Why is it so opaque?

I think it’s a combination of factors — one that comes instantly to mind is that the various insurance companies involved in the system have more or less relative bargaining power to negotiate what they will pay on behalf of their subscribers certainly comes into it, which means that your doctor may not even know what they will charge you for procedure X until they know what insurance you have. (Which: is there any other industry that works that way?) There was also an interesting article recently in the New York Times about how the medical billing codes are being gamed on both sides to maximize profit.

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