved money that way.)
I was referring to the total bill, in both cases. Sadly, yes, I do have a high deductible plan.
The $300+ bill usually gets adjusted to about 50% by the insurance (I’m in network), and then I pay my share, depending on the state of my deductible and out-of-pocket expenses. (So in my case, 90% before deductible is met, then 10%, until I reach my OOP max.)
UC bill is processed in a similar fashion, and my actual responsibility tends to be less than from my primary care doctor.
These pain points are present in the UK as well; a ton of people have to go to A&E and wait for hours there because their primary caregiver / GP is booked full. 1-2 days wait up to a week for non-urgent care sounds fine to me, but at $300 it's a bit ridiculous.
People end up getting worse and cost the system more, so the cycle continues.
Triage is hard. People may be mis-judging which is the appropriate service provider for their needs. If they don't know what's wrong they may worry that they stumble into a GP, and he just calls the ambulance/steers you to the ER anyway.
The thing that doesn't get mentioned much in these conversations that I've personally seen play a big role is the regulation. When you have highly complex regulations, you end up consolidating practices. As regulations increase, the number of distinct providers/owners decrease. Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people). It doesn't make a lot of sense to deal with the insurance, billing, recordkeepeing, etc for a single physician or two. They wouldn't be able to compete with the larger and more effiecent practices that have more bargaining power with insurance companies anyways.
This gets mentioned every time. The regulation boogeyman always shows up. If only there were fewer rules... everyone could make more money, the little guy would be able to enter and play fast and loose, and nobody would do the wrongdoing those rules were meant to correct/prevent. Yes, there are regulations in health care. There are regulations in almost every industry, and yes, they can be a pain to deal with. Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. As part of the general public, who are often the victims of business's negative externalities, I'm grateful that our government still manages to regulate businesses.
Or maybe regulation is in fact a problem. In my country there is less regulation in healthcare services. I can walk into multiple private facilities in my town, get full blood panel with almost everything you can think of included (hormones, vitamins/mineral levels, liver markers etc) for around 100$. The results are going to be available online the same day (with the exception of those that require more lab time). This is fully private enterprise which has nothing to do with "universal healthcare" my country has.
I don't need prescription or doctor recommendation to get it done. I can also take my own urine/hair/swabs, walk into a lab, pay and have the requests results online in a few days.
If I need MRI I can usually schedule it for the next day in multiple private points and again the results are going to be there the same day. The price is around 200 bucks for say cervical spine.
How is it in your country? Do you know how much is required to get those basic services in other countries?
Then maybe the government (i.e. the public) should pay for more of these regulations, as opposed to unfunded mandates, which small operators cannot afford.
In the example of the individual doctor's office, perhaps the government should provide software and billing systems to adhere to their mandated processes, inspectors, fund regulatory agencies, legislative support, etc.
Otherwise regulatory capture can drive out much of the competition, potentially leaving us worse off than we could be otherwise.
> Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on.
But that's the problem, isn't it? They don't. The smaller providers actually do go out of business or get bought up by private equity and then the quality of care suffers -- which is the thing the regulations were sold as improving.
Everyone knows the US healthcare system sucks. But the United states medical system is not uniquely under regulated compared to the rest of the world. It's uniquely poorly regulated.
Tell me you don't know anything about healthcare without telling me...
Sheesh.
Doctors are medical technicians, not lawyers, and the more you bury them in (largely billing) regulations, the worse care you get and the less time with that doctor you get, and the more money you pay for worse healthcare.
Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people).
It’s interesting that the one specific thing you mention is insurance. That particular complexity doesn’t come from regulation. It comes from the immoral insurance industry.
The widespread need for medical insurance only exists because regulation has introduced many artificial inefficiencies within the health care sector that in turn severely distort the pricing of medical services and medical products.
We'd see far more reasonable pricing, and much less need for something like medical insurance, without the regulations that artificially limit the supply of practitioners and clinics, that prevent competition, and that introduce unnecessary costs, among other distortions.
Regulations for healthcare exist are complex in every developed country, but in most everything works fine for a fraction of the cost, so I don’t think that’s the main issue
Ironically this statement glosses over the indisputable issue of the specifics of the paperwork volume, and the change in it over time. "Regulations exist everywhere" is far to general an argument to be meaningful in my opinion. Humans are forever limited by time and their labor capacity within it.
Measuring burdensomeness of regulation by number of laws is an incredibly poor measure. Though I'd still be surprised if many countries healthcare laws were as complex as our own.
For example
All doctors require 1 year of schooling
2 year
5 years
10 years
20 years.
Each is 1 law but has each also has very different level of burdensomeness.
I'd actually be in favour of deregulating a lot of healthcare, but probably not for the same reasons as you. I think a cheap but unverified device/consultation/surgery is better than none at all (where only an unaffordable regulated option exists). But that's miles away from how society, even American society, functions. Without some mechanism to manage trust you can just remove the safeguards. It's actually quite possible to keep the safeguards and run a half-decent healthcare system, and this is surely much easier than finding a way to let people take calculated risks without causing mass deaths and a collapse in social cohesion.
It's not just regulation. You have electronic health record systems and the like that are often beneficial for consumers. My personal experience is that a lot of older docs, one doc practices, and the like hate this sort of thing. But I personally love the modern systems that a recent merger brought to my local hospital system. It's no longer about (maybe) faxes getting to the local lab for tests after calling them a week before the physical.
There are one or two doctors here who operate individual cash-based practices. They don't deal with insurance companies or their paperwork. The seem to mostly focus on services that insurance is unlikely to cover anyway: weight loss, hormone therapy, but also still run a general/family practice.
They stay in business so the model seems to be viable, but perhaps only because there are so few of them doing it.
I've worked in healthcare, and pretty much my whole family does in all the professional roles you can think of.
I have mixed feelings about this article and others like it because the motivation to strip the system of everything until profit is left is a serious problem throughout US healthcare. However, it's not unique to private equity — private regional monopolies, or even privately owned clinics and hospitals, can have a similar effect. These articles then have a way of shifting the focus away from the underlying administrative practices that result in these problems, and toward private equity per se.
The regulation problem is real too, and I can give lots of examples. It's unlike a lot of other fields too in the scope and how ingrained it is in the system. EHRs are just one example: although well-intended, they were mandated with no "organic" roll-out, and pulled what was in-house staff and services and pushed it outside into large monopolies like EPIC (who are now the subject of an antitrust lawsuit IIRC). This happens over and over with all sorts of aspects of US healthcare.
I also have problems with the focus of these types of articles — for whatever reason, they often start with or are centered around this kind of wistful new physician (or very old physician near retirement) longing for the romanticized old days where physicians were in charge and ran everything. Should that be the case though? Do we really need MDs to do and approve of everything? Aren't there things that are done as well by PAs, DNPs, and other types of providers that don't even exist yet because of how calcified the healthcare system is? Can't patients do more at home without a middleperson — e.g., needing to approve of some medication that the person has taken for decades without incident and is really truly pretty harmless in the grand scheme of things?
The problem you described is very real. It's overregulated, in ways that incentivize large monopolies, either of clinic and hospital owners, or provider rent seeking guilds, infrastructure providers, etc.
I guess I feel like these types of articles point to one type of problem, but then tend to implicitly suggest the solution is to just roll back time to some earlier era, not recognizing that that earlier era had a smaller patient population, with less regulation, less monopoly where there was no need to scrutinize whether a certain type of degree is really necessary, where there weren't huge hidden overhead costs of all these monopolies permeating down to the patient.
Fixing US healthcare is going to require a bunch of things that collectively will cause pain for a lot of entrenched players: lots of antitrust lawsuits and laws, lots of deregulation aimed at giving patients more choice and self-care options, more public payer options, lots of eliminating or restructuring licensing requirements to create more types of providers, and so forth. They don't map on easily onto current US political party platforms either.
I have said this a million times and I will say it again: anyone who thinks the US healthcare system isn’t a flaming train wreck hasn’t used it much. Or is rich enough enough not to care.
This is also due to inequality which leads to more and more of the same. There just aren't many ways entrepreneurs can add value. It is easier to capture it from assets needed by lower classes. Get a wealth tax to fix this or at least tax the wealth out of the rich.
Private equity is no longer doing its job, to the extent if ever had one.
If there were a poorly run company, private equity could use its own money to acquire it, restructure it to be more efficient and valuable, and capture cash flow while owning it and profit from taking it public again. They would make money, the economy would be improved, and a healthy new public company would build more public wealth.
This is a bit idealized, but something closer to this really did happen.
Now they use raise money from rich people and operate more as alternative investment management, take over efficient operations, strip them, use leverage in the opposite direct (acquisition targets take loans and transfer the money back to PE). We end up with worse services, unsustainable and over-leveraged businesses, money transfer from the public to the wealthy from increased welfare and bankruptcies, and a worse economy because of changes to the velocity wealth returns to the economy from private fortunes.
This stinks when it is the Office Depot or Friendly's, but it is a massive problem for residential real estate, delivery of medical care, medicine, and basic food production.
You would think that the brilliant folks at KKR, Carlysle, Blackstone, and others would read their classics and know the story of the ancien régime and Romanovs.
> Private equity is no longer doing its job, to the extent if ever had one.
Private equity's job is to take a slowly failing company, extract the value, and turn it into a suddenly failed company.
See department stores in the 90s, Circuit City, ToysRUs and restaurant chains more recently.
This is a win for the former owners who get cash for their business and can blame the failure on PE, rather than admit it was on a path to fail slowly. This is a win for PE, because they can often extract enough value to make a good profit. It's a win for Spirit stores, because they get great locations like the old Circuit City that still has those maroon tiles up in 2024 and the old ToysRUs that still has the R up.
When a sector of business is being bought by PE left and right, it's a sign of unhealthy businesses and the owners want out.
Median is better here. Average wait includes homeless people who use the waiting room for a warm nights sleep and similar outliers. They quickly get triaged and a free sandwich
Not so sure the median would be so far off here. Just earlier this week I spent about 4.5 hours in the ER in a Bay Area hospital. Not DC, but 5.5 hours doesn’t seem crazy to me.
Readit News
There’s a variety of weird examples of this mixed system:
>Poor people use ERs for every day healthcare, usually they get away with paying nothing, no insurance
>Working people with insurance pay more to enable this access for the destitute (or criminal) portion of the population
>Old people are sort of entitled to free healthcare. They get medicare, but if they want everything, they have to pay for “supplements.”
>Young people pay for the old people’s healthcare twice, on their payroll taxes and in the form of higher premiums. A 25 year old male should absolutely not have a $300/mo health premium. But he does, because his premium is paying for other’s care.
This is a system pretending to be private, but it’s actually just inefficiently public. It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily.
Alternatively, abolish health insurance altogether—a notoriously inefficient and exploitative industry that does not suit the classic purpose of insurance (boat accidents and fires)—and see what happens. This is obviously a rather unpalatable option due to the chaos that would ensue, but it’s probably the best option.
I don't think this is true. Some countries with public healthcare are far more efficient than our system.
But there are countries that have systems similar to ours that are far more efficient as well.
We just have a really shitty system, and who pays for it isn't going to change that. It's a hard technocratic problem that doesn't have any easy answers. (Besides increasing the number of residency slots, removing the bachelor degree requirements and allowing foreign physicians to practice which are basically freebies.)
Typically, those countries have BOTH a public system and a private sector. This means the private sector actually has to be really competitive, because they're competing with "free" (or close to it). This isn't the case in the US, there's no competition.
Really? Which ones are they?
Urgent Care & Emergency Room combos are here on every corner. It’s a lucrative business, so it makes sense that private equity firms are gobbling it up. But I think the more interesting problem here is one level up. Why are there so many of them? I see two possible reasons:
1. Anytime one of my family members gets sick, it’s rather hard to make an appointment with the primary care provider. They are usually booked, and it takes a day or two to get in.
2. Bills from the primary care providers tend to be significantly higher than a bill from urgent care. Anytime I go to a doctor, it’s around $300 for a basic consultation visit. Any problem easily adds $50-100 to it. My typical bill from an urgent care visit for sickness is around $150.
Both places are in-network. Anyway, that’s my experience.
The next "one level up" might explore how much is because the community is quite morbid and unwell, because modern culture has displaced traditional home/self care with consumerized services, or because of other things.
There are people I know who are largely healthy and who consult paid medical services many times per year for everyday disturbances, and others who take decades to overcome procrastination to even get a physical. The demand for commercialized health services is very much a cultural thing, especially for everyday wellness, and that culture has been evolving quite dramatically.
Meanwhile, there's no ignoring that obesity and sedentary living are rampant, that a recent pandemic spooked people about infectious disease and its possible consequences, etc.
You're thinking about the pocketbook economics, here, but looking at it through these other lenses might provide further perspective too.
Not sure what you mean by this? If I have a broken bone, I'm not going to set it myself at home and take a few aspirin. Same if I'm puking my guts out.
If you just mean getting exercise and eating healthy then I fully agree with you. But, when you're actually sick, and need to see a professional, that is the right time for "consumerized services".
I cannot just schedule an appointment for 3 days ahead because “late” cancellation costs $$ too.
Told my primary care at my next appointment and she basically said she'd have done the exact same thing.
TLDR; it isn't at all surprising to me that yet another vulture on American health care expenditure has discovered how profitable emergency rooms can be and that we see such a mad proliferation of urgent care facilities on every corner.
But if you come in during UC hours and the procedures are outside of UC, you can still end up being billed as an ER customer. The difference is usually in thousands.
Do you have one of those high-deductible plans designed to discourage people from seeking any healthcare?
This is in fact not the purpose of those plans.
They try to actually be insurance (ie, in case of unexpected high expenses) rather than a combination of insurance plus pre-payment of typical expenses.
In other words they are actually insurance. Not a prepaid healthcare plan. No one should be using “insurance” to cover every day expected expenses like random doctor visits for the flu.
They are a small fight against the massive principal agent problem which is the sole issue anyone should be focusing on if they care about healthcare costs.
The $300+ bill usually gets adjusted to about 50% by the insurance (I’m in network), and then I pay my share, depending on the state of my deductible and out-of-pocket expenses. (So in my case, 90% before deductible is met, then 10%, until I reach my OOP max.)
UC bill is processed in a similar fashion, and my actual responsibility tends to be less than from my primary care doctor.
People end up getting worse and cost the system more, so the cycle continues.
This gets mentioned every time. The regulation boogeyman always shows up. If only there were fewer rules... everyone could make more money, the little guy would be able to enter and play fast and loose, and nobody would do the wrongdoing those rules were meant to correct/prevent. Yes, there are regulations in health care. There are regulations in almost every industry, and yes, they can be a pain to deal with. Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. As part of the general public, who are often the victims of business's negative externalities, I'm grateful that our government still manages to regulate businesses.
I don't need prescription or doctor recommendation to get it done. I can also take my own urine/hair/swabs, walk into a lab, pay and have the requests results online in a few days.
If I need MRI I can usually schedule it for the next day in multiple private points and again the results are going to be there the same day. The price is around 200 bucks for say cervical spine.
How is it in your country? Do you know how much is required to get those basic services in other countries?
One such regulation is "certificate of need" laws, where you effectively need to ask the incumbent for permission to open your would-be competitor.
https://spn.org/articles/certificate-of-need-laws/
In the example of the individual doctor's office, perhaps the government should provide software and billing systems to adhere to their mandated processes, inspectors, fund regulatory agencies, legislative support, etc.
Otherwise regulatory capture can drive out much of the competition, potentially leaving us worse off than we could be otherwise.
But that's the problem, isn't it? They don't. The smaller providers actually do go out of business or get bought up by private equity and then the quality of care suffers -- which is the thing the regulations were sold as improving.
No, this gets mentioned in other healthcare conversations but rarely in PI takeover conversations.
Sheesh.
Doctors are medical technicians, not lawyers, and the more you bury them in (largely billing) regulations, the worse care you get and the less time with that doctor you get, and the more money you pay for worse healthcare.
It’s interesting that the one specific thing you mention is insurance. That particular complexity doesn’t come from regulation. It comes from the immoral insurance industry.
We'd see far more reasonable pricing, and much less need for something like medical insurance, without the regulations that artificially limit the supply of practitioners and clinics, that prevent competition, and that introduce unnecessary costs, among other distortions.
Considering the ACA requires insurance, it indirectly does. While there are cash-only doctors, it's very rare.
Deleted Comment
Regulation is a tool that can be used for many ends. It's not very helpful to speak about them collectively.
For example
All doctors require 1 year of schooling 2 year 5 years 10 years 20 years.
Each is 1 law but has each also has very different level of burdensomeness.
They stay in business so the model seems to be viable, but perhaps only because there are so few of them doing it.
I've worked in healthcare, and pretty much my whole family does in all the professional roles you can think of.
I have mixed feelings about this article and others like it because the motivation to strip the system of everything until profit is left is a serious problem throughout US healthcare. However, it's not unique to private equity — private regional monopolies, or even privately owned clinics and hospitals, can have a similar effect. These articles then have a way of shifting the focus away from the underlying administrative practices that result in these problems, and toward private equity per se.
The regulation problem is real too, and I can give lots of examples. It's unlike a lot of other fields too in the scope and how ingrained it is in the system. EHRs are just one example: although well-intended, they were mandated with no "organic" roll-out, and pulled what was in-house staff and services and pushed it outside into large monopolies like EPIC (who are now the subject of an antitrust lawsuit IIRC). This happens over and over with all sorts of aspects of US healthcare.
I also have problems with the focus of these types of articles — for whatever reason, they often start with or are centered around this kind of wistful new physician (or very old physician near retirement) longing for the romanticized old days where physicians were in charge and ran everything. Should that be the case though? Do we really need MDs to do and approve of everything? Aren't there things that are done as well by PAs, DNPs, and other types of providers that don't even exist yet because of how calcified the healthcare system is? Can't patients do more at home without a middleperson — e.g., needing to approve of some medication that the person has taken for decades without incident and is really truly pretty harmless in the grand scheme of things?
The problem you described is very real. It's overregulated, in ways that incentivize large monopolies, either of clinic and hospital owners, or provider rent seeking guilds, infrastructure providers, etc.
I guess I feel like these types of articles point to one type of problem, but then tend to implicitly suggest the solution is to just roll back time to some earlier era, not recognizing that that earlier era had a smaller patient population, with less regulation, less monopoly where there was no need to scrutinize whether a certain type of degree is really necessary, where there weren't huge hidden overhead costs of all these monopolies permeating down to the patient.
Fixing US healthcare is going to require a bunch of things that collectively will cause pain for a lot of entrenched players: lots of antitrust lawsuits and laws, lots of deregulation aimed at giving patients more choice and self-care options, more public payer options, lots of eliminating or restructuring licensing requirements to create more types of providers, and so forth. They don't map on easily onto current US political party platforms either.
If there were a poorly run company, private equity could use its own money to acquire it, restructure it to be more efficient and valuable, and capture cash flow while owning it and profit from taking it public again. They would make money, the economy would be improved, and a healthy new public company would build more public wealth.
This is a bit idealized, but something closer to this really did happen.
Now they use raise money from rich people and operate more as alternative investment management, take over efficient operations, strip them, use leverage in the opposite direct (acquisition targets take loans and transfer the money back to PE). We end up with worse services, unsustainable and over-leveraged businesses, money transfer from the public to the wealthy from increased welfare and bankruptcies, and a worse economy because of changes to the velocity wealth returns to the economy from private fortunes.
This stinks when it is the Office Depot or Friendly's, but it is a massive problem for residential real estate, delivery of medical care, medicine, and basic food production.
You would think that the brilliant folks at KKR, Carlysle, Blackstone, and others would read their classics and know the story of the ancien régime and Romanovs.
Private equity's job is to take a slowly failing company, extract the value, and turn it into a suddenly failed company.
See department stores in the 90s, Circuit City, ToysRUs and restaurant chains more recently.
This is a win for the former owners who get cash for their business and can blame the failure on PE, rather than admit it was on a path to fail slowly. This is a win for PE, because they can often extract enough value to make a good profit. It's a win for Spirit stores, because they get great locations like the old Circuit City that still has those maroon tiles up in 2024 and the old ToysRUs that still has the R up.
When a sector of business is being bought by PE left and right, it's a sign of unhealthy businesses and the owners want out.
The average ER wait time across DC was 5 hours and 29 minutes. That's across all hospitals.