Go to almost any business for a product or service, and you can expect to be told what it will cost you, or at least to get a plausible estimate. The big exception is medicine. You’re never told what anything will cost. If you press your provider, the best you’ll get is a spread of a couple of orders of magnitude. People sometimes get hit with huge charges that they weren’t prepared for.

I recently experienced a bit of this. My medical provider billed me for $630 for a routine blood test as part of an annual physical. This came as a complete surprise. I called the billing department, and the man who took my call said that I should have been billed only for the copay, with insurance covering the rest. He filed an inquiry on it, which he said might take a couple of weeks to process. This left a big question open: Do blood tests by my provider routinely cost over $600? That’s a lot, regardless of whether I’m paying for it or Medicare is. Since he was working for billing, he wasn’t able to answer that question.

I called my provider. None of the voice mail options included “to ask what the hell is going on, press …” so I picked one. With a long wait time, I opted to let them call me back, and they did within a couple of hours. The woman who called me couldn’t help with my question, but she’d have someone who might be able to help call me.

That call never came, but I got an email later in the day saying that all but a few dollars were being refunded to me. No explanation. No apology. Some people might think all they can do is swallow the cost, and most likely their improper charges won’t ever be corrected.

This is how American healthcare works. The basic problem is that the patient is, as they say about social media, the product, not the customer. Insurance companies are the customers. Providers assume that costs concern only the insurer. Given that insurance is directly involved in almost every transaction, it’s not an unreasonable assumption. Medical providers operate under different rules from other businesses, in practice if not in law. In some cases there are plausible reasons for this. A doctor may not know what your problem is until you’re anesthetized and cut open; they can’t ask your consent for the more expensive procedure. But most cases are more routine and can be priced. Certainly a blood test which is standard with every physical can have a standard price.

The reasons for this situation go back a long way. Once upon a time, employers were given a tax deduction for employee health insurance. Individuals in general can’t deduct their insurance (with certain exceptions such as self-employment), and personal medical expenses have strong limits on what can be deducted. This has pushed the economy toward medical insurance paid for by the employer. This puts two layers of indirection, the employer and the insurer, between the patient and the provider. These layers help to create the illusion of free money, so politicians like them, but insurance is part of what an employee costs the employer. When insurance costs more, it comes out of what the wages otherwise would have been.

Politically popular actions like insurance subsidies push the market even more into insurers’ hands. Some people want a complete government takeover of medical insurance, which certainly wouldn’t cover everything people go to doctors for and would further widen the breach between patients and providers. “Medicare for all,” you say? I’m on Medicare; it didn’t help.

What would help? Several reforms are obvious, but I have no hope our dysfunctional government will seriously consider them. Require transparency in pricing, on a par with other businesses. Fix the tax laws so that patients aren’t punished for paying directly rather than using employer-provided insurance. Eliminate state-line barriers to insurance.

Until any of that happens, patients will keep getting shafted.