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This one is pretty shocking, and I didn't realize until my mother got cancer right around her retirement age. It pushed her retirement date a little earlier than she had originally planned, which was a little annoying to her, but probably for the best. In any event, she asks me to help her look through some financial stuff, because even though she's normally pretty good with that sorta stuff, "chemo brain" is a bitch, as is just aging in general. When she was able to get on to Medicare was my first real exposure to how the system works, what it costs (I'm not even sure if I really had much of a grasp on which parts were truly free and which parts you had to pay extra for), what all the options are, etc. I shouldn't have been surprised that it had similar terms to normal health insurance, with things like premiums, out-of-pocket maximums, etc. What I was definitely surprised about was just how shockingly cheap it was, with incredibly low maxes. Like, simply insane. Like, better than the best monetary value I've seen out of even the top tier, most expensive insurance I've ever been offered by an employer, with premiums significantly lower than I've see out of even the bottom tier, most cut rate insurance I've ever been offered by an employer. That was when I realized just how massive of a wealth transfer the program is from young to old. It was also when I realized how the incentives worked. Out-of-pocket maxes so low that if you have literally anything happen to you in a year, then you simply do not even have to consider the price of any other medical service that you might think about consuming.
That's when it sort of clicked, why the large conglomerate that is managing her care has bundled in everything imaginable into what seems to be their "cancer package". If you can squint your eyes and think that it might be helpful for the cancer, for managing or recovering from the chemo, whatever, it's part of their package. They'll pay for Ubers to your appointments, every therapy under the sun (physical, occupational, mental, etc.), even your gym membership (at their extra fancy, extra expensive gym that just so happens to be a part of the conglomerate). Feel like you're not sleeping the best? We'll send you to some sleep specialists, do the full workup. Not fully happy with a rapid recovery of mental faculties from chemo? We'll give you some brain scans, a variety of tests, and surely, more weekly therapy of various sorts. The list goes on. It's a good thing that she's retired now, because she has basically a full-time job just managing and going to all of the myriad of possible appointments and offerings they provide in their neatly-packaged conglomerate, and all of the expenses can be justified in some way or another with respect to the cancer or side effects from the treatment, or something.
On the one hand, cool that she can get so much attention to get every month of vitality possible; I really do value the additional time spent with her, especially with her still being able to be as clear-minded and engaging as she is. Moreover, cool that she doesn't have to constantly worry about money. She hadn't really saved as much for retirement as she would have liked, and pre-retirement, I really got the sense that she was kinda constantly worried about it and how things were going to work out. Now that all the paperwork has been done and the numbers are on the table, she can see how it's going to work, that it's going to be okay, and that she no longer has to worry about it. On the other hand, hot damn, that means that she (and we, by extension) literally do not even have to think for a millisecond about a cost-benefit ratio for literally any possible option within their menu. From her perspective, it is all literally completely and totally free. There is not a single moment where she has to think, "How much tangible benefit do I think this is going to provide for me, and how much do I really value that benefit, to the point of being willing to give up some amount of my own resources for it?" If anything, the only thing that she trades off is just the time of going to the thing and doing it, but of course, she's retired now and has a lot of time in the week. So if she assesses that the tangible benefit has any decent probability of being literally any value more than epsilon>0, why not? How much does it 'cost'? Who knows? Who cares? It doesn't come out of my pocket. I personally benefit from this, because 100% guaranteed that if there was any real expense, she'd be leaning on me to help figure out what's worth it and how to make the finances work. A nice burden off my shoulders, too. I can see the 'cost' now, but damn if the incentives don't do their best at making me apathetic, just because then I don't have to think about that stuff.
A couple final scattered thoughts. First, there was a moment where I thought, "Damn, I don't always sleep the best, and I've had some recurring sleep problems before. It would be nice if I could get a full workup and see if we could fix it. But that would be suuuuuper expensive, and I don't know that I can justify it, given the solid probability that they're not actually going to be able to help me in the end even after I wrack up huge bills." And even some jealousy that she can just go do that for free. I also sort of wonder, society-wide, if we'd be serving our population's health and productivity better if we did stuff like figure out people's sleep problems and fix them when they're young and have many years for those benefits to accrue, rather than make it prohibitively expensive for most of your life and then free right near the end.
Second, I almost wanted to make an analogy to the public school system. People often joke that the school system is mostly a daycare, with incidental ability to help educate children, primarily for the purpose of freeing up parents from having to take care of them. It almost is like getting hooked into one of these big health programs while on medicare is like that. "We'll take your elderly parents, give them constant care, keep them busy coming to appointments and such, and make sure they're at least doing alright," and it's not that genuine medical care isn't there (like how genuine education is not absent from public schools), but that it's more minor or incidental. "We make it so that you don't have to worry about your parent most of the time," just like, "We make it so that you don't have to worry about your child most of the time." A useful service, yes, with some amount of real value, for sure. Like I said, I realized that I genuinely benefit from it in that way. But how effective is it? How costly is it? How efficient compared to possible alternatives? Who knows? Who cares? The bureaucrats and the unions and the conglomerates control all that and don't really want you to know the answers even if you did want to know. All the incentives are just about perfect, so long as the whole thing doesn't blow up spectacularly at some point, and so long as the schools aren't so ineffective that China eats our technological lunch and conquers us via warfare.
When my father got cancer was the first time I discovered a very imaginable gap: long-term care. This turned out to be only a hypothetical problem in his case (there wasn't such a long interval between "brain damage sufficient to prevent living at home" and "brain damage sufficient to prevent living" after all...) but it's something to think about supplementary insurance for, despite how complete Medicare coverage is for so many other costs.
That's not to detract from the rest of your excellent point, though. His last several months of treatment had a price (at printed value; who knows what fraction of that was real cost vs weird provider-vs-insurer negotiation ploys) that would have bankrupted him out-of-pocket, but that was nearly free with Medicare plus a little supplementary insurance. Of course he still fought for every month, when it just took willpower rather than a life's savings otherwise aimed at his grandkids' college tuition, but if he'd had to weigh price vs benefits himself I wonder if he'd have turned it all down. (if he'd seen the future I'm sure he'd have just picked out cheap in-home hospice care instead, but the trouble with those "most medical care expense is in the last year of life" statistics is that you don't know it's going to be the last year without seeing the future)
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