David Belk

December 7, 2013

I am David Belk. I'm a doctor who has spent years trying to untangle the mysteries of health care costs in the US and wrote a website exposing much of what I've discovered AMA!

The name of the website is The True Cost of Healthcare: http://truecostofhealthcare.org

I've also written blogs for Huffington post which can be found here: http://www.huffingtonpost.com/search.php/?q=david+belk&s_it=header_form_v1

And here is my proof that it's really me doing this: http://truecostofhealthcare.org/proof_for_reddit

I have to sign off now because my wife is getting angry about the fact that I've been on the computer for eight hours without a break (I'm also starting to get delirious) Thank you all for your question and I really wish I had time to answer them all but, if I tried I would probably end up in divorce court. I'll try to answer more questions tomorrow.

I'm back! The wife and kids are in bed now so, again, AMA

Got to go for the night. My eyes are starting to gloss over.

I'm Back if anyone is still interested AMA

do you like hamburger

Of course, who doesn't?

Are we overcharged? Is it true doctors just write prescriptions to get more money? What is your stance on vaccines for babies? Are they more dangerous to get then to not get like some people claim? Edit: I apologize, I submitted the same question twice. No need to answer twice.

Yes, we're overcharged considerably for most medical services. Doctors don't normally get paid to write a prescription. Vaccines have saved millions of lives and are well worth any slight risk they might pose.

Do you believe universal health-care to be a possibility in the US in the future?

If you mean single payer, I'm skeptical our US Congress would ever allow it to happen.

Yeah, sorry, I was thinking single payer.

You would like it to happen, though?

I wouldn't be against it happening I'm just not holding my brealth.

This one of the reasons I think the US needs to break apart into a handful of smaller countries. If this happened, certain parts would very likely implement European-style single-payer systems and finally make some progress, without being held back by the other regions.

We tried that in 1861 and it didn't end well.

Would you agree that it has to do with the fact that there are too many insurance companies with too much money in politicians pockets? Being in the insurance billing industry for over 20 years, I very strongly believe that this is the reason that we would never, ever get to socialized medicine, or a single payer universal health care due to the number of lobbyists from every single major insurance company (BCBS, UHC, Aetna, Cigna, to name a few) that has too much money in too many politicians pockets.

I would love to hear your response to my comment.

You're right. But that's a systemic problem with just about every industry in this Country.

Agreed. So, it seems to all stem down to politics and money. How would you propose this being changed? If not for "every" industry, but for the health care industry, which you are an expert in?

this will be my first attempt in politics. Wish me luck.

What about state by state? A few states lead by example first.

Vermont is trying it. California tried to pass a single payer bill a couple of years ago and it was shot down by the legislature. There's a lot of money in preventing it from happening.

Have you ever watched John Bergman's videos on You Tube? If so, do you believe "If diet is wrong, medicine is of no use. When diet is correct, then medicine is of no need." ?

A good diet helps but it won't solve every problem in health care. Some people will live the healthiest lifestyle possible and still get sick while others can live like Homer Simpson and die in their sleep at 95 never having seen a doctor. Life isn't fair.

It's true. My grandmother lived on her own until 89, still taking care of her house and lawn and growing vegetables. When she required care, after rarely having visited a doctor in her life, she lived until 94, lucid to the end. My father is now 86 and gets quarterly checkups but still maintains his own place and drives. He never would have gone to a doctor either if my mother hadn't made him. I know that's not the norm but it does support your statement.

I was actually thinking more of a case like this one. The guy lives to be 107 on cigars and brandy.

What are your thoughts on the subject of improperly tested meds being rushed through their clinical trials by an FDA that accepts "consultation" fees from the same drug companies they're supposed to be monitoring? How often would you say dangerous drugs go to market without proper testing or necessary rejection, and how many lives are affected?

That's a good question. Part of the problem is that the FDA is underfunded. As far as drugs getting "rushed" that really started with the AIDS epidemic when a lot of activist were complaining that anti HIV medications are taking too long to get on the market. Streamlining the process improved the situation for getting some urgent lifesaving meds out early but, as with any relaxation in policy, it opened the door for abuse.

Mostly, the problem isn't that drugs are rushed through the FDA but rather the research and the evaluation of the drug research is conducted mostly by drug companies and they've learned to manipulate the process well. Here's an article that addresses that problem:


What is your stance on getting your baby vaccinated? Some people think it is worse to vaccinate your baby then to not. What do you think?

Both my kids are vaccinated. I refer you to Penn and Teller: https://www.youtube.com/watch?v=RLcOz4EKrxg

What can be done, realistically, to change the view of healthcare in the U.S. and to get people to wake up and make a change? Also, did you see Michael Moores doc. Sicko, your thoughts on it?

I saw sicko. Michael Moore was wrong on a few points but did a great job of exposing how intentionally evil health insurance companies are. I guess the answer to your first question is the focus of my crusade. People have to know exactly what's wrong with our health care system before we can really fix it.

Mind expanding on what you thought was wrong?

It's a bit hard since I saw the movie several years ago. I remember thinking at the time that I would love to sit down with him and explain a few things about our system that only someone on the inside would understand. One example is how the role of hospitals in treating sick people has been shrinking in this Country. It's not entirely because people are being kicked out too early (though that does happen unfortunately). It has more to do with the fact that hospitals were over-utilized tremendously in the past. I wrote an essay about that a couple of years ago. I should say, I wrote the essay before I got a hold of all the financial records for California's hospitals so I know more now but I think it's still worth reading if you like: http://truecostofhealthcare.org/yahoo_site_admin/assets/docs/Bankrupt_Hospitals.211200419.pdf


It's possible to negotiate prices and get deals on elective services and outpatient tests and procedures. It's not realistic to think you could do it in an emergency though. That's where people get hit the hardest.

Also for complex problems like cancer treatment, there are so many players involved in your care you couldn't possibly arrange a deal with all of them separately. And trying to do this while going through surgery, radiation therapy and/or chemotherapy would truly be a nightmare

Because of this...the numbers of different bills one occurs from one stay in the hospitals, I don't believe limiting hospital charges would be enough to fix our system. I think we need a system that places realistic prices on all specialists, tests, labs, etc. Not just the part the hospital charges. Although the hospital charges are most likely the most inflated.

I used to get a yearly exam from my doc for a little over 100 a year. Now because he has joined forces with our local hospital, and billing is through them, the bills for the same visit have been $350 and $475. Thank goodness I had Medicare, but it was affordable for me without insurance until he joined the hospital. Now without Medicare I'd never be able to see him. And he's just a family practice doctor...not a specialist.

Well OK but what I'm proposing is a good start.

Is there a way to ELI5?

Whenever healthcare is talked about, the concept that we are the "only western" or "only 1st world" country that exists with this ass-backwards medical system is always thrown around... How come our government/population is so complacent with this standing? It blows my mind that that statment can be so casually spoken without ANYONE being embarassed and subsequently affecting any change!

Here in America, we've always had issues with progress. Remember, we're also one of the few Countries that hasn't adopted the metric system and we still use pennies for some strange reason.

The only use for pennies is to keep yourself from getting more pennies.


And despite a few attempts we have refused to adopt the use of dollar coins which would save our economy billions.

I know

Great post but USA HAS adopted Metric system


I am a Norwegian, who have lived in the US. When I follow the health care debate in the US, it seems to me that American's are generally unaware or simply refuse to believe that it is better anywhere else. There is all this scaremongering about socialized medicine and what not. If all I knew about alternative health care systems was what was thrown at me from American media, I would not dear change either.

It's like a religion here

What would be your ideal healthcare system? I.e. What country do you believe has it "right"?

Every possible system will have its flaws. What makes our system so unique is that it seems to found a way to have all the flaws of every other health care system while avoiding any of the benefits.

Seriously though, I think one way to improve our system is to cap how much hospitals can bill. It's been done in Maryland since 1977 and works fin there. It won't fix all of our problems but I like to approach problems one step at a time.

Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

What do you think of this PBS Frontline episode that examines five different national health care systems? http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

I hope I'll have time to watch it later, thanks.

My extrapolation of the way hospitals work is that they'd react to a cap by doing the shittiest, half-done job, bill you for the full amount, and run you right out the door...

Also superfluous billing items. Yeah he came in for a mole removal, let's add a full urinalysis, blood work, and semen analysis, 5-day hospital stay, 12 different medications, 8 "expert consultants", and full-body x-rays.

Well, that's not how it's working in Maryland. Also, you might want to read this to see what hospitals do now.

Price controls? Really?

On hospital charges, yes. Simply making hospital prices more transparent probably wouldn't go far enough. Here's why:

-Several large hospital corporation now have monopolies over large regions of the US. These corporations have little motivation to drop their prices when people have to go several hundred miles to avoid using one of their hospitals. This is further complicated by the fact that health insurance exists as an option to negotiate lower rates for people.

-Most hospital admissions in the US are non-elective. The only elective admissions I can think of are some orthopedic procedures (e.g. a hip replacement). Here in the US hospitals are reserved primarily for the treatment of medical problems that can't be treated anywhere else so, the people needing such treatment rarely have the option of shopping around.

I'm guessing this solution goes against your libertarian values but it appears to be working and has been working for 36 years in Maryland. You can't argue with results. I'm a pragmatist. I can't afford too many values, I just want a solution that actually works.

That is a great documentary, I highly recommend it

Thanks, I guess I'm a bit better at video editing than I am at web design.

Why do you think price caps would work on a national scale?

I actually think it would be better to do it for hospitals State by State partly because we already have a model for it in Maryland and also because the US Congress couldn't pass gas let alone an effective bill right now. It's also easier to get things done at the State level

our system is messed up in a ways, but to say that their are no good things about it is sorely misleading, and it sounds like more of a political statement than some truths..

OK, I was exaggerating a bit but I couldn't help it. Anyway, it was kind of funny.

I was just in the hospital, came in to the ER for high BP, they hit me with Lorpressor, one bag of saline in an IV, and one day of my regular meds. They billed 745$ for pharmacy. 745$ I figured that if I paid what I pay the pharmacy the pills would have cost me less than 10 bucks,

You can actually get 100 metoprolol tabs at Costco for $7.18: http://www.truecostofhealthcare.org/medications/medication_table

Do you forsee any downside to implementing this across the country?

No, but I wouldn't count on the US Congress for anything which is why I think a State by State approach is more realistic.

Why don't you interview a non-biased hospital president? Would you like an email? I can provide one for you. If you're going to investigate healthcare systems, why don't you investigate the bullshit stories that go with it?

Have you read this yet? http://truecostofhealthcare.org/hospital_financial_analysis

Plus, a state-by-state system would appease a lot of right-leaning centrists like myself who want the federal government the fuck out their business.


So you dont believe putting a cap on bills would have any negative effects, such as creating service/care shortages or destroying wages? I believe that hospitals charge so much in order to offset the lowball number the insurance companies pay out, since they only pay a small percentage of whats actually billed anyways. So does this mean the hospitals are at fault, or the insurance companies?

Again, it's working in Maryland. Also, the caps don't need to be draconian, just reasonable. Right now hospitals in California bill an average of four times what they expect in payments and still made close to $6 Billion in profits in 2011 alone! Something's got to be done about that.

Price controls?

For hospitals. They've gone way too far with their billing excesses so we have to reign them in somehow

I agree that they overcharge massively, nobody is disputing that. I just feel like trying to introduce a nation-wide cap on a service industry's pricing can create shortages, among other possible negative effects that are unknown. I acknowledge that this would still probably be a better solution than what we have now, but i wouldn't base legislation on one isolated example of success... Just playing devil's advocate here.

Actually, I'm proposing State commissions and it works in Maryland so, you have that.

I don't know if I can take your study/website as a whole seriously if you omitted the role of the AMA as a powerful player in resisting change to the current system.

The AMA was historically very powerful and did a lot to hamper progress in the past. Now, however, they're a shadow of what they once were. Most doctors aren't members of the AMA. They're not completely irrelevant, yet, but they're getting there.

What makes our system so unique is that it seems to found a way to have all the flaws of every other health care system while avoiding any of the benefits.

Complete garbage. I think that's actually worth calling a lie.

I love your username.

What about the argument that statistics showing national cancer survival rates seem to say Americans do get the best health care?

That would work great if everyone could just get cancer

make data available to consumers. have a website that lists hospitals/doctors prices.

http://clearhealthcosts.com/ is one of many.

while avoiding any of the benefits.

Correct me if I'm wrong, but does not a lot of medical research, breakthroughs, and development happen in the US?

It does. I was making a joke OK. There is an incredible amount of waste and inefficiency in our health care system but it does do some good things. There, are you happy?

I wasn't looking to be "happy" I was just asking a question.

Sorry, I've been typing all day. Maybe it's time for bed. I'm becoming a grouch.

Perhaps. Too much reddit can do that to a person.

It's been an intense day:)

while avoiding any of the benefits

That's simply not true. Having lived in many countries, America definitely has the best health care system if you can afford it. The problem is that most people can't afford it, but if I got seriously sick I would choose a good American hospital ten times out of ten.

The next line in the comment starts with the words "But seriously" implying that I'm joking a bit.

Well, cancer is one of the top two causes of death (would be interesting to see some cardiology-related stats). Don't mistake me as a flag-hugging 'murican; I posed the question simply because I believe in challenging my beliefs whenever possible, and I presume you have a better answer than this, as amusing as it is.

Outcomes and causes of death are somewhat different variables. Treatment of cancer is what you might call reactive medicine (treating the disease once it's appeared) which we are actually pretty good at in the US. There is also what you might call proactive medicine which treats or prevents a disease before it's manifested.

Outcomes measure how well we deliver both types and, overall, for the amount we're spending it's not good. Here's a report from FOX News. You can find many more that state the same but I didn't want to be accused of liberal bias.

What do you think of this PBS Frontline episode that examines five different national health care systems? http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Well, I just watched it and, Thank you! That was really good.


Do you remember how much it did cost?

Interesting blog post! In it, you write:

California hospitals billed an average of nearly $4 for every dollar they received [...] California hospitals report their bad debt losses each year, and it averages less than 2 percent of what they bill, not 75 percent

If California hospitals bill $4 for every $1 they receive, what's happening to the other $3? If it's not bad debt, what is it?

Sorry to get back to you so late. This video should answer your question.

What are your thoughts on accountable care organizations? Will they bring down costs and improve care or will they make not much of a difference at all?

I confess, I don't understand them but I think they are intended to push doctors to provide more preventive care. In theory that's always a good idea. We'll see how that works in practice.

That is the big question. In the Hospital we have something called the 30-day re-admit rule. I.e. If you get re-admitted within 30 days of a previous admission for whatever reason the Hospital gets $0 for the 2nd stay. I love the concept of preventative medicine, in theory it makes a ton of sense. But how do you provide incentive to Docs/Hospitals to get people to not use their services. In reality because of denial in payment for things like the 30-day re-admit rule. We need to provide follow up and take certain measures to ensure they stay out of our Hospital not because we get paid for it, but because we will be denied payment and eat the entire cost of labor/medications/everything else if we don't. Its more stopping the bleeding than it is profitable.

My understanding of the rule, as far as Medicare goes, is that the 30 day re-admit rule only applies to re-admissions for the same diagnosis. In other words, if a hospital admits the same patient twice in a month for, say, congestive heart failure then that's seen as a premature discharge the first admit.

However, if someone is sent home after being hospitalized for CHF, but then breaks their leg, it will be credited as two separate admits even if both occur in under a month. If they do have Medicare, both admits will be covered under the same Medicare inpatient copay.

I live in the UK so I don't know much about your healthcare system, but I'm curious: the general consensus over here is that people in the USA might be avoiding going to see medical professionals due to the costs. Do you think this is true at all?

Yes, if you don't have insurance it's a minefield. If you do have insurance you're still not always safe. Just watch this and see for yourself: https://www.youtube.com/watch?v=vNJ6DYCaG-4

This makes me feel seriously ill to watch. Bad enough to be ill but then to be ripped off by the ones who are supposed to help look after you, that's unbelievable. I hope this changes soon.

I'm trying

You seem to be doing a great job :)


Hi, I'm the head actuary of a workers comp insurance company. Can you please explain why you seem to be putting the blame on insurance companies for what is clearly medical providers overcharging using inflated sticker prices? Insurance companies that can't effectively negotiate prices go out of business, there is nothing 'in it for them' to negotiate bad prices. Could they do better? Probably but it's disingenuous to blame them for the provider's billing practices.

Billing fraud is a very common problem in the provider community and there are always tons of bad apples who are inflating prices, upcoding charges and prescribing less effective treatments that make them more money. Providers offices will close and open across the street with a different legal name so they can continue their shakedown operation.

Insurance companies have to negotiate prices with practically every provider entity in the state in order for them to have adequate coverage, it's impossible for them to always get the cheapest price.

In the last decade provider consolidation, particularly with hospitals and certain high need specialists, has caused providers to capture huge pricing power and the ability to force large increases onto the insurance companies. There are areas where provider groups are operating with near monopoly pricing power.

Using insurance companies as a scapegoat is part of what got us to where we are now because it allowed us to ignore the real underlying problems.

Worker's comp is an entirely different animal than health insurance. They tend to pay nearly the full charge for most services. If you read this analysis of hospital financial records, you'll see that it's not the case with most insurers

Have you presented to a government funded emergency department in a large metropolis? Because literally 70% of what we see on a daily basis are

They come into the UCC or ED for med refills. Over half the time, it is for narcotic pain killers and they leave pissed when we tell them that we don't treat chronic pains. Isn't education the true issue at hand?

I did my residency at LA County Medical center.

I am in Texas and did not mean to across as divisive. I agree with many of your points, but feel that a fundamental problem with current system is how it addresses patient education. It is a huge, huge burden in the UCC and ED.

I understand. I just didn't want you to think I'd never seen a big city ER. It's a whole different world.

Being Canadian an living in the USA I have had the chance to end up using every aspect of the system. Insured, uninsured and in Canada free.

Even though I have a really good insurance plan now in the usa I can wholeheartedly say that this country and its people have been shoveled so much bullshit it's mind boggling. The system is unfair and the worst in any country I have visited. It's a "for profit" sham that has ruined the quality of life for so many humans that the government should be ashamed.

The people are so brainwashed it saddens me. They refuse to believe a single payer government controlled system will make the country so much richer and stronger. They only need to look north to see it in action. Yet they refuse.

True that.

As someone with insurance I can assure you its still a minefield of what will and won't be covered for whatever dumb reasons.

Second that

How is this possible? I live in Australia and I've never payed a cent for GP appointments or Lab tests or X-rays.

You're lucky.

How can the richest country in the world not have free health care. Isn't it a human right?

UK here too and we soon forget how lucky we are to have the NHS and how great it is. We take it for granted how we can go see a medical professional for free (you have to pay for some dentistry and other things). But then I think that everyone should feel like that.

The NHS is the nearest thing we have to a national religion. No politicians would dare try and change the basic principles of that.

We're the Country with the richest people in the world but that money isn't going around much.

We certainly do not pay provider sticker price, if that's what you're claiming. However we have the luxury of the state setting reimbursement rates for 95%+ of procedures. This doesn't stop providers from trying to charge us the sticker price though.

Look most of what you've said is correct but then you inexplicably keep trying to blame or insurance companies for actions taken by the hospital:

"He'll pay, out of his own pocket, 4 dollars for every dollar of care he gets, all so the hospitals and the insurance companies can pretend medical care is way more expensive than it actually is"

What? You said the insurance company is the buyer... sometimes that buyer is desperate and has to pay the $80,000. How can you possibly conclude that insurance companies are purposely paying $60,000 extra just to 'pretend medical care is way more expensive than it actually is'. That's like blaming an uninsured person for getting stuck with a sticker price bill.

No the truth is hospitals price gouge any sucker they can. Private insurance, work comp, medicare, medicaid, the uninsured... it doesn't matter. If you didn't negotiate a price ahead of time they will bill you an insanely high 'usual and customary' charge. Insurance companies are in the exact same boat as an uninsured person. If you work out a price ahead of time you can get a decent price but if not you'll get price gouged.

Here again: "This recent LA Times article shows how insurance companies have found ways to punish people with high deductible policies by getting them to pay hospitals more than even the uninsured pay."

No it really doesn't. This doesn't help insurance companies at all. If anything it costs them more money as patients burn though their deductible quicker. All this shows is that providers are practicing classic price discrimination. The lowest price is reserved for the most price sensitive meaning cash payer. If you have insurance or HSA then they will charge you more because on average you are richer and less price sensitive. There is no way you can blame the insurance company for how the provider chooses to bill people.

"allows both insurance companies and hospitals to randomly and arbitrarily victimize unsuspecting people on a daily basis"

Again how is the insurance company randomly victimizing people? By being forced to pay confiscatory prices that take money directly from their bottom line?

"As long as so many hospitals and insurance companies can continue to amass huge fortunes through obscuring real prices and confusing people"

Wrong. Health insurance is one of the least profitable industries. I suggest you listen to an excellent episode of Ira Glass's This American Life called Less is More. This is the best piece of journalism I've ever encountered on this topic. His conclusion about insurance companies was 'Insurance companies are not always as powerful as you would think.'

So, do you like my idea of having State commissions like they have in Maryland that cap how much hospitals can bill?

Can you see Obamacare leading up to Universal Single payer? IOW, is it possible that Obama re-packaged RomneyCare as a stepping stone to achieve the eventual goal of necessitating a single payer system?

It's hard to say. It would more likely lead to a system similar to what they have in Germany where the private insurance companies are highly regulated. Our problem isn't so much public vs. private for payers. It really boils down to the fact that health insurance companies operate like protection rackets because billing charges for most medical services are so high.


It's my opinion that we need to adopt a German-style health insurance system coupled with a Japanese-style fixed billing scheme. If I break my ankle, it should cost $xxx regardless of who my insurer is or where I got the cast installed. If I need treatment for early-onset Lyme disease it should cost $xxx regardless of my health insurer or what medical firm or hospital is providing the medical help.

You have hit the nail on the head in this regard.


How do you feel about patents and how they are used in pharmaceutical firms? These firms spend billions to find a drug that help save lives. Should they be able to sell their product at a higher price?

Well that depends on what you mean by "a higher price". $70,000 a year for glivec is a bit steep. Also, our patent laws are way too generous. The pharmaceutical companies can extend or renew patents on really flimsy grounds. Asthma inhalers may never go generic because, every time a drug company changes the design of the inhaler a bit, they get a new patent. The medications in those inhalers have been off patent for years.

I have year-round sinus congestion issues. There is a nasal spray that almost completely eliminates my symptoms (heavenly!) but it would cost me about $140/mo to purchase it. My insurance doesn't cover it and there's no generic.

What's your take on this? It's not life threatening, so should I just live without? Do you think that it's reasonable for a drug company to charge that price with the help of the government (preventing other companies from producing the same drug)? Something else?

Which nasal spray do you use? Also, I think the drug companies do abuse the patent laws. They'd make plenty of money if they sold you nasal spray for $20 but, in our system, drugs are sold at the maximum price the market will bear because so many people use insurance to buy them.

Veramyst is the one that really works.

Veramyst is fluticasone. It's the same active ingredient that's in flonase. Here's the price at costco: http://www2.costco.com/Pharmacy/DrugInfo.aspx?p=1&SearchTerm=f&Drug=FLUTICASONE

It's not often I get to school an attending and get away with it. So here goes. Veramyst is not Flonase.


I admit I just googled Veramyst because there are dozens steroid preparations out there. I'm assuming then Flonase didn't work for you?

at costco

Is this the same stuff at £7 ($11) ? http://www.boots.com/en/Pirinase-hayfever-0-05-nasal-spray_12408/

It look like it's the same.

Since this is on the topic of med costs, I'll ask you:

I've been using generic doxycycline for years. It's never been a high cost thing, only a few dollars a month. Suddenly it shot up to $200+. With insurance. The pharmicist doesn't know why. What's the deal? Fortunately I was only taking it for acne, so I just dropped it because I didn't need it that bad. But seriously, can you explain it?

I didn't catch your question the first time (it got buried I guess). You might want to know that minocycline does the same thing as doxycycline but is a lot cheaper.

What do you think of needymeds.org. I've seen it used at a volunteer pharmacy I help out at.

Sorry it took so long to get back to you.

It's hard to say. I was browsing the website a bit but didn't find actual prices very often. This is why I prefer something like this. An actual list of prices for actual products. That's what's missing in most of healthcare.

Isn't fluticasone going OTC next year?

Isn't fluticasone going OTC next year?

I hadn't heard that but it's good news if it is.

Would a better reform of healthcare in the US have been to rein in costs rather than to make the changes the Affordable Care Act is attempting to make?

Our health care system is broken in so many ways no one solution will fix everything. However, the focus of my website is actual health care costs because so few people seem to understand them. As far as reigning in costs are concerned, I have proposed an idea that I think will help. Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

That's a great idea. For the motorcycle accident you referenced in the article, what would the cost have been in the Maryland hospital system, instead of the Sacramento, CA hospital at $31613?

Also, would it stand to follow that the monthly premiums paid by healthy individuals under the Affordable Care Act mandate would be substantially lower if the Maryland system was enacted nationwide?

It was a bicycle accident and it would probably cost about $3000 because they did several CTs to make sure he didn't break anything. as for your second question: Absolutely

There needs to be more transparency with what the healthcare insurers are paying for these procedures. Not the bills. The hospital can bill whatever they want. But it doesnt matter. They get paid whatever the insurance company contracted with them.

The problem is the insurance companies are scum, and they deny payment when it is due. They are profit making machines. And they are the main reason why the "bill" is so high. But if you break down the collections the numbers start to average out.

Read this. It addresses much of what you're saying.

I think you are way off base with your analysis of healthcare "costs". You are analyzing the bill sent to the patient. That's not a cost. The cost only comes once the bill is paid. These numbers are inflated, everyone knows that. The numbers are inflated to offset all the Zeros they collect. The hospital will set the bargaining chip high, with the knowledge that they won't come close to collecting that number.

Why do you look at these numbers and say that the healthcare costs are high, when hospitals are losing money left and right? Do an analysis of the bills versus the collections.

Sorry it took so long to get back to you. The answer is yes and it's all here.

Is there anything that can realistically be done to stop the monopolization of medical supply companies? Part of the reason hospital visits cost so much is the fact that the supplies are ridiculously overcharged by the few approved suppliers.

Monopolization is a problem we have in most industries. In health care it's worse because there are no anti-gouging laws as well. As far as hospital costs are concerned, I've written a lot about them. You might find this interesting. It's an analysis of the financial records for nearly every California hospital over nine years: http://www.truecostofhealthcare.org/hospital_financial_analysis

As a libertarian, my belief is that monopolization through overregulation is the main reason for the insane price of healthcare. I'm curious about your ideas of how anti gouging laws would work better than a lowered market regulation allowing for (at least I believe) more competition within the healthcare market driving down prices.

Corporations will naturally want monopolies because it gives them complete control of a market. If you eliminate regulations, monopolies will always be the inevitable result.

Put another way: Bad regulations can lead to monopolies, No regulations will always lead to monopolies

Totally disagree with the latter point. Regulations always help to create an unfair advantage for someone. Lack of regulation means a level playing field. People would go to the provider that was either the best price or the best at what they do.

Lack of regulations will only cede control to the guy who can beat everyone else up. There weren't many regulations during the dark ages.

Of course there were, it was called Feudalism. You can't "beat everyone up" if you don't have an unfair advantage, and the only way to get an unfair advantage is to have the rules work in your favor.

The feudal lords were the guys who could beat everyone else up. They would lose their position by getting beat.

What measures to do you take so as not to be killed by the government?

I live in a city that has no tall buildings so snipers can't get me. I also don't have a very regular schedule so it's hard to predict when I'll be going anywhere.

I want to believe that you're kidding… But I have this nagging feeling that you're being completely serious.


As a soldier who know's a thing or two about sniping, just because there are no tall buildings around doesn't mean that a sniper cant get you. Just thought id let you know that:)

Thanks, I'll keep that in mind ;)

On the other hand, I'm a busy and sporadic person and I can firmly say I have not been sniped yet.

Good for you, Keep it up.

If the government wanted you dead or detained, you'd be dead or detained. End of story.

I know.

David Belk, thank you for the work you are doing. I have seen your work in the past and even cited it in a paper I wrote.

If I ran for President of the United States, could I hire you in as one of my advisers if I got elected? If you accepted, what would be some of your immediate policy advice (list a top 3 or a top 5...I know you're probably short on time. If you can give a super long and thorough answer, that'd be great)?

I'm not sure I'd like government work but, thanks for asking. Anyway, I'm definitely in favor commissions that cap how much hospitals can charge. It works in Maryland and, quite frankly I can't think of a better way to reign in the insane billing practices of most hospital. Here's a blog I wrote about it: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

I also think that the price of all medications and medical services should be easy to access the same way the price of everything else we buy is.

Also all anti gouging laws that apply to every other industry should apply to health care. I don't see why we should live in a Country where auto mechanics are expected to be more honest about their business than doctors or hospitals.

Quick question about your price-cap idea, as that seems to be your main point. If there were price caps on medical products, wouldn't that create a shortage, as the hospitals and medical companies would begin trying to cut costs where they could, such as salaries of nurses and doctors, which would lead to less people entering the medical profession, leading to overworked medical professionals and hospitals that couldn't keep up with demand?

Also, many people fear that if the cost of health care went down, research would decrease. While I'm all for lower health costs, research is very important too. How valid are those fears?

The price caps would be for hospital services and need not be overly draconian, Again, it's been working in Maryland for nearly four decades and their hospitals are doing just fine. You can't argue with results and, anyway hospital billing is insane. We have to fix that mess somehow.

What are your thoughts on people who abuse the system? I work in health care, and it seems to me that the people who are the most abusive to our current system, are the people for whom everything is subsidized. If we simply give everything away for free, what are the incentives to lead healthier lives?

There are people will abuse everything and health care is certainly no exception. The fact is that the people most likely to abuse any system are the ones who know how to get their way no matter what. Restricting access to anything usually does more to shut out those who reasonably need the service. The neurotics are the ones who always get through no matter what.

What made you decide to do this research?

All of the deceptions and misunderstandings at every level of this business were driving me nuts so I felt I had to do something about it.

I noticed that on your website that you put every single aspect of the health care system on the list of why it's so expensive except for one: providers. By providers I mean physicians. Why did you leave that out?

Sorry to get back to you so late. I think you'll find your answer here.

If you were given full power to rewrite out healthcare system from the ground up as you saw fit, would you do something completely new? Mix and match of different countries?

I'm American, was recently travelling in New Zealand and Australia for 3 years. My house mate hurt himself on a rock surfing once and I drove him to the hospital, they did tests, gave him pain killers, they thought he ruptured his kidney. After 7 hours he left (he was fine, week off work with painkillers) and didn't have to pay a dime. I should point out we were both long term travelers, we were working full time and paying taxes, I think it's different for people just passing through.

Anyway, I've broken my arm twice and have seen first hand what a clusterfuck the American medical system can be, and was amazed at how awesome it was in New Zealand.

Well, realistically, it would be a bit hard to redo the entire health care system in a Country this big from scratch. My first, and most important goal, is to get everyone to understand the system we have. I feel once everyone understands health care costs, how they are paid becomes less controversial. A major problem in the health care debate is that everyone is getting scared off by enormous prices that have no bases in reality

I remember a post on reddit a few weeks-month ago showing how these tiny little metal hospital trays cost $700+. If memory serves, the poster compared it to the corruption/over pricing we saw during Taft's presidency, do you consider this an accurate comparison?

Health care is a corrupt system with no price controls, I guess I'm not familiar enough with what happened under Taft to make a comparison though

in this context it's mainly referring to massive markups on price where corrupt people are pocketing the difference.

Sounds similar

Are you familiar with the recent conflict between the FDA, DEA, and drug manufacturers over amphetamine quotas (which has caused a significant spike in the cost of Ritalin and generic equivalents)? Do you have any thoughts on what could be done to prevent situations like it?

I know the DEA has been cracking down on the over-prescribing of many controlled substances and they're probably going a bit too far. I don't know that that, per se is what caused the price of ritalin to spike. If it is then that's news to me.


I don't think I really want my salary cut. The truth is, physician fees are a small component of overall health care costs. If I worked for nothing it wouldn't affect the amount paid to hospitals, pharmacies, pharmaceutical companies, labs and, of course, health cares biggest offenders, insurance companies. That's where most of the money really goes. There are doctors who are truly scamming the system and it's a problem. That said, it's far from the biggest problem this business faces.

The current system under the ADA requires persons to have Health Insurance or else that person will face a fine. I know alot of people who are between the ages of 18-25 who find it cheaper to not have Health Insurance and pay the fine, and recent polling supports this trend.

Do you see a problem with this trend of younger healthier people not entering into the system?

Most people 18-25 can stay on their parents' health plan. My understanding is that the "fine" won't really be enforced to any degree. The goal of the ACA is to make health insurance more accessible. If it does, more people will probably enroll but there will always be holdouts. We'll see how it works though.


Buy some I guess.

The owners of Reddit should step up and do something really important for this society that will cost them very little, simply by leaving this post at the top of the Reddit website for a few months, instead of "featuring" other irrelevant post that they like to feature on top. Do it Reddit, do it for this nation, this guy is exposing a lot of things and is showing us how to deal and pay for health issues and most importantly how to impact the healthcare community in a huge way.

EDIT: Who ever gave me a month of reddit gold thank you! I was never expecting anything from anyone for just typing a comment i felt needed to be said, thank you so much, I'm not sure what to do with it though :/

Gee, thanks. I'm not sure I could answer question all month though. I'm a slow typist and I'm afraid my fingers would probably fall off.

You wouldn't have to keep answering questions necessarily. Just keeping the information already giving at the top would be helpful.

Call it a weakness but I love answering questions. I just can't help myself

No offense, Dr, but in this age of web development, your site could really do with a visual overhaul. I am guessing that thousands more people would read the information you are trying to present with some simple upgrades to the way in which you've constructed your site.

Or just convert it to a WordPress template and call it a day. A couple of pictures, graphs, charts, etc and you're good to go.

As it stands, its pretty awful and uninviting.

(I know this is an AMA, but I would really like for people to read what he's wrote and form their own conclusions, and I believe reformatting would do a great service to the work he's performed).

I know, I've been told that often and I'm planing on doing that some day. The problem is I'm not all that good with computers and I'm doing this mostly by myself (though my receptionist, Heidi, helps a lot)

What do you think about doctors' salaries in the US? How should they be changed, if at all?

I'm happy with my salary.

How much of the cost of health care is attributable to the fact that insurance policies, for lack of a better way to put it, are trying to nickle and dime you at every step of the way? In other words, at what point do the bureaucratic costs of administering all of these various plans, all of which are ridiculously complicated, exceed the cost savings of denying care?

It's more complicated than that. The short answer is that insurance companies deliberately obscure how much health care costs so that they can function more like a protection racket. That's where the money is and that's why everything in health care is so confusing. Confused people are easier to take advantage of.

Would you please explain what you mean by 'protection racket'?

Good question. The price of everything in heath care is marked up dramatically; often five to ten times what the services are worth. Insurance companies, on average, get away with paying a fraction of the billing charges. If you uninsured, you don't get that break. What's more, insurance companies use those highly inflated billing charges to justify their premiums even though most of those charges go unpaid.

If you watch this and this and read this you'll see exactly what I mean.

Remember when HMOs were all the rage? The pure HMO has declined significantly, mostly because of two reasons. The administrative costs were so high that a great deal of the savings was lost. And nobody liked them (except those who earned a living off of them).

I have to admit, the HMOs are my highest payers by far. They're also very expensive plans. That's kind of ironic, isn't it?


None so far.


I find most health insurance policies to be only slightly more complicated than quantum physics.

How can QALY be used in this country to reduce the cost of health care?

I don't know. I'd have to look into it a bit.

For a half second i thought this was about Doctor Who. :(

Sorry, his AMA was yesterday.

Did this really happen and I missed it, or are you joking?

Joking. I must have gotten 20 Dr. who comment today:)

I would to tell you my situation, then you could comment on it.

Several years ago I had to have an umbilical hernia (I was an adult) repaired. I did not have health insurance of any kind and so paid cash for everything.

So, in my state, no specialist or surgeon will see you unless you first get a referral from a GP or family care practice....

It was obviously something that required surgery, since there was this soft fleshy bit poking in from the side of my navel; I had already diagnosed myself before I was able to get to my GP. I go in, tell him I think I have a UH, he pokes and prods for a few minutes ... yes, he agrees. ** Bill: about $140 (first time visit adds about $75 over a regular visit).**

Surgeon's visit - I pay one price, $850 or so, for all consult and the surgery itself. Note that the surgeon is the guy who is most responsible for the patient outcome in all this! I think I visited him 1 or 2 times prior and 1 time after surgery.

I have a prescription for an abdominal CT scan. I call around - the 2 hospitals in the area want between $2750 and $4000 including interpretation.

I remember an outpatient imaging place that my wife used a while back for an MRI - we call them, and find out that one of the above hospitals, BOUGHT THEM OUT AND THEN SHUT THEM DOWN - why did they do that, doesn't make sense or does it???...

But, they have 1 independant place that the hospital did not buy, still running in a depressed area 3 hours' drive away. Their price? "Well if you pay on the day of service with cash or credit card, the price is $264."

It gets better - the owner of this imaging clinic, who sold off the other branches to the big hospital? He is the Head of Radiology Deparment at a well-respected hospital about 1 hour away. So the hospitals bought him out, only because he was undercutting their prices!

CT scan in hand, surgeon ready to go ... I check out surgery prices at the places the surgeon has privileges at...

Hospital 1 - flat fee, about $3500 Hospital 2 - won't give me a price over the phone - because they charge by the minute! And it will matter if the OR is used for 45 or 55 minutes as to the price ... note how stupid this is, because ORs are not utilized anything near 8 or 12 hours a day, continuously

** Shiny-new Surgical Center, cleaner, less hectic, nicer nurses, etc. - $1800, but, "oh, if you pay cash or credit card on the day, the price is $1200"**

Anesthesia - $660 (note: almost as much as the surgeon, just for a nurse anesthetist!)

Add up the difference between what I paid cash for and what the "retail price" was ... to me, the shocking 10X difference in abdominal CT scan makes you wonder, "what exactly, is a fair price for CT scans?"

I welcome your comments on any part of this.

Your story is exactly why I'm doing what I'm doing. Health care in this Country is a scam that disproportionately a scam affects the uninsured and it needs to stop.


not exactly.

I even have insurance. I have traicare dental through the military (im a spouse) and I used up my entire years worth of insurance with one root canal.... Sometimes even with insurance you get boned... Oh I also had to pay for half of it out of pocket... My dental only covers half of anything but "preventative" is 100%, and that is REALLY GOOD dental apparently.... If the prices weren't so ridiculously high, it wouldn't have used up all of my coverage... Oh and it was a $2600 a year coverage, and think about it, I payed half and it still used all of that, so that is nearly $5200 for ONE root canal and crown, and that is with the price insurance companies get!!!

Tricare medical is better than that at least. I'm unfamiliar with their dental program.

Thank you so much. I know everybody is sharing horror stories, so here's mine: I had surgery for kidney stones a few months back and beforehand the hospital quoted me a figure as my cost, the rest to be covered by insurance, and we set up a payment plan for six months. Two weeks post-op, I started receiving bills from the hospital, and somehow my out-of-pocket expenses had gone up by several thousand dollars. I also started receiving nickel-and-dime bills (from $15 up to $300) for doctors and radiologists and labs, and I'm still getting these even now. My six month payment plan will now take around four years to pay off total, and I'm paying a few thousand more than my out-of-pocket maximum according to my insurance policy, but any attempt to fight it meets with derision and hang ups. One billing specialist tried to tell me I shouldn't have had the surgery if I didn't understand the word estimate. If I don't pay, I'm worried it will ruin my credit.

Scam hardly seems like a strong enough word, really.

Yeah, that's par for the course.

When are you doing to hire a professional web designer to make your website more appealing to read and navigate through?

You have to understand, I'm not getting paid for this so, whatever I spend on it comes out of my pocket. A few people have written me to offer help but they live in other States making it a bit more complicated.

I think a really easy route to go would be to use a content management sytem like Joomla, Wordpress, or Drupal. All of which have great support groups here on Reddit and it's very easy to keep them maintained versus updating a non-content management system website.

I'm probably going to do that next month. It's on my to do list

if you need help, just hit me up

Thanks, if you write me from the website, I'm more likely to remember you.

Would you be receptive If I put something together and sent it to you?

email me through the site

A doctor can't afford a website?

Prices aren't like they were two decades ago. Clean web design can be implemented for less than $200.

I guess what I was trying to say was that I knew nothing of websites, web design or any other media tool (including video editing) before venturing on this crusade. It's all been learn as I go when it comes to getting my message out and, since the message is somewhat unique, it's a little hard even for most professionals. Most web designs that are pitched to me are designed to sell things

Why don't you start a kickstarter campaign. I am sure you would get tons of funding to get underway with a mass marketing campaign.


Edit your home.htm file, line 23. Move the letter 'e' to the other side of "</strong></span>". It current displays as: The True Cost of Healthcare. Actually just take the <strong> tag out in general. It could really go.

Open your theme.css file, line 37. Change 'Times' with 'Helvetica'. I replaced Times because Times screams 'old internet'.

Difference: http://i.imgur.com/1bOBLoT.png

This is hardly a complete fix, but it's a step in the right direction (in my opinion, of course) but it's a step nevertheless.

edit: Judging by the code it looks like you're using a WYSIWYG editor. Hopefully you can reflect these changes in whatever editor you're using.

I think I'll need some sleep before I figure out what you're trying to explain but I guess that proves how much I need professional help. Thanks

Hi Dr. Belk. I don't know if you are still here, but I am a web developer, and I believe very passionately that American's deserve better care, and that more generally, we deserve a government that actually tries to solve problems. Under a few conditions, I would be willing to volunteer my services to help you get the site up to 2013 standards. Please PM me. I can and will help you.

I've had a lot of offers tonight but I haven't had time to go through them yet. Contact me at the site: http://www.truecostofhealthcare.org/contact_information

One thing to note is that the copy is a big part of the reason your site looks so bad and you don't really need a designer to fix that. Get rid of the all-caps text and the sentences where each word is capitalized. Get rid of the exclamation points. That stuff makes you look like a crank.

Thanks, I actually spent more that a year in the beginning trying to get anyone to look at it at all which is why it looks kind of desperate. Now that it's catching on I should probably back off a bit. This is actually the result of a couple of years of trial and error without being very sure about what does and doesn't work. I guess marketing doesn't come to me naturally.

Edit your home.htm file, line 23. Move the letter 'e' to the other side of "</strong></span>". It current displays as: The True Cost of Healthcare. Actually just take the <strong> tag out in general. It could really go.

Open your theme.css file, line 37. Change 'Times' with 'Helvetica'. I replaced Times because Times screams 'old internet'.

Difference: http://i.imgur.com/1bOBLoT.png

This is hardly a complete fix, but it's a step in the right direction (in my opinion, of course) but it's a step nevertheless.

edit: Judging by the code it looks like you're using a WYSIWYG editor. Hopefully you can reflect these changes in whatever editor you're using.

I actually just use yahoo web hosting and copy/paste off a word or pages document or type directly into the web page. It's pretty simple but I guess that shows.

many people rely on medicare, now doctors are starting to stop accepting medicare patients. what is the easiest political solution to this?

I don't know. Medicare is one of my highest payers so I can only assume these doctors don't understand how they get paid. That's more common than you think BTW: https://www.youtube.com/watch?v=bZCYblB3kHk

Where are you practicing? Medicare is one of our lowest by about 10%. We tend to be on the low end of reimbursement compared to the rest of the state (Rochester, NY). You must be even worse off.

The San Francisco Bay Area. Medicare pays me $83.10 for a 99213. I believe Blue Cross is my second highest payer at about $78. UHC pay only $67.

I'm from the UK so only know about the NHS, which is heavily overstretched but in my opinion a very good healthcare system. From my very limited knowledge of the US system, it seems so messed up that in a western country that one hospital admission can bankrupt a person if they are not insured, which leads to patients not getting health issues checked and causing further distress to the family during medical emergencies.

What do you think of the British system(pros and cons)? And what would the implications be of implementing the British system in the US?

We'd be better off with the British system but it's not going to happen here. I address that here: https://www.youtube.com/watch?v=bBJAnrBc9n4&t=10m3s

What can I do to help you?

Post my site and my videos anywhere you can. If you show people the three minute videos I made on, for example, the cost of generic medications you can get them interested. Those videos play well on a smart phone so you can show them to anyone.

I enjoyed the part about the "free" samples. My first "chronic pill taking" was for a psychiatric disorder, and when i got my first prescription it was the first time i'd ever been prescribed something other than Allegra for allergies. I was given a free sample of Lexapro, which at the time had no generic. It cost $200+/month before I hit my deductable, and even then $50/month after. And when I raised a few concerns about it my Dr. suggested I stay on it for over a year. After I finally decided it wasn't working, I was switched to a med that would "work just as well," and go figure, had a generic. Since then I've been on four different drugs (I'm hard to medicate and the initial diagnosis wasn't correct anyway), all of which had generics. But when I have to find a new doctor, they ALWAYS want to give me Lexapro (which just recently got a generic) free samples first.

You know what feels good? Paying less than $20/month for three generics (instead of $300+ brand-name) before deductable, and $0 after.

Course now I'm re-thinking the pricing of those generics, but still.

You've seen this I hope.

Wow. My co-pay just went up to $40 for 3-months of my blood pressure meds, and apparently Costco sell a years worth for <$30. I'm indignant, but I just want to be clear who I should be mad at: my insurance co., the drug makers, Rite Aid, the terrorists, or all of the above?

Your insurance and Rite Aid


This is why I recommend buying in bulk. My point is, if you can purchase a medication (or anything else) for less by not using insurance, what's it good for. People pay extra to have insurance coverage for generic medication and their copay ends up being more than the medication costs. That's like buying a book of coupons that says "one for the price of two"

I would fully support some kind of kickstarter program for you. I'm sure many of us would.

What's a kickstarter program?


Thanks, I'll look into it.

I want people to see this which is why it is not a pm. You have a phenomenal point, but your website is sensationalised like a scam to attract unintelligent people. Present your findings and research in a less pissed off way and you will attract more fans. I understand your frustration but do not let it affect your presentation of the powerful material you have found.

Just so you know, I think I found someone to help me fix my site. I'm away on vacation now but I plan to meet with him as son as I'm back which will be around the first of the year.

I will admit I am lenient towards conservative, and I obviously dislike Obamacare. Everywhere I look everyone keeps saying "single payer system."

My problem is, I don't trust the government enough with all the scandals, corruption, and no money to pay for my insurance. Does the single payer system have some way to avoid that? I don't want it to end up like the IRS and targeting people based on their political views.

You can't trust the government much but you really can't trust unregulated corporations either. Bottom line is you eventually have to trust someone because you'll never be able to remove you own appendix.


Most aren't but some are. Even if you have insurance the system can screw you a number of ways. This video goes into that a bit: https://www.youtube.com/watch?v=vNJ6DYCaG-4

Not to be an over simplification, but is Obamacare as currently written good or bad for America?

My guess is it's overall effect will be an improvement (not much could make things worse, after all) but more needs to be done

Do you have any qualifications in economics?


I have MS so I take a specialty drug called copaxone. With my insurance my copay is/would be over $6000/month. That's gone up about $1000 in the last year. Since there is no way that amount is even remotely affordable I'm able to qualify for the copay assist program. That brings my bill to about $35/month. The organization that admins the copay assist is the manufacturer. So, do they write off the balance? Their reaping in money from my insurance and essentially waiving the cost to me. How is this? Are taxpayers having to foot the bill? How and why is this happening? Do you know if obamacare will address this issue is any way?

No, the drug costs the pharmaceutical company about $50 to make so they make more than enough money to be charitable at times.

This is very relevant to me. Can you provide some source material on drug manufacture cost vs. price? Especially for Copaxone?

No, that's a proprietary secret but it's only a polypeptide made with four amino acids so I don't see why it would be very expensive to make. Most low molecular weight molecules are very inexpensive to make.

I have a couple of patients who worked as chemists for pharmaceutical companies and they confirmed that a couple of kilograms of most standard medicines can be manufactured for a few dollars.

About the only drugs that are expensive to make are the biological agents like monoclonal antibodies. How expensive? I don't know and we'll probably not know for a long time since none of them will likely be generic for decades, if ever.

My girlfriends dad is a pharmacist; he only has one client who takes copaxone he said its a very expensive drug - no generic and he pays a lot for it. basically he said your list of medications on your YouTube were all cheap drugs and out of the thousands of medications you found a list of 70. I'm assuming your speaking of the pharmaceutical company is making all the money because he's making literally dollars on the prescription

I said copoxone doesn't cost the pharmaceutical company much to make. I fully acknowledge in my video and website that pharmacies pay a bundle for brand name medications.

Monoclonal antibodies that are generic are called biosimilars. The FDA has already set up a process for biosimilars and the first biosimilar came out November 2013 (tbo filgrastim). Many monoclonal antibodies will be coming out in the next 3 years.

That's interesting to know. I was of the impression that it was going to be tough for the generic companies to prove their MAB was the same as the original because the molecules were so complex. I guess I was misled, thanks

It will be tough for companies to prove similar efficacy. The increase in research to make a Mab, production costs, and possibly trial data will result in less of a discount. For generic drugs it is about 30% cost of brand, right now for biosimilars it is 80% of brand (for tbo filgrastim and from what I've heard). Hopefully as this new area progesses the FDA will be able to streamline the process lowering the barrier to entry while still making sure there is safe and effective care.

That's a start I suppose but 80% the cost of an Mab is still a mint.

I'm curious how you come up with your $50 generalization? Does this include R&D, navigating the cumbersome FDA trials process, etc. or simply manufacturing?

In that question she was asking how a pharmaceutical company can sell a drug at a huge discount when she couldn't afford it. I commented that each batch of the drug probably doesn't cost much to make.

It's interesting the way everyone jumps on R&D as the justification for the high price of pharmaceuticals. Is the pharmaceutical industry the only industry in the Country that employs scientist?

I wasn't providing an opinion either way, just wanted some clarity on how you arrived at that number.

The current pharma model is high risk/moderate reward. As I watch the big companies cut back their pipelines and focus on specialty products and smaller disease states, I start to wonder what impact it will have on innovation.

My observation is that innovation has been quite dead in the pharmaceutical industry for well over a decade. Most of the new drugs that have come out since the late 90's have been little more than subtle tweeks on old drugs, and not always for the better. There have been a few exceptions but I think, by and large, the era of big pharma is mostly at an end.

What is wrong with the Affordable Care Act? Why are so many people, including those who don't have healthcare, against it? I really want to know why it's bad for the country.

People fear the unknown and, since few people really understand health care in this Country, any proposed solution can seem frightening.

So do you personally think it's good for the country?

I think it's helped a lot of people so far but, we'll have to wait and see.

Is insurance strictly needed? (There are many things we buy that do not involve insurance companies.)

Is it not in the interest of insurance companies that health care becomes increasingly expensive to firstly, scare people into buying insurance and, secondly, justify high premiums?

It's needed for emergencies and high priced things you couldn't afford on your own. Most people would have a lot of trouble paying for a new liver if they needed one.

How do we know that without insurance in fact many of these things would be affordable? (Could be paid on time, if extremely expensive.)

Mathematically, making a bet with a negative expectation is hard for me to swallow.

Sorry it took so long to get back to you.

You can't know until all prices are posted and all anti gouging laws that apply to every other industry apply to health care as well. Until then, health care in the US is a mine field.

Hello, and thanks for doing this AMA, I'm a premed student who's studying for the MCAT at the moment.

Do you have anything you'd like to impart onto students who are looking to get into health care, given what you know of its financial hardships?

That's tough. I went to USC medical school in the 90's (California not Carolina). The year I graduated (97) USC had the dubious honor of having the highest tuition for a medical school in the Country. It was just over $30,000 a year. Now I hear Public medicals schools cost about that much. It's insane by I can only address one scam at a time so University tuition will have to wait.

What role do you see mhealth or other wearable technology in driving down costs?

I don't know. What is it?

mHealth- using mobiles as a foundation for different smart apps / addons to help people manage their health better


Wearables - any sort of technology that's worn instead of carried. eg: http://www.misfitwearables.com/inspiration/wearables_saving_lives_since_1975

I confess I'm a natural born luddite so I'm probably the wrong person to ask.

Thankyou very much for your time though :)

That's dedication.

I'm both a slow typist and a luddite. I'm hopeless.

Slightly not relevant, but you may know anyhow. Why is it that doctors can bill whatever they fill like after the fact. Anything else you do, you're notified of prices before they get done. I recently went to an ENT doctor who looked at my throat, then I got a bill over $300 because he used a special tool. I think I would of dealt with the scratch in my throat if I knew it was going to cost $300. Thanks

This video sort of addresses your question.

Maybe a stupid question, but something I always thought would be obvious:

If end-of-life care accounts for so much of the cost, why not make living wills mandatory? (Could be implemented at every point of healthcare interaction, via the IRS, etc).

Death panel crazies wouldn't have to worry either because someone could still specify that they want all possible methods used to keep them alive, but I suspect that most would not.

This would also solve the problem of family members keeping them alive when they don't know what they actually want.

To be honest, I've not found living wills to be of much help. There too long and complicated and usually not available when they're needed. If a patient tells me they don't want CPR I make a note of it but, unfortunately, that note won't leave my office. Communication in health care is currently somewhat slower and less efficient than the pony express. What's more, EHR systems have made it far worse since none of them can communicate with each other.

I've worked in home health care for the past decade. Despite the rampant misuse and fraud, do you believe home health an become part of the solution?

It would help if it were more organized.

What it's the most earth shattering discovery of your investigation?

The fact that so few people in health care seemed to care about what I found. I thought they would find it helpful but most doctors really don't seem to want to know any of this.

I mean if anyone were to be a little turned off by this, wouldnt it be the people involved in healthcare? I mean its definitely warranted, but arent you basically telling them their services shouldnt be as costly as they are? its logical, but a lot of doctors are narcissistic and driven by monetary gains.

its logical, but a lot of doctors are narcissistic and driven by monetary gains.

I think that's a lot of people in general

You are fucking with their business model. I doubt they will thank you for it.


What about marijuana does it help with cancer!

I'm not expecting it to cure any cancer if that's your question.

Why isn't a cost-benefit analysis part of a doctor's treatment plan? It seems like we are spending insane amounts of money on people that are about to die.

I've had this with my great-grandmother. Her doctor recommended a pretty broad set of very expensive tests. He did a great job of explaining what we could find out. It turns out that no matter what the test told us, she was going to die. We didn't do any of the tests and instead focused on making her comfortable. The set of tests would have cost thousands of dollars and wouldn't have been any fun for her.

Health care is too emotionally charged. People aren't often very comfortable with a logical approach to something that emotional.

As a Brit, I'm well aware that our health service costs a lot of money to run (around £100bn/year) and tales abound of inefficiency and wasted resources, but in reality this comes out to around £1500 per person per year which seems like incredibly good value compared to the cost of US health insurance plans that I've observed.

Does health insurance in the US absolutely cost more than this? Is the cost due to insurance providers ripping off consumers, or just hospitals charging exorbitant rates for procedures?

Most studies show that our per capita health care expenditures far exceed those of other developed Countries and most of our outcomes are worse. We really do spend a lot more for less here.


Watch the video: https://www.youtube.com/watch?v=r9q1Id41wGo

What did you think about the long article in Time by I think Bill Brill on how costs are passed on to the patients via the chargemaster?

It strikes me that if the industry could agree on a uniform chargemaster, things would be much better. Could this be done?

It was good but it doesn't tell the whole story. Also, a universal chargemaster is kind of what this blog is about: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html


it's not appropriate and it's worse than you think. Watch the video: https://www.youtube.com/watch?v=r9q1Id41wGo

What is your opinion of Kaiser Permanente?

They're far less organized and have far less ability to control their costs than I would have expected. The contracts they offer for outside services appear way to generous to me. It as though they really don't understand how the game is played.

They're also very good with conventional medical problems but completely lost in most special cases.

As a PSW trying to become more integrated in the field, what is your best advice? I am taking many different certifications to help my chances improve and to help a wilder group if people.

what's a PSW?


Everywhere in Europe is better than here. I've had people write me saying they moved from the US to Columbia to get better healthcare. We still have Zimbabwe beat though.

"Better" healthcare in Colombia? That seems a little ridiculous, unless you're talking about the cost. Everything I have read is that the quality of health care in the U.S. is second to none, but the problem is the price.

I've never been there so I only know what they told me.

I honestly appreciate that you're trying to improve health care in this country, but don't you think you'll have more impact if you stick to facts and not throw out hearsay and anecdotes? If you can't factually back up a statement like that, with the particular metric that was supposedly "better", maybe it would be wiser not to make the statement.

Also, if you're ignorant of how the quality of United States health care (irrespective of price) compares to other countries, perhaps you shouldn't make statements regarding that, either.

Like I said, I appreciate the obvious work you've put into this. But just as a point of feedback, things like this make me question every conclusion you might make. How much else in your analysis is based on just "I only know what they told me"?

I hope this isn't coming off as too harsh, but if you want to influence people, as you seem to want to, I think it's crucial to stick to well-documented facts. Otherwise, you end up looking like (say) Michael Moore, who might have some good points, but it's buried in obvious sophistry.

I've had people write me saying they moved from the US to Columbia to get better healthcare.

That's simply a true statement. They did write me and that is what they said.

Hi Dr. Belk!

I work in EMS, and I'm interested to hear what you think would be an alternative solution for all the people who call 911 to go to the emergency room by ambulance for things like hurt toes, colds/general sickness, toothache, etc. These people not only clog up emergency services but their insurance plans will not cover these non-emergency ambulance rides. On top of that, the ER becomes overcrowded with people who don't need emergency services, and the hospital has to shell out time, money, and other resources to care for them.

Any ideas on a better way to handle this?

Seriously? I never knew someone would call an ambulance for a cold. Is there a way to screen them better before sending an ambulance?

As a UK medical student I've been considering working in America for a while.

However, the thought of turning someone down for treatment because of lack insurance/funds just feels fundamentally wrong!

The other day, I was talking with one of my supervisors, and he said something along the lines of: "Countries like the US spend a lot more of their GDP on healthcare costs yet can't deliver a service that is not as inclusive as the NHS despite the UK spending less of the GDP on healthcare".

I mean you hear about doctors ordering a lot of investigations and expensive tests to justify the costs they claim from the insurance companies... but were they really necessary? Do their results alter the patients treatment? It just seems wrong on so many levels.

But how and why has this come to rise? I mean surely with the amounts of money being spent in the US a more inclusive service can be provided. My understanding of Obamacare is that it covers the poorest of the poor. Why can't it go a step further to cover more of the population?

On a different line, I totally disagree with the culture of suing doctors that is well established within the US and slowing crossing the pond over to the UK! God help us and all the new and upcoming generations of doctors against these malpractice issues!


You should read this: http://www.truecostofhealthcare.org/conclusion

and this: http://www.truecostofhealthcare.org/malpractice

I'm a 2nd year medical student and I read your "conclusion" webpage.

What I’m proposing isn’t radical. We in the healthcare industry need to place an honest value on everything we do, sell our products only for what they are worth and involve a third party for payment only when absolutely necessary! In what other business would this be considered radical?

Doesn't that contradict what you said here?:

We all know how important an MRI can be, or an Emergency Room visit, and as long as people think an MRI really costs $4,000, and an ER visit costs $4,500, maybe they'll resign themselves to paying big insurance premiums, and we can all tell ourselves that it's the only way we can continue to have "the best health care in the world."

Healthcare costs a lot because people value their health more than anything so they are willing to spend/borrow/sell anything to get the care they need.

What's your opinion on these doctors and can their model be expanded elsewhere? http://www.surgerycenterok.com/

I'm of the opinion that healthcare costs are high because of the disconnect between service and payment. Not only by who pays but also when it is paid. Would a mechanic be content to receive his payment never or months later?

The cost/regulatory barrier to practicing medicine in the US (lobbied for in the past by the AMA which has recently began changing their tune) means that a doctor can often charge what most people would consider "dishonest". As long as healthcare demand goes up and supply of new doctors is limited, most of these suggestions aren't going to change the cost of healthcare dramatically without affecting the quality (queues and/or long drives to get certain procedures).

The system has to be seriously reformed before those two statements don't contradict one another. I guess that's one of my goals.

As a doctor could you tell me just how the affordable care act affects you and just doctors in general?

I would guess that if more people have insurance they may go to the doctor more and I'll make more money. We'll see.

Is there any way to make health care costs public, so that everyone can see exactly what the costs are at all times? Not just what the hospitals charge, but what insurance actually pays, and what the actual costs of each thing costs? So if the hospital bills you for $1000, you can see that it really only cost them x amount, insurance paid out y amount, the bill to you was z amount, and v amount vanished into thin air by being waived, or by costs being reduced through deals, etc.

After looking at your website, I understand this is kind of what you are trying to do, but is there a better way to do it nationwide?

Not easily. Not yet. clearhealthcosts.com is working on that: http://clearhealthcosts.com/

I have an underlying medical condition- Ulcerative Colitis. Got diagnosed about 6 years ago. Its fairly mild, controlled by daily meds. I'm under a low-key but always available 'watch' by my docs and nurses, and I can turn to them at any time. Case in point: I had a little bit of "gastric flu" last week for 4 or 5 days, and a bit of a lazy gut for a day or so afterwards. Got some cramps because I couldn't pass wind, called my docs to get an emergency appointment. In there an hour later, and he confirmed that all was well.

Now, I'm lucky because I'm in the UK, and this is all paid for out of general taxation. I'm a taxpayer. We get a better deal all round because of the economy of scale that a country buying its healthcare from providers can give. Its not perfect, but it sounds about 1,000,000% better than in the US.

What I've never understood is why those who defend it say that the American system is democratic, that other nations are 'socialist' (as though that's degenerative). Why can't America just see that they have a system that's designed to bilk them?

Whenever a system is inefficient, a lot of players will make huge amounts of money on the inefficiencies. Those players will do anything they can to prevent change

Why is an insurance based system preferred over a healthcare service funded directly from taxation? UK citizen here also.

Many Americans just hate the government. It's like a religion with them.

So what's the way to convince people to see how bad the system is? I see a lot of information already about how bad it is but they never seem to take affect. Realistically, how would you convince people to read the information that you put on your website? What's going to stop someone and make them think, "hmm...I think I'll learn a bit more about how health insurance works in this country."

I guess that's the very problem I've been working on for 2 1/2 years now.

I'm an RN at a children's hospital in the US, but I'm looking for a change. Would you recommend home health as a growing field, or something else?

I don't know much about the life of home health nurses. My wife's a hospital RN and I know I wouldn't want her job to save my life. I guess you can always try.

Many people get extremely comprehensive health insurance plans through work, since these benefits are tax free. The problem I see with these extremely comprehensive plans is that they make it so you don't care how much anything costs, since everything is covered and the co-payments are so low.

How can we expect medical prices to come down when so many people don't care how much anything costs?

that's a good question.

I read recently that Vermont is adopting an all-inclusive, single-payer system that will be funded through Medicare, Medicaid, ACA money and tax increases (slight). Do you see this program working out for Vermont? As a follow up, what are the primary hurdles for other states instituting a similar system?

Other States are bigger so they'll have far more powerful lobbying forces to block single payer. We'll see if Vermont can pull it off though.

Thank you for doing this. I'm sure it's no easy task to navigate through the disaster that is health care.

My question is, how have the healthcare companies responded to you exposing them and their methods?

They don't seem to know I exist yet.

Dr. Belk,
I am a 45 year old male who is in nursing school now. I have been politically active for much of my life and this is an area that is near and dear - but I've been at a complete loss as to what to do about it. As a nurse, I feel like I'll have a voice to enact change in this arena; How would you recommend that I get involved? What can I do - especially once I'm an RN and work in a large-ish health-care system - that will help?

My one true political campaign so far is mentioned in this blog. It's an idea that might work too.

Mystery? What's so mysterious about profiteering?

The devil is in the details. I explain how.

Would you rather treat 100 duck sized horses or 1 horse sized duck?

I'd run like hell from either.

thank you for doing this. hope i'm not too late. as an immigrant I'm amazed that Americans somehow "fear" government control of the healthcare system but have no problem letting healtcare insurance agencies basically doing whatever the flip they want. Am i right in this? and what do you think?

You're right. Hating the government is like a religion here.

Damn, probably way too late for this, but what the heck...

Would it be possible to create a non-profit health care company, the healthcare equivalent of AAA?

It doesn't take much imagination to think that it could grow very quickly as it's costs for members would immediately be lower than the rest of the bloodsuckers out there. And then as it grew, it's purchasing power could then be used to drive down related costs. It's morally outrageous that these companies make the profits they do off the literal pain & suffering of this country.

It's harder than you think. If you're small, the hospitals will likely take advantage of you and overcharge you. this is what they do to employers who self insure. It's also hard in the beginning to not go under for some truly catastrophic event like having a client with CML (costing $70,000 for meds alone) or needing a new liver.

What country has the best health care system, and why is it Denmark?

I take it you're from Denmark

Dr. Belk thank you for this AMA. I was just accepted to medical school and hope to be part of a movement towards positive change.

Thank you.

Any advice for those of us just starting out (most doctors tell me to stay away, or be a PA)?

Study your ass off and try to get some sleep every once in a while. Seriously, Med school is intense. I'm glad to done with it. Also, I hope when you come out the system we have will be better for you because it really sucks now.

How have people tried to discredit you? Have you been physically harmed or threatened?

They haven't. I've actually been surprised. When I started doing this I joked that if I didn't get at least three death threats a week I'd be disappointed. So far I've been very disappointed.

At first, I was completely ignored. Now, almost all the feedback I've gotten has been very positive.

If you could sum up why it's so expensive in a reddit response, what would you say?

No one knows what anything in health care costs and hidden costs are easy to inflate.

the biggest driver in our health care costs are attornies.

Read this

How big an issue are lawsuits and malpractice insurance? I suspect not as large a part as we're often led to believe.


Why is the health care in the US so expensive?

I lived there for a couple of years and my impression was, that the system was broken beyond repair. As insurance costs so much parties involved on all levels ( e.g. doctors, hospitals, medical devices makers) are more likely to charge a lot as a general rule. Is that a correct impression?

yes and, please, watch the show: https://www.youtube.com/watch?v=r9q1Id41wGo

I'm a physical therapist, and we are constantly fighting an uphill battle for reimbursement and authorized visits as well as seeing a growing trend of patients coming in with $40-60 copays (PT for 2-3x/wk for several weeks can start to really add up). Any thoughts on these "specialty" areas of health care and what we as providers can do to be better advocates for patient access?

I wish I did. I think my receptionist spends far more time authorizing crap than anything else. It's a pain everywhere.

One thing I always hear is that ER costs are so high because the uninsured use them. However, I also hear that ER costs are low as a percentage of healthcare spending (reason.com and politifact.com). What are your thoughts on the laws the US has in place to accept ER patients unconditionally (with triage, of course), but that does not reimburse the hospitals that are effected by the mandate?

I think this section answers your question: http://truecostofhealthcare.org/hospital_financial_analysis

What are your thoughts on Epic? (and/or the EMR bonanza over the last few years in general) Specifically the fact that a majority of hospitals purchasing the software end up with lower bond ratings, bloated IT costs, and (arguably) limited improved efficiencies leading to cost savings?

EHR packages are horrible; all of them. The problem is they're all bought sight unseen and once you buy and install them you're committed to that package. Your only options are to make it work or dump it and start over again.

The analogy I like to use is this: Say every male in the country was forced to marry. Now, in order to help us find brides we're all issued a catalog of mail order brides. What's worse is that every woman in that catalog is a blow up rubber doll. That's EHR in a nutshell. Overpriced useless software that's been forced on us. It's all but ruined my practice.

I'm going to have to disagree with you on a part of this...

The sales process in these EMRs goes on for more than a year in most cases. "Sight Unseen" isn't correct - although "sight unseen" by the employees who will have every aspect of their daily life upended is accurate.

That said - you mention "my practice", which makes me think you are/used to be a primary care physician, and at most, worked in an office with less than 10 doctors. In that case - I can't speak from experience in that market and I could very well see where you do have to make a purchase with very little information.

Is it safe to say then, that the primary driver for your purchase was the fact that the government came up with Meaningful Use and basically said that you HAD to have SOMETHING...or else. My understanding is that practices like yours in the last year and coming year (2013/2014 - as penalties are starting) essentially have two choices. (1) Buy your own (POS) EMR, or (2) Join up with the local 'major' hospital and get an extension of their platform. (Most hospitals are pushing this method as a model for growth right now within the community and increasing the speed of consolidation in the healthcare market --> which will either lead to increased prices (less competition) or lower prices (scale of economies) ...all depending on which theory of economics you believe will prevail.

I have a solo practice. I bought the system but Medicare reimbursed me for it and had I known what a pain in the ass it was to operate no amount of money would have enticed me to get it.

My mother is dying of cancer and I sold my jaguar to help with costs. Apparently since my mom is catholic she has some charities that can extend a helping hand to her so she's finally getting the care she needs. But what a fucking nightmare this healthcare system has been.

Thank you so much for doing all this.

do you receive any attacks from the religious right?

what country do you think "does it the best"?

No attacks yet and I haven't practiced in another Country so I don't know.

Do you prefer taco stands or chain restaurants?


What are your thoughts on currently-available health care price transparency tools like Castlight Health and HealthCare Blue Book?

Disclosure: I'm an engineer at Castlight Health. Curious to know what you think of the potential for impact here.

I think they help but only for elective procedures and outpatient costs. It's the stuff you don't expect that bankrupts you.

Do you think deregulating the health care market is the solution, or have we just implemented the wrong regulations?

If we completely deregulated health care we would probably go back to the days where this and this were possible. I'm not sure that would be a step forward.

I would disagree. You think businesses that did stuff like that would stay afloat and people would continue to buy their products?

In the first example I gave you; the one where a pharmaceutical company accidentally poisoned over 100 children with antifreeze, the company, SE Messengill, wasn't really harmed financially by the fiasco. In fact, they're still around today. People forget these things very quickly.

The company doesn't exist today because everybody forgot about the incident. That's not how the free market works. They were most likely bailed out. More importantly, are they still poisoning kids with antifreeze? and is it only because of government regulations? I would say that morals would and a desire to stay in business would keep businesses developing high quality/safe products

They weren't bailed out. They paid a total of just over $16 thousand for mislabeling their product as an elixir when it, in fact, contained no alcohol. Believe it or not, that's the only law at the time that was broken.

Sorry if this is a duplicate, I scanned through your answers quickly before writing this. You seem to suggest that capping the amount hospitals can bill as a way to help healthcare costs significantly.

However I don't actually see how this addresses a huge problem that I came to understand working at a CAH. EMTALA requires hospitals to treat all people the same in an emergency situation (stabilization and transfer at bare minimum, and who is going to accept a transfer of an uninsured patient). So when uninsured people have massive, costly emergencies, the hospital system eats that cost. Consequently, they overbill anywhere else they can to keep themselves in the black.

With the caveat that yes, most hospital system administrators salaries are INSANE, and yes some hospitals are doing quite well financially, how do you propose we address the problem? EMTALA requires hospitals to spend money they won't get back, which especially in CAH and the like would quickly eat them alive if they couldn't overbill elsewhere. I certainly would never want anyone to be turned away from emergency medical care, but the question becomes, who foots the bill when the patient can't?

Please read: http://www.truecostofhealthcare.org/hospital_financial_analysis

Can you list 5 things( that contribute to high costs) that should tackled head on first? Things are the readily fixable.

I would put this at number one

Have the price of all medications and medical services easily accessible to everyone and apply all anti gouger laws to health care the same way they apply to everything else.

I guess that's not five but I'm starting to get tired.

Based on what you know about the ACA, do you feel it will bring in enough revenue to break even and bring costs down enough to be effective?

Like I said before, I think it will help but we need much more.

I think a major first step is to have a system in which you can compare apples to apples. A universal code system where the code for each item, like an 80mg aspirin is listed the same for a hospital, insurance company and billing system. This way you can, as a consumer, can see what is charged by hospital, what is paid by insurance and the additional cost like billing system per transaction costs. Don't think its not much? Your talking 100 of billions.

Please read this: http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html

cant the U.S just increase everyones income tax by like 0.7% and then for every medical thing ever at non-private hospitals, the government pays ? im pretty sure thats how they do it in my country (australia) 1% or so of our income is taxed and goes towards medicare, and whenever we do anything, from see a GP to getting neurosurgery, you just tell them your medicare number and thats it, you dont have to pay anything, including hospital stays. we have private clinics and stuff too, they take the government money AND charge out of pocket, but our public healthcare is the bomb so no need for private clinics i understand this would be harder to do in america at the federal level, but maybe the state level? what are your thoughts david?

Yes, but that's communism and once we embrace communism well... I'll let Ronald Reagan explain it to you: https://www.youtube.com/watch?v=Bejdhs3jGyw

Approximately how much money would the country save if everyone followed a whole-foods plant-based (vegan) diet, therefore greatly reducing rates of obesity, diabetes II, heart disease, etc?

If you mean shopping at Whole Foods then I can assure you we'd be bankrupt in a week! Have you seen their prices?

How much blame so you put on physicians? Many act as though they are burdened by insurance companies, but they turn a hefty profit through them.

I blame doctors for taking no time to understand the business they represent and allowing themselves to be misinformed about health care. No one really says no to money but we should take at least a little time to see where it's coming from and understand the financial burdens we inflict on our patients.


Most hospitals have their own pharmacies which, to my understanding, are stocked no differently than any other pharmacy.

No offense, but your website has very poor visual design. I hope you find a visual designer who can make it more inviting to read. Stark color scemes, a scattering of wordy titles and fonts, and huge paragraph blocks of text are major turn-offs for the average visitor, unsure if they want to read it or not.

I think this is about the tenth time someone has informed me of that. I know.

Any thoughts on the medical school system in the US? Is the high amount of time and money required worth it or are there things that can be changed to make it more similar to, say, the UK model?

I think the tuition is insane but I don't think med students in other Countries take less time to train. I could be wrong about that though.

The idea of putting a price tag on life/death is quite disheartening...

I'm sure it always will be.

I know I'm late but I'm just letting you know that I agree with your movement 100% and that I wanted to thank you for actually confronting it head on. It takes balls, and you got some big ones. I'll be sharing this website every chance I get. Good luck my friend!


I suppose you are familiar with the articles of Steven Brill, like the recent Bitter Pill: Why Medical Bills Are Killing Us in Time? There seems to be a lot of overlap, but I don't find Brill cited anywhere on your site.

Confession: I haven't read that article (don't subscribe to Time) but Brill's discussion with Ira Flatow on Science Friday covers the main point, which is that the ACA contains provisions that would go far toward clarifying the healthcare marketplace but the administration hasn't gotten around to writing the regulations that would implement it.

I think Congress block a lot of those provisions as well. Here's my solution to that.

Commenting to read later, looks like an awesome AMA


you said

the price of all medications and medical services should be easy to access the same way the price of everything else we buy is.

Sure, All well and good. But drug prices fluctuate wildly. and frequently. and drastically. Who's going to keep this list up to date and accurate? Sometimes us people in the pharmacy don't even know the price has gone up as much as it has until we get the invoice. just make sure they can't spike the price up 1000% because of a "raw ingredient shortage" or at least require them to prove it.

My next blog will address exactly that. Stay tuned. It should be in Huffpost early next week.

What did you think of Michael Moore's Sicko documentary?

I answered that on one of the first questions. I would find it for you but I'm swamped right now. Overall, it had some flaws but I liked it.

I just watched your talk with the Alameda Rotary Club video and you absolutely blew my mind at several points. I'm a paramedic and about to finish nursing school and I thought I knew a lot more about the finances of the healthcare system than I actually did.

Thank you for that extremely eye-opening video.

My only question is this. Do you think there could be some alternative structural solution to providing healthcare financing to the average American? I'm thinking of some sort of healthcare-cooperative that people could pay a subscription fee to be a member of, that would negotiate with labs, pharmacies, and hospitals on behalf of the cooperative members at the true market values rather than the inflated nonsense we see in their billing documents.

Does such a thing already exist? How would people create it if it did not?

A lot of companies try to self insure their employees. Bottom line is the system often takes them to the cleaners

Thanks for the work you are doing. This is an important message to get out there and you seem to be doing a great job. I hope to see you on the major networks and making the daytime talkshow rounds someday soon.

EDIT: Hell, Oprah might be interested in your message. I'm sure the majority of her viewers certainly would be, at least.

So far she's not returning my calls.


I haven't been to India so I don't know.

If you could sum up your findings in 1-2 sentences, how would you state it?

Health care in the US is a complete mess.

Have you considered writing a guide to finding and comparing a reasonable health care plan?

Since you are aware of the confusing nature, it would be really helpful to have some sort of guidelines concerning deductibles, copays, and prescription costs.

I think that's the purpose of the ACA exchanges. We'll see how that works next year.

Do any of your proposed findings or solutions involve Tort Reform?


I have a high deductible health plan, so I always want to avoid spending money on procedures. I always ask how much a procedure costs when a doctor suggests it. It is absolutely amazing to see how little doctors know about billing. They have no idea how much anything costs because no one ever asks or cares. Do you think high deductible health plans are a good way to get consumers interested in health care costs?

These two videos should help. The first will make you laugh the second, not so much: https://www.youtube.com/watch?v=CEnD2aMfPjE


One of the biggest costs for a medical practice is PAYROLL. Maybe we should get patients to file charts, clean surgical equipment, and wash dishes in the cafeteria in exchange for services rendered. Medical barter system. I'll remove your wart in exchange for snow plowing our driveway.

I've read that 60-70% of all Bankruptcies in the US are due to medical bills. Medicine for profit is part of the problem. What the f@#k is wrong with our species? NO money = no life. Good luck with that humans.

How do we become a different species?

Robots son. Lots of robots.

Thanks, I'll work on that.

Where is the money going? Who is making the profit? If hospitals are overcharging, one would assume they are rolling in dough but that's not true. From what I can tell insurance doesn't make much. Hospitals are hemorrhaging money. So is it doctors being overpaid? Is it the supply companies overcharging? What supplies? Why isn't there more competition then?

I think insurance companies have just foud clever ways to hide their money.

Let's also not forget that there is an implicit subsidy given to companies to offer health insurance. Insurance started to get offered during World War II, when the government used price controls to prevent wages going through the roof. After the war the system where companies could offer benefits instead of wages continued.

To this day it is "cheaper" for companies to offer $1 in benefits (health being the primary one) than a corresponding $1 in wages.

Dr Belk I'm curious what your opinion is on the French healthcare system. As I understand it the system is basically that there is a public option available to everyone paid for through payroll taxes and that companies still offer private insurance (I saw a stat I think in Forbes that about 70% of healthcare is covered through the public option and 30% private insurance). Considering that the World Health Organization ranks France as having the best healthcare system in the world I'd start there, but I'd love to hear your take on it.

From what I understand most European health care systems are better than ours. That's not hard to do though. I don't know enough about any individual Country to comment specifically.

There's a mistake on your medications page.

Novolog isnt $25.

Novolin is $25, novolog is around $300. Novolin is plain human insulin first synthesized in the 80s, which absorbs slowly when injected subcutaneously, novolog is modern insulin, modified molecularly to absorb faster into the bloodstream (though still not as fast as from a functioning pancreas).

You're probably right. I was just quoting the pharmacist at Walmart and I may have written the wrong one down. I'll fix it when I get a minute.

Thank you! I love people like you and appreciate your wok at uncovering something so foreign and important to all of us here in the US.

One tip, though. Seek a professional web designer. The site you currently have looks very scattered and makes me not want to read it. Otherwise, I found some very interesting information on there.

Again, thanks, and good luck in the future on this work.

Yes, I know.

Okay I'll keep it simple, Obama Care, good or bad ?

OK, but not enough.

PLEASE upvote this so David can see it. David, I'm a co-founder and chief designer at Medko, a startup that helps people find quality and affordable care outside of the US (http://www.medkohealth.com/). I'm also a bay area native.

I saw one of your comments about the quality of your site and would love to talk with you about offering my web design services, free of charge. I'm confident we can coordinate enough via Skype and Email to get you something much more professional.

You can contact me at: dev @ medkohealth (dot) com.


email me at the website.

So hospitals are the biggest form of bankruptcy in the United States.


Are they just that corrupt? Or is it the fact that the US is so big and spread out that the infrastructure increases the price? Someone posted that while CA hospitals only receive 25% of what they bill, they are claiming fiscal loss of only 2%..... This sounds like major corruption and doctor's are still some of the highest paid jobs (yes school is expensive, but that's an entirely separate problem).

So I guess the real question is how can hospitals hurt people so much while claiming to be helping?

It's a very weird system that's unlike anything you're familiar with. take some time to read this. It will either help you understand or make your head explode.

What's your opinion on the Canadian healthcare system?

Better than ours

Hi there. I'm currently entering medical school and I'm curious how all of these changes will affect doctors. I'm honestly not concerned about making money because I plan on doing work with Doctors without Borders or a similar organization. I'm only concerned about paying off the 300,000 or so dollars in debt I will have when I'm done with school. If we lower the costs of healthcare (which I am in favor of 100%), will medical schools also have to lower their costs? If they don't, how will doctors ever be able to pay off their debt?

I have to sign off soon because my wife is getting angry about the fact that I've been on the computer for eight hours without a break (I'm also starting to get delirious) But I will say that doctor's fees aren't a huge part of what drives health care costs in this Country so we can control cost without forcing our doctors to eat in soup kitchens. Med school tuition is another matter. It's flat out outrageous.

So what insurance company have you found, if any, that is decent and takes care of their customers?

none so far.

What is your opinion on the consolidation of the lab test market into two companies? Quest & Labcorp

In my view this is yet another blatant violation of anti-trust laws in this country. Prices for lab tests have increased as competition decreased, and yet every one of these mergers and acquisitions along the way claimed that it would benefit consumers. With only two companies in the market it's also likely that they collude to keep prices high, but even if they don't, in many places there is NO competition since only one of these two serve that particular region.

Monopolies are never good for the consumer.

Why do you think a review site (such as Yelp) does not exist for doctors, hospitals or for any other aspect of the health care industry? It has been implemented on a very small scale in the past such as RateMyMD and Yelp itself, but for something we pay so highly for it seems there is a surprising lack of consumer input.

Are you kidding me? If you google my name my Yelp reviews are usually on top.

I would LOVE to know how accurate John Green's video on this topic is without having to do days of research. http://youtu.be/qSjGouBmo0M

He's mostly on target. I'd love to chat with him. I'd also love it if I had a tenth of his audience.

What would be the easiest part of this that we could change. (What is "Step One" to fix this system?)

I don't know what would be easiest but I think this would be the most relevant change we could make.

on a scale of 1 - paris hilton, how fucked are we.

This fucked

you sir win the internet and my all time allegiance.



why, who are you?

It takes a life's work to figure out that American healthcare is a racket?


how does one "write" a website?

Well I wrote everything on it (with some help from my brother who's a better writer than me). Since the site contains mostly text, how would you put it?


There's certainly no advertising for the cheaper, sometimes better meds so doctors don't hear much about them once they go generic. It's really a matter of reps for the brand name meds pushing their product hard every day to try to get us to forget about the generics

My mother can get a prescription at one pharmacy for $30, and the same exact one for $3 dollars at the County pharmacy that my county's employees are allowed to use. Rediculous!

Check this out

Hi Dr. Belk. First, thanks for doing this AMA.

I am currently a student and am leaning towards studying medicine so that I might be a psychiatrist. I feel inspired to devote my study and practice to learning to heal mental illness, as I have a special sympathy for those who experience the strange breed of pain and suffering that such diseases cause. I am discouraged to enter medicine in America, as the state of the medical field seems particularly flawed. Do you have any advice for someone such as myself who wishes to practice healing amid this broken, poisonous system?

The state of psychiatry is even worse than the rest of health care in this Country. Outside of a few States that have moderately good programs, most psychiatry in this Country is provided in our prisons.

Well that's a solid bummer.


I will likely get overlooked, but my biggest question is, have you come across any evidence of someone dying due to insurance either refusing to pay, or dropping them (when it was still legal) and thus leaving them with no ability to pay for something like chemo or expensive medications that were necessary for them to survive?

I know it isn't about the cost of health care, but I've been looking all over. I'm admittedly liberal, and have heard the idea for a long time - but until challenged recently, I realized that I've never actually read anything about it.

Of course, there are people who have lost coverage and gone on to die because of a lack of insurance, but I'm talking about someone who died because they lost their insurance mid-treatment and was unable to pay the bills, thus being denied treatment. Given that Drs are only required to get a patient stable, not continue to give them treatment after, I'm just curious.

Hopefully you (or someone else) could answer this question. I just don't like repeating a line that isn't true, or at the very least, is said but not entirely supported by facts.

I had a case like that once. She had a severe stroke and, once she capped her insurance, everyone kind of walked away. She died but I'm not sure she would have lived with any amount of care.

What I'm hoping to find, at some point, is an article related to say a 14 yr old teenager who, because they exceeded a lifetime cap or via some other means was denied insurance when they previously had it, ended up losing their ability to get chemo and thus died whereas with the chemo they could have survived.

Perhaps part of the issue is that in situations like these charities will take over. Perhaps part of it is that settlements are made in private that keep them under lock and key.

But I anticipate the moment that someone dies because a plan was cancelled and someone failed to fill out the paperwork in a timely manner or meet with someone regarding new coverage, that they will get denied treatment and every conservative outlet will rail on this about how Obamacare killed someone. They'll ignore the fact that millions of uninsured people are able to get coverage that otherwise would not have, and that those people would have died of routine illnesses simply because they could not afford to go to a doctor previously - but it will still be focused on.

And so, because for so long people have said that insurance companies have thrown people off and killed them because of it, I don't want to have to say "well, we said it for a long time".

I know it seems stupid, the amount of people who will live and/or benefit from the ACA far outweighs those who have been the "losers" of the ACA. But I still want to be able to go to my annoyingly conservative family when they bring this up and tell the to STFU because I'm already about to disown them for the crap they say (seriously).

Typically, life saving care is never denied in this Country. Emergency medicaid will often pick up the tab once the family is tapped out financially. Early death due to chronic neglect of a treatable medical condition (e.g. diabetes) because an uninsured person couldn't find a doctor to prescribe his meds but that's harder to document. Our health care system causes far more bankruptcies than deaths though.

That's a frightening thought. I could not cap my insurance if I tried. I had 7 surgical procedures over 2 years, and it all came to roughly €60k. My plan caps at 3m/annum.

Her's caped at $75 thousand.

Also why did ibuprofen cost me 600 dollars when it was given to me at the hospital?

Because that was the best ibuprofen ever! Couldn't you tell?

I am sorry I have nothing to contribute to the conversation. However, I thought you should know how I was mislead by the first 4 words after your name, and had to reread it a few times to understand that "doctor who" is not who you are. I became uninterested immediately after realizing that. I kept reading it wanting it to be Doctor Who who has done... but yeah... HI Yes I am an idiot.

I've had at least 30 posts now from people who have confused me with The Doctor. If it's any consolation I am trying to build a time machine (in my spare time).

Just how the proof_for_reddit was done makes me love this guy. :) Doing it all himself, and interested enough in things to learn to do it himself. And what could be a cause more worthy of attention than this in the US today? Well done, sir.


Dr. Belk, have you done research on the state of dental care as well? Isn't it even worse because most dentists refuse to take Medicare/Medicaid patients? And dental insurance usually have a yearly coverage limit of $1000-$1500?

Not really but dental isn't nearly as complex as health care because a lot of dentist are accustomed to working for cash and dental problems don't get as complex as medical problems can (e.g there's no equivalent to a liver transplant in dentistry)

A root canal or a crown will set you back couple thousand dollars. Also, I've read an infection from the mouth can lead to a heart attack.

A mouth infection can lead to a heart infection called endocarditis which can set you back a few hundred thousand dollars

What is your opinion of ObamaCare? It's a given that it's imperfect and not going to fix everything, but do you think we're better to have it than not to have it?

Yeah, we're better off with than without it.

Mr. Belk, what is your opinion regarding the possibility of there being a group of globalist elites, an "Illuminati," if you will, who dictate the goings-on of the world and are seeking to establish what is commonly referred to as a New World Order?

I'm one of them. Do you have a problem with that?

I'd like to know WHY the general population continue to "support" the current system. It seems that every time a government tries to bring in a new system that models the same as other countries (Australia, UK, NZ) the self interest groups that DON'T want change drag out the rent-a-crowd to shut down the debate and bring into question "socialized medicine, and freedom" queue flag waving and all that stuff.

What is more important? "Freedom" or the ability to be CARED for?

There are a number of reasons including fear of the unknown and the fact that so few people understand what it is they're trying to fix. That leaves any potential solution open to a deluge of misinformation.

Just say "It's like the Fire Department, and Postal Service, both are Government funded, which means you get cheap stamps, and free service when you need a fire put out".

Or that the government put men on the moon. That wasn't easy.

god fucking dammit reading through this thread really, really pisses me the fuck off.


wow, I really didn't expect that YOU of everyone here would respond :) first off.. THANK YOU. Thank you, thank you, thank you for what you are doing. This entire subject is SO confusing and frustrating, and intimidating for a 25 year old facing the real world. You're a beacon of truth, and coming across your website earlier this year has shifted the way I think about a lot of things, really. I sent your link to one of my good friends, who works for a medical device company, and he swears that this website was the singular best thing he has ever come across.

I'm 25, and will be dropped from my father's really great healthcare plan in just a few weeks. It just seems like american healthcare is so complicated, everything is so convoluted, and the ones in power are SO fucking greedy and stuck in their ways, that we as a society will never actually progress. It just seems like the vast majority of Americans are absolutely stuck in this mentality of "why would I ever pay for some lazy person's healthcare when I have to work so hard to get it. Do you REALLY think more handouts are the way to go?"

I just... I want to know that if I get in a car accident, or my right ball starts throbbing to the point I want to keel over and die that I can simply go to the doctor, and know that I will be taken care of, because I'm a fucking human and other humans should want to help me. Instead it just feels like the main incentive for anyone and everyone to be in healthcare is the massive paychecks. No one wants to take responsibility for "the system" or its obvious flaws, and instead we get the small group, who is in control, benefitting immensely (weird, that NEVER happens....) while the vast majority of citizens are afraid that even a simple visit could potentially ruin them. I just want to know that if people get sick, other people want to help them and not because it's really, really profitable to do so.

I know I'm making sweeping generalizations, but I don't know how else to convey my feelings..

Yeah, that about says it all.

You've been doing this for a while. If you're still doing what you're doing, considering what you know, there must be some hope, right?


I'd have moved by now if there weren't

At my local clinic/hospital/nursinghome (all same facility) they do "extra" unneeded and sometimes unwanted tests. I discovered they only do this with patients who have insurance. They do it to increase revenue. They are really big about xrays for everythting, even in small children. My son had about 20 xrays before he was 2. Every time i would take him in for anything, caugh, fever,etc, they would do exrays just to check them out.

My husband went in for his frequrnt heartburn, they did CT, MRI, Eco, and still never treated his heartburn, just told him to take OTC meds. Is this common everywhere to increase sale? Or is it just this crappy clinic?

that's a problem, of course. It not one I address directly because there are so many problems to go around in this business that no one could address them all.

Dr. Belk, have you shared your research with Harvard School of Public Health? If you could get connected with a group over there who is working on healthcare reform, this valuable information may help with future reform/policies. The Harvard name brings a lot of cachet and influence. Massachetts first implented Romneycare, which Obamacare is based on as you no doubt know. MA legislators have a long history of sponsoring healthcare bills for the benefit of all. Elizabeth Warren is also very pro consumer protection.

None of them have called me yet and I don't have their numbers

This guy John McDonough might be a good person to get connected with: http://www.hsph.harvard.edu/news/magazine/health-care-reform-mcdonough/

Contact info including email addy available at below:


I'll try but these guys are mostly the "don't call us, we'll call you" types

'I am David Belk. I'm a doctor who...'

... C:

If I said "I'm the next Dr. Who" I would have really shot to the top.

In the US, Cancer survival rates are much better than they are in the UK. You might not expect that to be true with all those uninsured people in the US, but it is.



Not a simple issue(more in the links) but the fact that the uninsured in the US have a better breast cancer survival rate than those covered in the UK does make you do a double take: http://www.factcheck.org/2009/08/cancer-rates-and-unjustified-conclusions/

Why do you think that the cancer rates are better in the US then they are abroad, even though there are so many uninsured in the US?

OK but, if everyone has to get cancer to get good health care, is that really a good system?

What do you see as the biggest driver of healthcare costs in the U.S.? Patents, the fact that most research happens here, insurance itself, medicare/medicaid, malpractice, etc?

My money is on the health insurance companies. There are a lot of bad players in this business but I think the health insurance companies are on the top of the food chain.

If the American healthcare system is so bad, why does it have the highest cancer survival rates in the world for every single type of cancer, including twice the survival rates for certain types of cancer as countries like Sweden and Denmark?

Would you prefer a system where more people die but is more 'fair'?

So many people keep commenting about cancer. Cancer isn't the only disease we treat!

Does America have lower survival rates than these countries for other diseases?

From FOX News: http://www.foxnews.com/health/2013/07/10/united-states-health-outcomes-far-worse-than-other-comparable-nations/

Totally irrelevant. This study shows more Americans are dying, but doesn't show whether that is because Americans are living less healthy lifestyles or because they have poor quality healthcare.

I would have expected more than a random google search for news articles from someone who has apparently been studying this for years.

I'm doing an AMA for Crist's sake! Do you have any idea how busy I am? FOX News says our outcomes are bad. That's how bad it is hear. I was looking for something without "liberal bias"

Have you discovered any evidence suggesting Obama is literally Hitler?

Yes and he's looking good for being for a 124 year old. Maybe if I invade Poland I'll look as good at his age.

From my quick perusal of your posts, it's apparent that you like the Maryland way of doing things with regards tpluo healthcare.

I have a fond appreciation for the Finland way of doing things with regards to healthcare.

Care to share your thoughts - plus or minus? Finland keeps coming up on top as a society that excels on all metrics.

I not familiar enough with the European systems to comment on them but, I hear they work better than what we have hear. I refer to the Maryland commission because it effectively fixes a serious problem with our health care system: Hospital over-billing.

Your site is out of date. When will you update it to include the ACA?

I guess I don't discuss the ACA much for two reasons:

Thanks for your reply. OK, then your site is current, relative to the changes the ACA brought to the market?

I update information as it comes to me and when I have the time.

Why are drugs so much cheaper in Canada than they are for the exact same drug in the US? Do you think Canada's health care system is better or worse off than the States and other countries. Whos health care system do you most admire/envy?

Generic drugs are pretty cheap here. It's the brand name one that will bankrupt you.

If all Americans had healthcare, what would it cost the average family of four to have a good plan? I'm assuming to portion of my healthcare that covers expenses for uninsured patients would go away.

It's more complex than that. Even if everything else stays the same. insane charges, inefficiency, etc... health care costs overall are likely to drop once everyone has easy access to healthcare. Why? Think about this, treating high blood pressure and high cholesterol only costs pennies a day. Not treating those conditions leads to heart attacks and strokes which cost thousands of dollars. Do the math.

But if people with high blood pressure and high cholesterol, and don't currently have insurance, go to the ER at dire times, passing on some of the cost to those of us with insurance. Wouldn't the overall costs go down if the people with these health problems had insurance and sought treatment sooner?


ELI5 this to me, I don't undertstand

Try watching the video. I don't quite think it's for five year olds but I think it makes things pretty clear: https://www.youtube.com/watch?v=r9q1Id41wGo

Do you think capitation and The DRG method of charging is a viable option?

I already receive capitation checks for my HMO patients and, the they pay me a lot of money, it's easily one of the most opaque processes in this business. I guess you could say I have mixed feelings about it.

Hospitals have been on the DRG system since 1983. It ended a lot of abuses that were going on at the time and bankrupted a bunch of hospitals.

Could you elaborate further and how these things benefit or hurt both hospitals and consumers?

I missed this question when you posted it.

The purpose of capitation is to encourage a doctor to do what's best for the patient. It works like this: If someone in a capitated program chooses me as their doctor I get a certain fixed payment each month whether I see them in my office or not. That means I have no incentive to over-treat them, which is the primary flaw in fee for service, but if I ignore them too much they'll choose another doctor.

That works in theory but you can see how doctors might be encouraged to ignore more difficult and challenging patients in such a system.

DRGs are primarily used by Medicare to determine hospital reimbursement. I wrote an essay on that Story a couple of years ago. I think it's worth reading because it provides a lot of context as to why so little of what hospitals do appears to make any sense.

What about straight forward paying? Would it make it more cost efficient? Because I heard that it cuts costs. Like this http://americablog.com/2013/06/doctor-in-maine-stopped-taking-insurance-lowered-prices.html Do you think it would be something good to have?

For the routine stuff, probably but the pricing system has to be reformed first

More or less government involvement?

How about proper government involvement?

could you be more specific?

Not easily but, in short, laws that prevent unfair advantages and gouging and encourage transparency are far better than laws that do the opposite.

Way late to this one and I'm too lazy to read through so I'm sorry if it's been covered before but isn't the high cost because of the legal system? I mean the insurance companies are stockpiling money for the inevitable lawsuits. The system allows for lawsuits for monetary gain and we the consumers are the ones that pay for it right?

Read this

"...I am a Doctor Who..." So...... You're the doctor? Just The Doctor?


What are your thoughts about that whole "Death Panel" bill that failed in 2008-2009ish? Quite a few people mentioned it would have not only helped people live longer (ironic), but it would also greatly reduce health care costs.

It was a diversion. It hard to say what difference a policy will really make if it never gets implamented.

Was it true that the "Death Panels" were really about giving severely ill patients more freedom of choice of being in/out of a hospital? For example being able to be moved to a nursing home/assisted living facility/families house if there was not much doctors could do for them in the hospital? Or was that more confusing chatter?

My understanding was that it was about offering doctors a better reimbursement fee to discuss end of life care with patients. Right now, if a patient wishes to see their doctor just to discuss that, we have to make something up if we wish to bill for the appointment.

What would you thinking of forcing health insurance companies to be non profit?

Many of them are non profit. It's a deceptive word in this Country. Just like most hospitals are non profit yet make billions in profit anyway. In the US non profit means not publicly traded. It also means that none of your profits are taxed. Heck of a deal

Related American healthcare discussion thread: http://www.reddit.com/r/news/comments/1rz2m6/as_hospital_prices_soar_a_single_stitch_tops_500/

Yeah, I posted a comment there. Interesting point: If you read my hospital financial analysis, there's a profit graph that shows California Pacific as, by far, the most profitable hospital in California.

Best IAmA so far. Really sad i missed it :(

First off all just want to say thanks to Dr. Belk. He is one of the few medical professionals out there who dare to stand up against the corruption in the healthcare system and the pharmaceutical companies manipulation.

Many physicians out there know about the corruption in the healthcare system very well, but they choose to ignore it. Ignore the The Hippocratic Oath they took on their graduation day, and instead walk upon the road of greed.

I know this might sound silly, but you are a role model to me. And i just hope one day after im done with Medschool that i can become someone like you.

Good luck with your quest, and i hope your message is spread.

"I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm."

I'll be back a little later today after I've had my coffee.

How long until you're assassinated.

Don't know. No one's told me yet.

I thought for a second this was a Doctor Who post.

You're not the first.

No, that was William Hartnell

I'm glad Dr Who isn't doing an AMA this weekend. I would have been completely ignored

Thanks for doing this AMA!! I had my mother in-law come visit us and she seemed to have some pain in the ribs (rib fracture we later found out), so we went to the ER at the County Hospital to have her checked. She was visiting and had no health insurance, and none of the hospitals would be upfront with the costs. They checked her vitals and after waiting for 2 hrs outside (and not actually going inside the Emergency Doors or seeing a doctor), we gave up hope and went to a nearby private Urgent Care clinic which charged us $162 including everything (vitals + doctor visit) Yesterday, we received an invoice from the ER: $128 for the ER visit. What should I do ? Should I ask for an itemized receipt, because I do not know what they did that could have caused $128. All they took was her vitals.

They do that all the time. All you have to do is fill out the forms and they bill you for that! ERs are merciless when it come to getting money

This thread has been reinforcing my desire to move out of the country.

I'm 28 female no health "issues" until this year. My major issue this year? Unexpected pregnancy. My only drs appointments the last 8 years has been my yearly visit to renew my birth control. Ironic I know.

I'm a part time flight attendant, so no insurance options and my husband is self employed and he makes pretty decent money and since we are both healthy we decided it makes more sense to keep a savings account instead of paying 2/k a month for individual coverage.

Our state is opting out of the expanded income guidelines for the Aca. My best option for coverage with out bankruptcy and draining all of our savings was to move in with my mom 1000 miles away and apply for insurance in another state.

You're not alone. Health care is a mess in this Country

Dr. Belk,

Thank you for this post.

This local Dr. in the US opted out of accepting insurance and as a result his prices (on his website) are drastically reduced. He was interviewed and Huff. Post still has it.


What can you comment about this video interview?

His website - price list page:


I am interested in your insight and comments into this practice model.

Thank you!

I addressed that issue in my section on office billing. Here's what I wrote:

(1) If I don’t accept a patient’s insurance, then the insurance companies won’t allow me to authorize diagnostic tests, procedures or appointments with specialists. This would greatly diminish my ability to help the people who are already paying extra just to see me.

(2) I would be adding to the medical costs of people who are already paying too much for medical care. This is especially true if they got hospitalized; they’d really be in trouble. In effect, I’d be punishing the victim.

Dr Belk, I am late to this but I hope you can answer this question. It is very important. Do you think that an analyst AI like IBM's WATSON can replace a general practitioner? When I go to the my GP, most of my illnesses are extremely easy to diagnose. I personally do it myself but I can't buy my own medicine. I have to go to him where he spends about 1 minute thinking about it and sends me out the door and I pay almost 200 dollars for it. I envision a future where a computer can diagnose a patient and if the illness is serious or the diagnosis is inconclusive, the computer can advise the patient to see a specialist. One should also have the freedom to buy medicine without a prescription. I know the medical association won't like it because they're there to protect the trade. As noble as medicine is, it is still a trade and a highly profitable one. I believe that this sort of freedom in medicine will lower the cost of healthcare dramatically. For example, if a patient needs a blood test, he can take his own blood with a kit and send it in. The costs would be dramatically lower. I know people who do lab tests, they just throw it on a machine. We could have general medical education in school. Taking blood is extremely easy. It is much easier than auto mechanics and we learn that in school. It's just that in American culture, medicine is sacred and only a doctor can perform it. That's just not right. Obviously I would need a real doctor to set a broken bone or do any kind of treatment that requires technical skills but those situations are very rare for an individual.

I'm not sure I like the idea of being replaced by a computer but, you're right, a lot of what we do is routine and mindless. That's true for every profession though. Only on TV do Doctors, cops and firemen run around all day heroically doing heroic things. Ordinary life is mostly mundane for most people. That's why we have TV.

I tend to think offering all prescription medications over the counter would be opening a Pandora's box. I envision hypochondriacs administering themselves chemotherapy each time they feel a lump on their necks. The other stuff like blood tests are already being made more available. As technology improves that sort of thing is inevitable.

How does an outsider like a nurse or doctor identify and quantify administrative waste?

How do we get data? Admin controls all of it

i don't know. one person's waste is another person's necessity. You really should read The Dilbert Principle. It's a fantastic book.

So if generics drugs are so much cheaper, why has generic phenobarbital and cephalexin increased in price so much lately? I own a veterinary practice, and some of my clients have been requesting that I send their prescription to Wal-fragging-Mart so they can get it for $4.

Some generics become more expensive when they stop being used for much because no pharmaceutical company wants to make it. Paradoxically, low demand can lead to a high price. That might be what's happening with phenobarbital. Keflex is another story. my next blog is about how even generic pharmaceutical companies are manipulating the market. It should be in Huffpost early next week.

Awesome! There are so many confusing pricing in vet med, like why enrofloxacin is so expensive in pill form, even a generic chewable, compared to the injectable brand name! And why Clavamox hasn't gone generic? It's been Clavamox since I was a high school kid cleaning shelves at a vet clinic.

My blog won't answer all of those questions (Huffpost wants me to keep them less than 1000 words). I just looked up Clavamox. That's just Augmentin in liquid form, right? If I had to guess, I would say they probably changed the formula of the liquid they use to suspend it and used that as an excuse to extend the patent. That's one of the many evergreening tricks they use and it often works.

Awesome! There are so many confusing pricing in vet med, like why enrofloxacin is so expensive in pill form, even a generic chewable, compared to the injectable brand name! And why Clavamox hasn't gone generic? It's been Clavamox since I was a high school kid cleaning shelves at a vet clinic.

So here is my latest blog about how bizarre prescription drug prices are: http://www.huffingtonpost.com/david-belk/drug-prices_b_4440142.html?utm_hp_ref=fifty&ir=Fifty

You are a paid hack who continues the false narrative of hospitals/providers and insurers being evil.

They all are operating as the government regulations mandate. They are not malevolent on purpose. (in most cases)

Who's paying me and how much? I really would like to know. where can I pick up the check?

I was wondering how Dave (and my fellow Redditors) feels about Health Savings Accounts? It seems to me that it would be far more efficient and secure for people to pay into these instead of the Ponzi scheme we call Social Security… I envision something that is withheld from payroll, rolls over annually in perpetuity and can only be used for healthcare expenses. A portion of the withholding could even go towards a nationalized catastrophe insurance in lieu of SS. Any thoughts?

In theory they're a good idea. The problem is many of these plans have obscenely overpriced fee schedules for many of the services. here's a video that talks about that:


Why do doctor visits cost more if you're not insured? Example: I went to a urgent care center because I thought I broke my foot. I sat in the waiting room for 2 hours, then saw the nurse/doctor/xray technician for a combined time of about 10 minutes. I ended up paying 270$, just to be told my foot is fine. I understand I'm paying for the doctors expertise, but I hardly took up ANY of his time, I spent more time talking to the nurse and xray tech. Face to face time? Less than 5 minutes.

I answer that in this video: https://www.youtube.com/watch?v=bZCYblB3kHk

Is the insurance industry the bad guy in this sordid USA medical bankruptcy tragedy? I think they are; here's an anecdote to illustrate my view on the topic:

As an undergrad student, I dated a girl whose stepdad was the VP for a major health insurance company in the area I went to school. The guy described his job as "schmoozing," and he proceeded to take us out to the finest steak dinner I've ever had (several hundred dollars a head), and I had the privilege of watching a university basketball game from their corporate suite (wasn't carded at the open bar despite my being under 21 at the time, excellent view, other big shots present, etc.). Of course I benefited from his largesse, courtesy of his being a good schmoozer, but I was just the poor college student in this story, so I think I can be forgiven. This was right around 2009 during the financial crisis, and he retired with an awesome benefit package and took his earnings down to somewhere in Mexico, where he presumably now lives in a fancy villa on the coast, with the money of the poor sob stories on this page.

So I'll repeat my question: Is the insurance industry the bad guy?

There are a lot of bad guys in health care. I would put the insurance companies on top of the food chain but I would never say they were the only bad guys.

I know I'm late for this but would really like to hear your opinion about the accuracy of Michael Moore's documentary, Sicko.

Someone else asked me that early on. I'm not sure if you can find the answer I gave anymore in all of these comments. In short, I liked it but he got a few things wrong.

Yeah, found it. Thanks for the response and for the work that you're doing. I've shared some of your videos.



Escape Fire discusses a different problem than what I address. Health care in the US is an inefficient dinosaur for quite a number of reasons and it would be hard for any person or organization to enumerate them all in one sitting.

Hey David, I'm an internal medicine intern and interested in this sort of thing. In your hospital financial analysis you common on county hospitals and profits. My understanding is that for a lot of these hospitals (county or not), they are not-for-profit, meaning that no individual or part of the hospital is keeping these profits. Instead, I thought all these profits should in theory be put back into making the hospital better. In other words, these hospitals should be taking the "profits" and re-investing them into hospital repairs, building new hospitals, and expanding capacity. Is that not what is happening? thanks!

The individual reports I analysed can all be found on this site. You can search by hospital name, city or year. The PDF version is easier to read.

anyway, profit is listed as net income in the center of page two on the reports. It's what is left over after all operating and non operating expenses are tallied. I believe much of what you speak of is itemized on the top of page 3.

The reports themselves are 134 pages log so everything is listed, often more than once. Most of the useful information is on pages 1-5.

hey david, one more point of confusion as I was reading through your hospital financial analysis piece. Towards the end you comment that hospitals like usc county, almaeda county and olive view county make 1 billion, 700 million and 600 million in profit, but when i looked at your financial summary report for each hospital the profit graph appears to be much less than that. were you commenting on the revenue instead of profit? just wanted to clarify. by the way, it's awesome that you've compiled all this data! Thanks for spreading the word and for doing this AMA!!

That was total profit over the whole nine years added together for each hospital. So, LAC/USC netted just over $1 billion total from 2003-2011. You can see in the last figure that, for them, most of that was made in 2003-2004 when they made about $750 million in profit.

Can I mention something that I have to get off my chest? I am a medic and I do pulseoximetry on every patient I get. This takes all of 8 seconds and it is a job a nutless monkey could do. When I go to the Dr for a checkup, I get charged seven dollars for it. How is this possible?

And you can buy your own pulse ox at fry's for about $100 now.

David, what is your take on centralized electronic health records, such as with the Carte Vitale, as used in France? It seems that much of the administrative cost and waste in America could be remedied with such a tool. Why aren't these more widespread?

That would improve things a lot but all of the conspiracy theorists (many of whom are doctors) would scream about it being a government plot to spy on our health care. It's sad but true.

Some folks might see it that way, sure. But do you think there's any hope that such a system would improve the delivery of care while controlling costs? It seems those virtues would outweigh the concerns of the tin-hat set.

Of course it would help... if it could be implemented. That will be tough though. The current EHR vendors are in love with the chaos they've created. Getting them out of the way would be a huge fight. I'd love to see it happen if it did.

Your last edit is that you are still answering questions so I'm gonna hope I'm not too late. In your opinion, is Obama care a step in the right direction or the wrong one? If right, what still needs done, if wrong what do you think would work better. Thanks for doing this.

I was asked about Obamacare maybe a hundred times or so and, I admit, it's a subject I like to avoid partly because it's so polarizing. Overall though, I think it's a step in the right direction.

What would I add? I write a blog for Huffpost and in my latest one I talked about a commission in the State of Maryland that cap how much hospitals can bill. They've been doing it since 1977 and it works pretty well. Maryland is the only State in the US that doesn't have insane billing charges.

Aside from that, I would mandate that the prices be posted and easily accessible for all medical services especially medications and that the anti-gouging laws that apply to every other industry apply to healthcare as well.

Do you get paid via fee for service, capitation, or salary? What do you suppose is the best method in terms of effectiveness in increasing overall healthcare for the patient and physician?

Also, with Obamacare in effect, how would these systems change?

I get fee for service and capitation. All systems have their advantages and disadvantages because, well, we're human. Fee for service encourages over diagnosing and over treatment. Salaries encourage the opposite. With capitation, some doctors will find ways to make their patient list as easy and profitable as possible. There's no perfect solution other than perhaps some combination of the three so that the faults cancel each other out.

I'm very simplistic about healthcare. I just don't see the necessity of health insurance beyond its use for catastrophic care. We have become accustomed and accepting of its arcane ways. I just see it as a leach siphoning millions(or is it billions?) of dollars that would be put to better use as payment for service between patient and doctor. Can't someone just write a computer program that automates insurance?

Yeah, as I've said before, we need to seriously reform how health care services are priced before that's feasible.

What's your thoughts on the costs of medical malpractice insurance and it's effect on healthcare costs?

Sorry to get back to you so late. I've written extensively on malpractice costs. Here's a blog I wrote and here's a section from my website.

What is your position on physician ownership in hospitals, specialty centers and capturing ancillary services revenue from services and procedures that they order?

Also, what did your research show about payor mix in physician owned facilities?

Sorry it took so long to get back to you. I'm always suspicious of any system that allows physicians to benefit from the services they order because it invites conflicts of interest. I've noticed, for example, that any physician who owns an x-ray machine often finds a reason to order an x-ray on nearly every patient. Call me a cynic but I think all professions should avoid conflicts of interest whenever possible.

Who do you think is to blame for so much misinformation in regards to how our health care system works here in the US? I mean, if you listened to the past two Presidential elections you'd think both parties lived in separate countries.

Sorry it took so long to get back to you on this. I'd put insurance companies on top of the food chain in most respects but they're by no means the only offenders in the misinformation game.

Of note, I find that many of the people spreading misinformation about health care costs tend not to do so intentionally. Most truly believe everything they say. What's weird about health care is that the business has become so convoluted and the myths so widespread that even most "experts" in the business really have no clue what's going on. I include in that the experts who are really trying to help.

The insurance lobby is one of the (3)most powerful lobbies in DC. the ACA is a windfall for insurers (as i understand it, Insurance is a huge racket and now MANY more people will be forced to pay premiums each month because of ACA - vs single payer) so why in the world are the republicans trying to shut it down? isn't the GOP financed by the insurance lobby? Haven't the Insurance giants paid for the republican influence as much as dems' influence if not more?Thanks!

Sorry it took so long to get back to you.

The ACA does indeed bring the insurance companies more business, which you would think they would welcome. It also brings increased regulations and oversight, which they hate. This is why the insurance companies are completely opposed to the ACA. They want to have their cake and eat it too but the ACA won't let them.

Hi! Would you comment on the seeming proliferation of drugs that are now prescribed that are required to be taken every day forever - i.e., for DVT, asthma, etc. I am skeptical of any drug that must be taken without question into infinity and beyond - thank you!

Sorry to get back to you so late.

Most drugs that are prescribed to be taken indefinitely are drugs that treat conditions that historically were responsible for people dying young. High blood pressure, diabetes, high cholesterol, etc... were the major causes of people dying before the age of 70 in the past. Now they can be treated so there is little reason for a person who doesn't smoke not to live to be at least 90.

I've always thought that it makes no sense for health insurance to be an employment benefit. Why not my car insurance? Why not my groceries? Are there other countries where you access to medical care is so tightly tied to your employment?

Sorry to get back to you so late.

I think health insurance as an employee benefit started off well intentioned but it's morph into a monster in the last couple of decades.

Nobody would disagree with that. I just think the unintended side effects have destroyed any advantage to having health insurance be a benefit. It's helped drive up the costs big time.

Access to health care should not be tied to your employment status. I was really hoping that Obamacare would ban the practice of employer provided health insurance.

I think one of the intentions of Obamacare is to make it easier to get health insurance even if your employer doesn't provide it. Remember, employers with less than 50 employees still don't have to provide health insurance for their employees. Also, the self employed and part time workers are on their own.

If these people can afford their own health insurance then they won't feel the need to work for a major corporation just for the health insurance. That's important because, if it works, people will be more free to leave their jobs at big companies to start up a small business that (in theory) would increase competition. This might loosen some of the stranglehold the big corporations have on us now.

I know this for myself because I have a solo practice so I'm self employed. If it weren't for the fact that my wife gets health insurance through her employer (she's a nurse at a major hospital) I would have trouble getting good health insurance prior to Obamacare.

I'm graduating as an FNP in a few short months (hurray) and I find that the biggest issue running with my "rural, low-income, low health knowledge" population is access to the right medications. I refer to GoodRX.com multiple times a day for price checking/availability/coupons. How do you manage this with your patients?

GoodRX is helpful. So is HealthWarehouse.com or simply using Costco's site.

Here's a table I compiled of recent Costco pieces if you're interested.

Why did you decide to write a website/blog rather than submit your proof and argument to reputable (and considerably more public) news sources?

Sorry it took so long to get back to you.

A website was the best way I could think of of putting all of my findings in one spot that could be shared publicly. I have been mentioned in the news a few times plus I write a blog for Huffington Post and I recently got an interview on a local news station.

For the most part, I find the main stream news sources are just looking for quick simple stories that address one or two small aspects of the story but fall way short of the big picture.

Thanks for doing this AMA! I'm curious as to what you think might be the most feasible healthcare system for the US. For example, do you think a single payer system would work here? Obviously every system has its flaws, but some are more/less flawed than others.

Sorry it took so long to get back to you.

This was posted near the top of the answers and is, by far, the best answer to your question I could ever come up with. If you haven't yet seen it I highly recommend it.

It's fine, I'm surprised you're still answering questions. Thanks a bunch, I"ll definitely check it out.

I'm pacing myself. I think I'm about a third of the way through the ones I missed last weekend but I'm on vacation now so I have some time.

Do you believe executive compensation is part of the problem? I know the top earners in several small systems who make between $300K and $1 million yearly. That seems like too much for a basic management job. When you get three to seven of them in one hospital, you are really looking at big money just to pay the top 1% who do not perform any patient care and are not usually MDs.

Sorry it took so long to get back to you.

Yes, many insurance executives and the CEOs of some of the device manufacturers get eight figure incomes and that certainly adds to health care costs.

Not sure if this will be seen. But would you agree that the simple answer to the problem is implementing a single payer system like Vermont is doing?

Sorry to take so long to get back to you. I was asked about single payer a lot in this AMA and my best answer is here. In short, single payer would help a lot but I'm not holding my breath waiting for it to happen.

I started a company rating MDs on efficiency of healthcare costs and am currently seeking vc. I am in talks with a Medicaidprogram in one state to save them 10 percent or so by identifying the worst offenders. Reach out if you'd like to chat.

My email is here: http://truecostofhealthcare.org/contact_information

Do you have a link to donate to? I truly believe that many people, when they read your writings, and watch your videos (like I have been doing for the past hour), they will just have their mind blown, and will want to know more.

You should get a Paypal or something set up with a "Donate" link on your page. It would really help with website management, resources to keep doing research, you know! Keep up the work. I have already shared some of your videos on my Facebook, and have posted a link to your site on my Facebook.

Thanks for offering. Believe it or not, much of what I do doesn't cost me anything so, if I did start taking donations, I'm not sure what I'd do with the money (other than put it in the bank)

Hi David, I think what you are doing is amazing and I wish you the best of luck with your mission. Is there anything we can do at help?

To my question, how long have you been a doctor, and did you have a defining moment that brought you to action?

I'm sorry I missed your question the first time through (they all came at me so fast). I got my MD in 97 but, for my answer to your second question I'll share with you part a something I've written but have yet to publish:

About 15 years ago, while I was an intern at Los Angeles County Medical Center, I had the opportunity to rotate through Neurology for one month. I noticed, at the time, that the neurologists there had an interesting (and I thought rather expensive) habit of ordering an MRI on every single patient admitted to their service. I had often wondered how much this was really costing especially since, at the time, the hospital was downsizing a lot of the services they provided due to budget cuts.

My question didn’t go unanswered for long. As an intern, one of my duties was to escort patients from the hospital to the MRI center. Los Angeles County Hospital didn’t own an MRI so they contracted with a separate service that was, conveniently, right in front of the hospital. One time, while I was sitting there waiting for a scan to be completed, I struck up a conversation with the director of the center and asked him: How much do you get for each of these MRIs?

His answer just about knocked me over. He told me they get $280 for a regular scan and $350 if they use contrast. I asked again because I assumed he had misunderstood my question. I was sure MRIs must cost at least ten times that amount. He assured me that was the case many years prior but insurance companies hadn’t paid that much for an MRI in over a decade. His answer made sense, of course, because everything in technology becomes less expensive over time so, why not MRIs?

Still, there is this prevailing belief that an MRI should cost thousands of dollars. Even most doctors believe this. One reason most people share this perception is that most hospitals still bill several thousand dollars for an MRI. Only three years later, a neighbor of mine was hospitalized for a medical emergency. He had no insurance so, among other things, he was billed over $4,000 for an MRI. He also had no money so he declared bankruptcy then went back to Greece where he was originally from.

Why are countries such as Canada able to run on free healthcare and here in the US we have to pay exorbitant costs for life-saving procedures?

Sorry it took so long to answer your question.

We're overcharged in the US. That's all.

First, thank you much for your work explaining the truly dysfunctional US healthcare system!

It seems like a root cause of problems in the US is the almost religious belief that capitalism is the ultimate socio-economic system. Healthcare in the US has evolved with "for-profit" entities placed at the heart of what is an essential social service. This inherent conflict of interest continually tries to monetize healthcare, leading to a rising US GDP expenditure whereas socialized countries like Canada are able to reduce their GDP expenditure on healthcare. Do you think there's a fundamental shift from a capitalist perspective on healthcare to a socialist one that needs to occur before real progress can be made?

Also, US politicians simply refuse to support a single-payer system which seems to be integral to the success of socialized healthcare systems. Without single-payer, do you think the US can ever hope for universal healthcare on par with Canada or UK?

Sorry it took so long to get back to you. I'm not defending or attacking Capitalism in this statement but it's the answer I give any time someone implies our health care system is "capitalist':

Never mind what you think of the free market or what you think the best way to provide health care in this Country. Our current health care system actually employs very few aspects of Capitalism, Socialism or any other organized economic system. If anything, it’s a bizarre hybrid of perhaps all of the worst aspects of multiple economic systems cobbled together in a way that ensures maximum waste and minimum benefit. The best way to describe it might be “parasitic”.

I think it's important to make that distinction because it serves to shut down anyone who accuses you of attacking the free market when you criticize our health care system.

Thanks for working your way to my question!

I'm glad that this AMA got such attention and hope that your work can bring some sanity to the US healthcare system.

It was intense but I really enjoyed it. I'm going to work with someone to improve my site next month then, hopefully, I'll be able to do another one maybe in February.

I'm still going over the questions from this one now. Maybe I'll be done by the end of the month.

As a Brit I can't help but feel this is karma for throwing all our tea into the harbour that one time...

I missed your comment first time around. It's a pity because I needed a good laugh then:)

I've perused your site a bit. It seems that your main point is that health care is not nearly as expensive to provide as we Americans believe (I'm inclined to agree). So who gets the extra money? Is there a way to chart that? Doctors? Hospitals? Insurance Companies? I'm sure it's all 3 and more, but who's the big player and by what margin. If we're going to make changes to healthcare, this is the first piece of info I'd like more transparent.

Also, you use the word "abuse" here and there to describe insurance company's actions toward patients. Do you get the sense that this is malice? greed? indifference? or that they believe (much like many doctors) that this is just the way it's done and changing it would be more trouble than it's worth. "All the other companies do it this way; we're just one of the flock". Is it possible that our legislative / legal climate encourages their "tactics" (loaded word... wasn't sure how to rephrase).

I missed your question when you posted it so here I am a week later trying to catch up.

In any inefficient system there will be a lot of players who find ways to profit from the inefficiencies. As the inefficiencies grow, those benefiting from them become more powerful and better able to fend off anything which threatens to hinder their way of life. Such is the case with health care in this Country. There are quite a few entities making huge profits because health care in this Country is a bloated and inefficient dinosaur. They certainly don't want to see that end.

That said, it appears to me that the insurance companies are the primary drivers of most of health care's ills at this time. There's plenty of blame to go around but, at this point, most of the shots are being called by the insurance companies and everyone else is largely going along.

I think one of the mistakes most people make in trying to understand why a system functions as it does is to anthropomorphize it too much. Large corporations are run by people but doesn't mean their motives should be personalized. One reason for this is that, as corporation grow, those running them become more and more detached from that which the corporation is supposed to provide.

I'm convinced, for example, that the CEOs of most major health insurance companies have the actuarial skills of an orangutang. Because of this, they have no way of knowing what a scam their business has become and have effectively convinced themselves that they make so much money because God loves them for all the good they do.

Most corporate boards are equally detached. In a publicly traded corporation this is especially true. Board members of publicly traded corporation usually have two primary concerns:

All other issues relating to lesser matters like what the corporation produces or whether that product is any good is dealt with by lesser people who are of little importance.

What's so ironic is that, whenever we're trying to understand what's happening when things go wrong, we go to the people "on top" to look for answers. Is it any wonder there's so much confusion and misinformation out there.

Do you think that US corporations are going to try and force their employees off company plans and into something provided by the AMA? I ask because I've seen my costs triple last year and this year I get a sir charge for covering my wife because she could get coverage from her employer.

I got behind last week so I'm just getting to your question now.

If corporations did find a way to stop providing health insurance it might be a good thing. If everyone is responsible for their own health insurance then the insurance companies are brought under greater scrutiny. I'm not saying this is the ideal situation but it might make things better than they are now.

It seems really really important that you prepare for meetings with people who have power, and it seems like you're going to need some very specific policy recommendations, no? What would those be?

My first one is this. I've already started working on it so will see how it goes.

This interview was transcribed from an "ask me anything" question and answer session with David Belk conducted on Reddit on 2013-12-07. The Reddit AMA can be found here.