The dirty secret of the runaway prices in medical is that they are built entirely on bullying and extortion of anyone without council (insurance or other advocate). That seems wild until the second reason is known: emergency care cannot be refused to the indigent. This second point is actually the entire reason for everything. It has created a class of person, who abuses emergency service for general care.

Medical pricing, then, is a constant haggle and negotiation where most Americans aren't aware of it happening and don't participate in it. The hospital quotes you high-unto-unreasonable, and you look at that price and assume it's just the price, and then wonder why insurance payers don't go out of business. They don't because they ignore the bill and send them the only money they're going to get, and the hospital takes it quietly. That is not "price-fixing" in the monopoly sense, that is price dictation in the haggling sense.

My own experience in this was a surgery for my son. I examined every bill and watched the negotiation in real-time between my insurance and the hospital's many, many entities. Finally, when all was settled, there were some outstanding items that the insurance didn't participate in by their own election (not their purview because my coverage didn't include it). The hospital turned their Eye of Sauron on me and wanted immediate full gratification on the remaining items.

I had a phone conversation where I dictated my own terms to them, basically insisting on a pay schedule for the outstanding amount. They were unhappy and pushed back, and I said, "It's what's happening. The first check will arrive next month for this amount." Finally, after conferring out of my hearing they came back to the line with, "ok," and immediately hung up. I sent my checks as I'd promised, and they never contacted me again.

The extortion system can be fixed. Trump's attempt to mandate that hospitals post prices was a great first step in that, because it forces public competition and eliminates the haggling requirement of pricing being an individual affair. The reason the extortion system exists, can also be fixed, but that is a harder ask because we have 40 years of ER rooms receiving people with non-emergency problems who are up-front about the fact that they will not pay, and no ability to stop it. The hospitals have to squeeze money from payers to cover non-payers they can't refuse. Until that is addressed, this will continue to spiral.

I'm pulling nothing out of my ass. I'm not saying they ended up homeless. I'm saying they downsized to a lesser home.

You're right. I imagine some honest people (or suckers depending on your outlook) actually try in earnest to pay their hospital debts. Most people just deal with collections.

As a former poor person with no insurance, I can tell you that actually going to an ER is usually the last resort. The working poor who fall into the gray area between the dirt poor and the insured classes don't qualify for Medicaid and can't afford the premiums for any sort of insurance (Obamacare was/is a total joke).

Many so-called "blue collar" jobs either offer no insurance or bottom-tier insurance with huge deductibles.