I'm in March, reading your posts backwards and there's a clear theme emerging here: Handing over social needs (housing, healthcare, wage security, online sanity) to a financial system that doesn't care about social needs was never a good idea.
we can unpick all the reasons it doesn't work under a microscope, but the eco-socialists, and wellbeing economists have it right, as far as I can see. Neoliberalism failed.
Well spotted. We're building a foundation for specificity in how and why financialization has failed, but also how the mindset is in fact pervasive across business and government. Then we can explore a path forward that gives people back agency and ownership over these critical decision. :)
Thank you for describing what I’m seeing and feeling. Have there been any recent changes have helped give regular people a bit more transparency into costs or bargaining power?
So, there have been some promising developments over the past two years:
The Hospital Price Transparency Rule (effective 2021, enforcement tightened 2024) requires hospitals to publish machine-readable files of their actual negotiated rates. In theory this lets you compare prices. In practice the files are buried, inconsistently formatted, and most have no idea they exist.
The No Surprises Act (2022) is real. For out-of-network emergency care and certain scheduled procedures, you now have enforceable protection against surprise bills. This is the most tangible consumer win in recent years. It doesn't fix negotiated pricing opacity, but it specifically targets the "we can't tell you what it will cost" situation at pre-op. There's now a legal requirement to include a good-faith estimate for scheduled procedures. My own experience would indicate that this legal requirement hasn't percolated through much of the system, and it seems like a ton of healthcare professionals aren't yet equipped to actually provide these answers.
And the Inflation Reduction Act capped Medicare Part D out-of-pocket at $2,000/year starting 2025, and allowed Medicare to negotiate drug prices for the first time. But private insurance patients still face full exposure.
I also have friends working on startups that aspire to give patients access to AI tools that might level the algorithmic shooting wars. One of them was super helpful in editing this essay for technical accuracy.
But, and not to telegraph where we're going in American Dreaming too early, what hasn't changed is the fundamental architecture: employer-bundled insurance, opaque negotiated rates, prior authorization as cost control, and the fact that health insurers are structurally designed to work downward from their return on equity to the needs of their policyholders.
There's a giant governance gap here. We continue to address by attempting to "harness" the beast through complex regulation that can inadvertently makes things even more opaque and confusing. At some point we need to address why we've unleashed the beasts in the first place.
I'm in March, reading your posts backwards and there's a clear theme emerging here: Handing over social needs (housing, healthcare, wage security, online sanity) to a financial system that doesn't care about social needs was never a good idea.
we can unpick all the reasons it doesn't work under a microscope, but the eco-socialists, and wellbeing economists have it right, as far as I can see. Neoliberalism failed.
Well spotted. We're building a foundation for specificity in how and why financialization has failed, but also how the mindset is in fact pervasive across business and government. Then we can explore a path forward that gives people back agency and ownership over these critical decision. :)
Thank you for describing what I’m seeing and feeling. Have there been any recent changes have helped give regular people a bit more transparency into costs or bargaining power?
Great question.
So, there have been some promising developments over the past two years:
The Hospital Price Transparency Rule (effective 2021, enforcement tightened 2024) requires hospitals to publish machine-readable files of their actual negotiated rates. In theory this lets you compare prices. In practice the files are buried, inconsistently formatted, and most have no idea they exist.
The No Surprises Act (2022) is real. For out-of-network emergency care and certain scheduled procedures, you now have enforceable protection against surprise bills. This is the most tangible consumer win in recent years. It doesn't fix negotiated pricing opacity, but it specifically targets the "we can't tell you what it will cost" situation at pre-op. There's now a legal requirement to include a good-faith estimate for scheduled procedures. My own experience would indicate that this legal requirement hasn't percolated through much of the system, and it seems like a ton of healthcare professionals aren't yet equipped to actually provide these answers.
And the Inflation Reduction Act capped Medicare Part D out-of-pocket at $2,000/year starting 2025, and allowed Medicare to negotiate drug prices for the first time. But private insurance patients still face full exposure.
I also have friends working on startups that aspire to give patients access to AI tools that might level the algorithmic shooting wars. One of them was super helpful in editing this essay for technical accuracy.
But, and not to telegraph where we're going in American Dreaming too early, what hasn't changed is the fundamental architecture: employer-bundled insurance, opaque negotiated rates, prior authorization as cost control, and the fact that health insurers are structurally designed to work downward from their return on equity to the needs of their policyholders.
There's a giant governance gap here. We continue to address by attempting to "harness" the beast through complex regulation that can inadvertently makes things even more opaque and confusing. At some point we need to address why we've unleashed the beasts in the first place.
It was a choice.