US cities pay too much for buses

Not defending insurance but theoretically you do also get a better rate than the uninsured rate just by having it go through the health insurance.

I say “theoretically” because I’ve also heard they’re often willing to cut some pretty good deals if you don’t have insurance and pay cash. And I mean “good” relative to the initially billed amount, not “good” relative to what it should actually cost.

Yeah, I suspect this is very country and region specific.

In my country I don't have health insurance. I've noticed that medical providers charge me less on discovering that. Party (I suspect) because I'll pay immediately so there's no financial cost (ie cost of delayed cash flow) and much lower admin cost (ie they don't need to deal with insurers.)

In some places I've seen signs advertising 30% discount if you "pay now, claim back from your insurance yourself". This informs my hypothesis that providers see the insurance system as a major overhead.

No, it’s the opposite actually. There are a couple of reasons why:

1. You have a deductible. Insurance is incentivized to make things more expensive so you don’t use it. With a $10,000 deductible, are you going to pay $500 for a service outside insurance or $2,000 with insurance?

2. Hospitals really have no idea what anything costs. Nobody does. There is a maze if agreements between providers, contractors, hospitals and insurance companies. If you have insurance, hospitals are more likely to throw out a higher random number;

3. There is more process and paperwork for the hospital with insurance; and

4. You are more likely to be able to negotiate down a bill without insurance.

I was told it's also illegal in the US for a hospital to bill you as uninsured if you have insurance.

You won't get in trouble but the hospital will, but if they ask if you have insurance and you say no when you do, that could change the situation.

Again, I'm not a lawyer but this was they told me once a few years ago because I got charged a ridiculous amount for something and wanted to see if it would be cheaper if I just paid without insurance considering my deductible was many thousands of dollars.

This is correct. I have been in situations where I am told the cash price and then "I cant tell you how much it will be with your insurance". Come to find out cash was A LOT cheaper. They cant undo it.

I have also been in a situation where insurance price was cheaper.

Thereinlies the problem..without know the price people CANNOT make an informed decision. There is no freemarket. This done on purpose and only happens in America.

I always view the initial billed amount as the MSRP for a really shady industry.

While it’s often 2x-3x the allowed amount, I’ve even seen it closer to 20x-40x one — an amount for a simple outpatient procedure the would lead to financial ruin if it had to be paid in full.

I really don’t understand why there is any math in the initial amounts.

Why don’t they just bill $1M for every single item and then see what they get?

Every time I’ve gotten a large bill that hit my deductible, going back to the provider and asking to pay cash without insurance has resulted in a lower bill.