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.

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 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.

I know a surgeon who had their employer bought up by private equity. It's a disaster; the paperclipification of care

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.

The ER is to some extent a fictitious entity. Politicians took to blaming the poor for abusing their access to ER's. But healthcare is anything if not statistical. They can figure out how many patients walk into an ER, who could be served in an urgent care setting, and provide those services on site. In fact, the ER closest to my house works in exactly this way.

> Meanwhile, to minimize costs, private equity-owned staffing firms often replaced more expensive physicians with nurse practitioners and physician associates. It was a move likely to worsen patient care: While these professionals do highly skilled work in a variety of clinical settings, the emergency department is one place where care outcomes are more likely to suffer if a doctor isn’t involved.

Using more PAs and NPs seems like it could potentially be beneficial, since 1) they are cheaper than physicians (this could be attractive to patients if it lowered the bill for treatment), 2) the supply of physicians is more constrained (due to limits in med school and residency slots to avoid "oversupply", as well as longer training time), and 3) NPs and PAs may be well positioned to take care of many non-emergency patients in the ER, urgent care, non-life-threatening cases, etc. What might be helpful is a higher tier of ER-specialist NPs and PAs, as well as an adequate supply of ER physicians to treat the emergency patients in the ER who really need them.

Is there anything that private equity doesn't decimate? Is there any industry that is made better by these rent-seekers?

I had an interesting experience in the ER lately that caused me to do some research.

The average ER wait time across DC was 5 hours and 29 minutes. That's across all hospitals.

I hate private equity they bought our company and proceeded to nickel and dime it -

How can I avoid an ER run by private equity?

A key question is why the free market does not work in this case. Many business are "profit obsessed", yet it does not mean they won't provide quality products or services at increasingly lower prices. What's different in the health care?

The US Healthcare System is a cruel and unusual punishment.

Sell everything in the US and move to a cheaper country like India. You will have free health care.

For anyone looking for more information about the game dynamics of the “profit-obsessed monster” and why it is inevitable in our current economic system, I highly recommend the following Scott Alexander piece: https://www.slatestarcodexabridged.com/Meditations-On-Moloch

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.

MBAs will turn everyone into The Joker.

Capitalism is ruining America. We're headed to where everything is buried behind oligarchical institutions.

Isn’t huge profits the definition of success in capitalism? As a capitalist society shouldn’t there be cheers instead of complaining? This part I don’t understand about American culture.

It would be great to see some real solutions to the menace of private equity, or at least to see these solutions discussed in the mainstream public discourse. Which is a good reason to vote third party, if you're in the US: they might never win, but if they get enough votes, eventually their ideas will be heard (unless and until they too get co-opted by lobbyists from Vanguard and Blackrock).

Funeral homes and anything else not run by a single professional has had this treatment. This is due to inequality. The wealthy have nowhere left to invest but things like this which raise costs for the lower classes. Taxing wealthy far more is the only solution but people have a hard time voting in their interests. We're doomed.