Murder is only justified when it's your business model and behind numbers and profit margins in an Excel sheet are the real people you are sentencing to a lifetime of suffering and/or death.
A quick look at United Health's P/L shows a 6% profit margin. This does not quite support the popular rhetoric of a corporation in search of relentless margin (unless the argument is they are bad at it despite all efforts).
Very interesting, the insurance with the highest rejection rate where the medical spendings are twice the cost per capita compared to European average and the median age is younger, the insurance makes only %6?
What do you do so wrong? What is your mechanism of getting rid of those who provide you the healthcare at low efficiency and hight cost? In Europe we have elections and when those don't yield the desired results we storm the HQ and replace by force.
You can't be expecting that when too many people die the insurance company will lose customers and the shareholders will replace the top management, right?
They are required to spend 80% on actual medical care, add various administrative costs etc. and 6% sounds reasonable. Problem is that this incentivizes them to waste as much money as possible but the whole industry has to "agree" to do that for it to work. So that other insurance companies couldn't undercut them.
Aren't health insurance company margins capped? i.e. if they are required to spend 80% on medical care so effectively they can only make more money be bloating costs more and more.
It's better to waste $4.75 by maximizing the inefficiency and costs of the entire system thorough extremely overpriced drugs due to various nonsensical middlemen based market structures, administrative bloat etc. and make 0.25$ than to reduce premiums. Of course it still costs $5 to the society. It might actually be better if they had higher margins...
> the stock part doesn't impact the company's profit margin
It certainly does if you use GAAP. A lot of tech companies cheat by providing GAAP and non-GAPP figures (of course there are some other cases where it makes sense) to hide stock based comp.
... or that they have used creative accounting to come to that number.
Regardless, people who are debilitated by injury or illness aren't going to look at 6% and say, "well, jeeze, I guess these guys really are hard done by."
They're going to wonder why something that costs them tens of thousands of dollars a year (health insurance premiums) isn't paying for a medically-necessary procedure, profits be damned.
All public companies, especially of this size, have their financial statements audited. Of course, shenanigans still happen but I haven't heard any credible claims regarding UNH just yet. More importantly, corporate hanky-panky is almost always designed to boost revenue and margins and not lower them so I am willing to bet the numbers here are trustworthy.
> profits be damned.
But, profits cannot be damned, at least not if you plan on being a going concern. At some point, the companies need to make a profit otherwise they go out of business and cannot provide any healthcare at all.
My point is not that UNH is a sterling example of healthcare service but to point out that the narrative justifying the public outrage is not really logically coherent or supported by evidence. If there is no public healthcare service, you will need to have private insurers. If you have private insurers, they will need to make profit. The best you can do in this situation is make sure there is competition so the profits are not out of line (which seems to be the case) and there is minimal waste in the system (jury is out on that one).
Also, public healthcare is not the panacea that it seems to be promoted as. Healthcare is expensive and at some point, limits will be placed to avoid bankrupting the system. Take a look at any number of the systems of any number of European countries and see the wait times, approvals, etc.
BTW, I support the idea of a government provided healthcare system, but I just don't think it will solve all the problems the way people seem to think it will.
> But, profits cannot be damned, at least not if you plan on being a going concern. At some point, the companies need to make a profit otherwise they go out of business and cannot provide any healthcare at all.
More than a handful of the BCBS health insurance companies run as non-profits. Other countries find a way to make it work without shoveling money into the gaping maw of retirement and pension funds. Hell, even profits are fine. No one expects the people at these companies to work for free. They just expect to receive coverage when they have it deemed medically necessary by a doctor. If that means that c-suiters make a max of $500k a year and that the institutional investors have to kick rocks, that's what that means.
> My point is not that UNH is a sterling example of healthcare service but to point out that the narrative justifying the public outrage is not really logically coherent or supported by evidence.
We have type one diabetics rationing their insulin to the point that they die, while the people who run the companies that are supposed to help cover the price of said insulin make millions of dollars in compensation per year. The American male has a median lifetime earnings of $1.8 million. This isn't logically incoherent or not supported by evidence; if you have a pulse and have looked at American news over the last 15 years, you'll have seen stories about people being screwed by their insurers, sometimes to the point of literal death.
> If you have private insurers, they will need to make profit.
See above.
> Also, public healthcare is not the panacea that it seems to be promoted as. Healthcare is expensive and at some point, limits will be placed to avoid bankrupting the system.
No one's suggesting it's perfect, just that it's better than having profligate executives and major shareholders insult your intelligence by telling you they just don't have the money to cover your claim for prescriptions and necessary procedures after you paid the cost of a decent used car in premiums over the last year. Even wait times seen in socialized systems could be tolerable to those who otherwise would not get to see a doctor.
I don't think a government-run health system would solve all problems either but it would address a lot of problems re: access, affordability and having a health baseline. Obviously doctors, nurses, supplies, etc are a finite resource and so they can't see everyone all at once so you have to prioritize based on need and severity. I think that's fair compared to... prioritizing based on who can pay.
Why can't US pretty much just directly copy-paste the entirely private (more so than in the the US since there are no Medicare/Medicaid equivalents) Dutch or Swiss systems, though?
If a government-run health system is such a contentious issue... turns out privatized healthcare can work just fine if there is sufficient regulation.
The US did essentially copy and paste the Swiss system. That's what the ACA was modeled after.
It left out a few key bits though - like requiring those who sign up for healthcare backpay premiums for the entire period they were uninsured to whoever they sign up with.
Also AFAIK drug prices are fixed nationally and negotiated by the government?
Then the basic plan is around 300-400 CHF (regulated by the government) and the deductibles are capped at CHF 2,500. This seems to be covering the overwhelming majority of costs (if we exclude government + cash) since the volume the market for premium/supplementary coverage seems to be pretty small (<20%):
> there is minimal waste in the system (jury is out on that one).
How could that be? Unless that's sarcasm..
I mean the US government alone (so excluding all private spending and insurance companies) spends more on healthcare per capita than many European countries which have universal healthcare.
Switzerland has a pretty much entirely privatized healthcare system (in theory too a much higher degree than the US) which is (relatively) well regulated. Also considerably higher median salaries and GDP per capita (albeit disposable PPP income is quite a bit lower) yet they spend 35% less on healthcare than the US.
My understanding is a lot of difference in healthcare spending in Europe v USA can be explained by the cost of pharmaceuticals and the fact that we have fancier (read more expensive) stuff.
The pharmaceuticals pricing is due to the factor that pharma companies believe they can charge higher prices in the US than anywhere else so the US consumer effectively subsidizes the rest of the world. I'm not sure how to solve this problem in a way that lowers prices AND maintains availability of the drugs. The obvious solution is to demand that pharma companies lower prices in the US, but (assuming they are unable to increase prices in Europe) this will just lead to some (many?) drugs not being profitable and reducing availability of drugs for all.
As for the fancier stuff, we do want to have fancier stuff. That means you get better healthcare outcomes for some pretty sick people. We should not want to cut that out. We're in trolley experiment territory when you start discussing whether it is better to have a life-saving, but expensive, procedure available but not everyone can get it because of cost or to not have the procedure available at all for anyone.
There is absolutely 100% of the same stuff used in the US, just fancier names.
Other countries reduce cost by having the state negotiate instead of many small insurance companies all negotiate separately. This is why other countries get a better deal because they offer a larger base of future sales.
Don't the Swiss also have very fancy stuff, though?
But yeah, drug pricing might be a significant part. I'm not sure about the reduced incentives for pharmaceutical companies, though? From what I understand the system is very inefficient, there are a lot of middlemen (i.e. waste) involved and price discrimination going on so a lot of that money might not necessarily be going to the drug companies doing the research.
Cynically, this sounds to me like something that people typically suggest we leave up to markets. Is that insane? Yes, but it's already a business model, and health insurance basically does that.
These people make vast sums of money every year by asking the American people what it's worth to them to not be ruined by a chance illness or injury, then finding ways to make sure they don't have to save people from financial ruin or death. I don't see how that's really so different from a protection racket, except for the fact that most protection rackets were operated with more good faith effort towards the extorted.
>These people make vast sums of money every year by asking the American people what it's worth to them to not be ruined by a chance illness or injury, then finding ways to make sure they don't have to save people from financial ruin or death. I don't see how that's really so different from a protection racket, except for the fact that most protection rackets were operated with more good faith effort towards the extorted.
This definition of a "protection racket" is a bit loose. By similar logic landlords are also a "protection racket" for having a place to hive.
> This definition of a "protection racket" is a bit loose. By similar logic landlords are also a "protection racket" for having a place to hive.
“As soon as the land of any country has all become private property, the landlords, like all other men, love to reap where they never sowed and demand a rent even for its natural produce.” - known Marxist-Leninist Adam Smith
I was thinking the same thing. Oh and why stay in the healthcare vertical? Surely the CEO and employees of Raytheon deserve to be shot in the back leaving a hotel. What a ridiculous set of conversations…
Most of those people are making several multiples the average Indian's lifetime earnings. Should those call center folks pay for the Indians' healthcare?
That's a cop-out. Just as the CEOs could transfer their higher wealth to average Americans, average Americans could transfer their higher wealth to Indians without changing or giving input on their healthcare system.
(which is absolutely not universal in any OECD-country sense)
I didn't say the consequences should be proportional, I said the responsibility (or blame); and profits derived should just be one part of the equation.
Criminal consequences of a company collectively being responsible for the deaths of individual(s) shouldn't just disappear because no one individual ostensibly caused it. A company is a system of incentives and processes, and if those incentives and processes are leading to preventable deaths and suffering, those who benefit most from and are most responsible for perpetuating those incentives and processes should be held liable.
While I have trouble wrestling with the assertion as well, it does hold pretty true to the way the US justice system works. Sentencing is generally far harsher for financial crimes as $ goes up.
In stuff like drug crimes, US even has the death penalty as sanctioned remedy for quantities and enterprises of sufficient organization for mega profits. The thought process seems to be if you provide bad health care in the form of selling illegal drugs, at some level the death penalty is on the table.
>While I have trouble wrestling with the assertion as well, it does hold pretty true to the way the US justice system works. Sentencing is generally far harsher for financial crimes as $ goes up.
Right, but only for financial crimes. You're not going to get off murder by saying you only got $100 for the hit.
If you sell a few hits of fentanyl you aren't going to meet the statutory definition of a criminal enterprise and therefore will not be eligible for federal death penalty even though fentanyl induces death.
If you sell $100M of fentanyl you can get the death sentence, since fentanyl is an element in inducing death at basically any sufficiently large quantity of a criminal enterprise.
It is not exactly the same, but it has a lot of parallels to the argument I see here. If you are an insurance salesman selling contracts you know will not be honored and such denied claims will be an element of death, many will not see it as serious as being the criminal enterprise leader who orchestrated it. Even in such case that the policy can be attributed to a single salesman, the executive is likely to be held more culpable just as the US code holds the criminal enterprise executive to the death penalty whereas it may not hold the low level guy who sold the fentanyl.
The government has had a very hard time classifying what type of crime drug dealing is. First they said it was a tax crime (well before that, an import or tariff crime). Then the 10th amendment was basically gutted, and it became a crime where all the facts could be identical to a pharmacy dispensing a script, but sans paying for a DEA license.
It is definitely a very strange one. The classical liberalism argument is that the most prominent aspect remains essentially a financial crime of failure to pay the licensing tax.
>and it became a crime where all the facts could be identical to a pharmacy dispensing a script, but sans paying for a DEA license.
That describes a bunch of crimes? If you raid a drug dealer's house and kill a bunch of people in the process, you'll go to jail. If it's the police doing it with a "license" (ie. a warrant), it's suddenly fine. More banal is you driving along, following all applicable laws and causing no issues, but if you're doing it without a license or insurance, it's suddenly illegal.
Yes of course. All of this seems to me totally psychotic and not at all a dystopia I want to live in. Which is why I lived in an area with almost no government, very weak police services, little to no code/zone enforcement, weak environmental controls, etc etc.
I pointed it out largely because I find the drug laws to be particularly strange.
Financial crimes are literally crimes that deprive people of their financial property. They are crimes because property is understood to have utility. This isnt rocket science.
Under me is 1000 salesman. Every salesman knows and understands I am selling a plan that will deny or delay for some covered minor ailments that once in a million set off a chain inducing death.
As CEO of ICI I collect $300M in premiums and from that take $3M.
After selling a million policies, a patient dies as a side effect of intentional strategy of denying authorization to pay for care. That plan is traced to going through a single salesman, who collected $5 from that sale and $50k in all his sales. From that same sales, I, the CEO only collected $1. That is, the dollar profit for the death is greater for the salesman than the CEO.
The salesman and I are both direct paths in the death, in fact the salesman more than me, hell the salesman even made more of a commission than I did. The public will likely hold me more in contempt.
My point is he (CEO) is viewed by many as most culpable for fraudulently denied claims at UHC -- and there are crimes, even non-financial ones like drug dealing, that tightly couple level of organization and sales of a product to differences in penalty for even a singe death. That is, this line of thinking is embedded in the USC.
The contrarian view is that drug dealing is a financial crime of not paying for the credentials of a DEA license, or that fraudulently denying medical claims is a crime of criminal negligence resulting in bodily harm.
As for where I started, my initial comments involved both financial crimes and drug dealing. Most but not all probably consider insurance fraud as a financial crime but one that some can only atone through vigilantism. The line to me on all accounts looks blurry.
I would seriously wonder how much you understand about proportions given the average nurse makes about 00.000002% of the $4.5 trillion in annual health care spending in the USA.
I also didn't say that should be the only factor. Clearly proximate responsibility for the relevant decisions should be (and already is) part of the equation.
That's the scary part. It's very tempting to just sentence someone like this. But more you dwell on it, the worst it gets. There is a reason why death penalty is considered an extreme.
The entire argument for high CEO renumeration is that they take on total responsibility for all actions of the company. The buck stops with them. So, why do we think it's acceptable for that not to be the case when the company does something bad?
Thats a good argument in a vacuum. But the world has determined "I was just following orders" is not a good defense.
We know the crimes against humanity are bad and subordinates are guilty if they do them. We don;t just let everyone off free except the head of state.
Not to see that united healtcare (as bad as they are) are anywhere near that, but I am saying that its clear that we, as a society, already hold all people complicit in evil as guilty. Not just the person at the top.
We don't need to know this exact number to know that American patients are getting uniquely fucked by their healthcare system compared to every other developed nation. Once we're on-par with what other countries achieve, then we can have the philosophical debate.
This is a purposefully disingenuous hypothetical. There are people who have real shots at a better life, or continuing their life for that matter, who get denied the insurance they pay for! It isn't only people who are already on death's door.
The thing is, you have to start somewhere and then you can go backwards. And putting a price on what people should shoulder for other is the main job of insurance companies.
Now you can hope for a state owned one which would have "everyone" chipping in so you should be able to cover more extreme cases. Or you can (and should imo) criticize the algorithms used by the current companies. But you cannot expect society to pay for anything, you have to do some triage.
To your point, there is a concept called "social murder" [1]:
> When one individual inflicts bodily injury upon another such that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder. But when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live – forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence – knows that these thousands of victims must perish, and yet permits these conditions to remain, its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission. But murder it remains.
We can compare this to, say, all the people involved in the death camps in Nazi Germany. Who exactly is culpable for murder? Ther person dropping the Zyklon B? Or were they just following orders? The camp commandant who gave the orders? Or were they just following orders? What about the camp guards? What about the train operators? Those who maintained the trains? Those who built and maintained the camps? Those who loaded the trains? Those who detained Jews and other "undesirables"?
In the case of death-by-denail of health coverage, there are many hands involved (hence "social murder"). Personally, I don't blame the people who man the phones, for example. They are coerced into a job. But someone is responsible and you can make a reasonable claim that the CEO fits that bill. Where you draw the line between those two is another question. There are no doubt people working at United whose job it is to come up with creative ways of denying claims. Their bonuses are probably tied to it. You can make a reasonable case that they're aware of the consequences of their action. Are they culpable too?
Additionallly, people tend to view violence as violence or not depending on who does it. Like tossing tear gas cannisters at protestors is not violence but throwing the cannister back is [2].
UHC has one of the highest rates of claim denials. Sure, there are some people getting the support they need but there are a lot of people who are not. What justification is there for that? The only justification is "profit", and that is not something that should ever be involved in healthcare.
It should be noted that not all claims denials mean people aren't getting the support they need.
For example I had an insurance company not want to pay for a particular prescription drug my doctor prescribed. They were happy to pay for treating me, but they wanted it be done with some other drug.
They actually had a medical reason for this. The drug I had been prescribed had recently been found to have a risk of bladder cancer. There were other drugs just as effective but that did not have that risk and so they had removed it from their formulary.
In this case I wanted the first drug because I had used it before and knew that it worked well for me and that I didn't get any of the numerous annoying side effects that it and the alternatives could all have, and I had good reason to believe that I'd only need to be back on it for a month or two and then would be permanently done with it.
I concluded that the risk of bladder cancer from a couple months of the drug were negligible and preferable to dealing with drugs I'd never had before.
My doctor probably could have convinced them to go ahead and approve a one month subscription with the possibility of one refill, but I realized the drug was one of the ones that Walmart had on their $4 drug list and so had my doctor send the prescription there and I bought it for the cash price.
BTW, that $4 cash price at Walmart was cheaper than what I would have paid if my doctor had convinced the insurance to cover it and I filled the prescription at my regular pharmacy.
Health insurance companies are also legally bound by payout ratios. Having a higher denial rate doesn't mean they're paying out less money than other companies.
I think this is a bit of a naive take. First off I agree 100% that their employees are not deserving of death so let's get that out of the way here. I'm not trying to argue that murder here is justified.
But the take that purchasing insurance is a simple two-party agreement of willing participants who have options to go elsewhere is just purely naive. This is not a simple financial product like buying life insurance or car insurance or fire insurance for your house where you go shopping and buy or don't buy.
In the United States, there are just no other choices. You get health insurance as part of your employement (typically), which is insane on the face of it. The government (basically) does not provide health as a service, even though it would seem that health is as fundamental a service as it gets.
Health Insurance companies are for-profit entities whose absolute incentives are to maximize financial return to their shareholders, not maximize health in their policyholders. And whether they say it explicitly or not, the way you maximize financial return as an insurance company is take in more money than you pay out. And in situations where you have some amount of leeway over whether to pay out or not, the way you do that is try to pay out as little as possible and deny claims as much as possible. That's just pure logic.
This is not "did your house burn down" or "did you car crash" or "did you die" binary type of stuff with typical insurance. This is nuanced decision-making, all with an overarching goal is maximizing financial return and minimizing claims paid. Period.
While a specific person at a health insurance company may not be evil, and while the business itself may not be evil, the net result of the entire end-to-end system can absolutely be quite evil.
Again, the default state of the world is "no insurance or free healthcare at all". You absolutely have a choice – to not buy health insurance and always pay for your own healthcare costs.
The result of health insurance is that people who could otherwise not afford to pay their own healthcare costs frequently can (but not always, when claims are denied). In turn, people who are healthy (and lucky) subsidize those less fortunate than themselves. This is not evil, this is good. This is something humans have invented to make us stronger as a collective.
You can argue that a society should do more to proactively provide healthcare so that you don't need a private health insurance system, but that doesn't then make the private system bad.
Why should the rates always be the same? Different insurers can make different decisions about who they insure and what they insure and how they insure. This would (entirely reasonably) result in different rates of claims and whether or not they are accepted/denied.
Ahaha, yeah, right? It's just ridiculous. What a laughable debate, this whole insurance thing is. It's just the free market working to optimize outcomes.
By the way, can you help me understand what a 'pre-existing condition' is?
Literally nobody outside of America has experience with this term.
Most health insurance in most of the world has the concept of "pre-existing conditions".
How could it be otherwise? Insurance was invented to hedge risk. In the case of healthcare, if you literally already have a condition that has known and ongoing costs associated with it, it doesn't make any sense for an insurance company to insure you against that risk – the risk has already manifested.
No, that's not right. Public health insurance in the EU does not use that concept. Participating insurance companies are not allowed to set rates that way, since it doesn't serve the public good.
Only since the Affordable Care Act (“Obamacare”). Before that, it was common to not be able to get insurance with pre-existing conditions at all without being covered by your employer. And even sometimes your employer’s plan had a waiting period for pre-existing conditions. I got stuck without insurance for a long time after college (being able to stay on your parents’ plan after graduation is also an ACA provision) and still have nightmares about it.
You’re implying the situation is as stable as it is in other first-world countries. It’s not. It’s brand new, and Donald Trump has sworn it’s going away.
With respect to pre-existing conditions, it is equal treatment. I don't know what you mean by stability. I'm just reiterating the current state. Policy in other countries is also contingent on government policy and subject to change. Any alternative would be new too.
Plenty of people outside the US will have experience with pre-existing conditions as a factor in health insurance.
For example many Germans will have experience with it because they have a system that has both a public and a private system. Those with high enough income (around 70k Euros) can opt out of the public system and use the private system instead. Also there are some classes of people that only can get part of their coverage from the public system and so need to buy additional coverage through the private system.
Insurers in that private system can take into account pre-existing conditions. They cannot reject an application over pre-existing conditions but they can charge higher premiums because of those conditions.
Another example is Switzerland. They have a universal healthcare system based on mandatory insurance from private health insurance companies. For that mandatory insurance pre-existing conditions are not a factor, but there is also supplemental insurance available that covers things not included in the mandatory insurance.
The supplemental providers can and do consider pre-existing conditions when deciding whether or not to provide coverage.
Only a “laughable debate” and “just the free market” if you haven’t actually had to deal with these insurance companies when you have a health issue and have never paid your dues late. I’m guessing you’re from somewhere in Europe with universal health care?
I'm foreign to the US and no longer work there (Thanks to Trump, literally and directly.)
While I was there... I literally worked for an insurance company. I have also done work for a pharmaceutical company.
The motivation in healthcare in the US is purely profit. It is not like that anywhere else in my experience.
At the very least, it's the charge of the insurance company to serve the customer in a way that passes on savings to the customer in the form of lower premiums or increased amounts of care.
It's insulting to a person's intelligence to tell them "we just don't have the money to cover the surgery recommended by doctors to solve your debilitating injury or illness" and then turn around and give your c-suite seven-figure compensation packages every year while also instituting a dividend for the free riders known as shareholders.
I think most people would say that Switzerland is a "healthy society", yet:
>Switzerland has universal health care,[3] regulated by the Swiss Federal Law on Health Insurance. There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country)
I would prefer to live in a society that puts the well-being of its people over fretting whether someone is getting a "free lunch" or worrying "how will we make money off of this?" The US is so backwards, we spend so much money on healthcare for the worst impacts in the world, and we pump billions into our military blowing up people abroad. A healthy society would spend that money into taking care of its people, and that includes providing healthcare for everyone no matter the cost.
I bring the military budget up just as an example of how the priorities of our society, or our government rather, are completely backwards imo. One reason why we haven't "figured it out" is because health insurance companies effectively lobby the US govt to secure their monopoly. They know that we just got rid of the middle man that is insurance companies, we'd spend less money and get better care.
I am happy to bear the cost of providing care. I am NOT happy to bear the cost of the huge profits generated by the U.S. healthcare system. Insurance companies are increasing profits by denying care.
A separate issue is consolidation. In my area, what used to be locally owned clinics and hospitals are being bought up by national conglomerates. Their first move is often to reduce staffing and cut costs, driving up delays and driving down quality of care.
Actually, I take that back. If we think of a "free lunch" as something that isn't earned, the only free lunch here is the one that shareholders (which includes the c-suite given their share grants in the compensation packages) receive quarterly in the form of dividends and earnings-per-share. When you take someone's money (usually $200/month or more... much more actually), find every single excuse to not provide a service a doctor of medicine has declared to be necessary, and then pay yourself more money than most people would even know how to spend in a lifetime, you're pretending you're entitled to a free lunch.
The Health Insurance for my wife, two children, and myself is _$1500_/mo and that's _with_ a $20,000 deductible.
When I started working ~25 years ago, my health insurance was typically fully covered by my employer and I had no deductible that I was aware of. The cost of insurance has only gotten worse, and finding a plan without a outrageous deductible adds to that.
As a society, this is something we can totally solve. So many other countries have socialized healthcare. Its not an impossible goal.
Really? My son hurt his knee on the job, workman's comp paid for him to get an MRI and a pretty detailed workup from the orthopedist, a brace that the orthopedist told him not to wear, etc. The advice in the end was "rest" and "return to activities gradually".
My insurance pays for a colonoscopy every 5-10 years, telehealth therapy appointments with no copay, free vaccinations, really a lot of stuff.
I'm not going to disagree that its expensive but I'm not going to say that it is low quantity or low quality.
If the US does worse on population health statistics than other countries do it is not the fault of our healthcare system but rather the fault of social determinants of health such as social disconnection, inequality, etc.
> If the US does worse on population health statistics than other countries do it is not the fault of our healthcare system but rather the fault of social determinants of health such as social disconnection, inequality, etc.
I pay national insurance every month, its automatically taken from my salary. Most of the time it pays for other people's care - and that's absolutely fine with me. And if at some point I need care, I know it will be there for me and how much money I have won't come into it, the costs of my care won't be weighed against the value of my life, i'll just get the care I need. It doesn't need to be so expensive, the US has just built such an incredibly inefficient system ( or efficient if you accept it is designed to generate outrageous profit from the suffering of humans).
For-profit health insurance is the ultimate rent-seeking industry. They provide a net-negative to their customers, scraping profit off the transaction between a patient and their care provider.
One of the rhetorical devices I despise the most is what I'll call "stranger in a strange land fallacy", the idea that we should re-litigate the most basic questions at the most basic level over and over and over because people think they're the main character on the debate channel on TV.
This is a take that lacks any nuance and it doesn't even pertain to what anyone said. Typical for conservatives.
No one is saying we need to provide healthcare for literally $0 and pretend it has no costs. No, most realize our current cobbled together system with middlemen everywhere isn't working and it's costing lives. Why we can't have a single payer system that gets rid of the paperwork and makes it easier to bargain against prices is beyond me.
Sure, let's keep this system where you have to worry about in/out network hospitals, jump through a bunch of hoops to get treatment, and middlemen causing prices to surge. Madness.
Ever done any work for a US health insurance company? You won't find many conservatives. You will find many "free lunch" advocates who spend half their day lobbying to protect their job and their industry. They are playing politics with your healthcare costs. How is that for nuance?
It's great and even more reason to get rid of these useless corporations. The conservative thing to me was the basic take "ummm actually it's not free" which lacks any actual thought. It doesn't further the discussion and perpetuates the suffering all to... own the libs? I'm not sure.
The "libs" who lobbied for so-called universal healthcare? They further empowered these corporations and now they want to get rid of them. The libs owned themselves on this topic, obviously.
The ACA was substantially watered down to get (conservative!) Lieberman's deciding vote in the Senate. "The libs", as always, were told they'd have to wait later for their stuff.
What if this entire sector just didn't exist and the money paid out to health insurance secretaries and janitors who clean their offices and the people in the accounting department who handle their salaries just went into paying for actual healthcare instead?
Like isn't the entire sector just inefficient bloat? What value does it provide that can't be provided much more efficiently?
> What if this entire sector just didn't exist and the money paid out to health insurance secretaries and janitors who clean their offices and the people in the accounting department who handle their salaries just went into paying for actual healthcare instead?
What is the purpose of a medical license then, if insurance can step in and deny the procedure? Who is right? I think dissolving insurance altogether is extreme (I agree but don't want to waste time on pie in the sky ideas).
Why can't we start by removing insurances ability to deny anything from a licensed doctor? If doctors are padding their wallets or stealing, bring it up with the board of medical examiners or court just like any other malfeasance in any other regulated industry. If you are board-certified in X it means you are entrusted to do X. Insurance should never be involved.
You're still paying the same people the same wages to work for the government.
Or is your solution that we should pay health insurance workers less money?
You originally proposed eliminating all the jobs. Now you've moved all the jobs to the public sector. So unless you're paying them dirt, all that money is still going to people working to make sure healthcare fraud isn't 80% of GDP.
In a perfect world, you have 6% more money to spend on healthcare instead of corporate profits.
That's not going to change the picture that much.
And you're unlikely to arrive in a perfect world.
You'll probably get a 10% more expensive system that's 9% more inefficient and has 0 profits.
Canada isn't hypothetical. It is very easy to compare costs and outcomes.
I live in BC, Canada, and we don't have an entire industry built around claims processing, administration, etc. They still pay health care workers, but they don't have to have phone banks filled with people answering questions about claim denials. I'm not even sure if a claim denial is a thing here, or who I would call. We don't have healthcare insurance CEOs making 23mm per year. We don't have customer service reps, we don't have billing specialists in every medical practice, we don't have medical coding experts. These things kind of exist in a bare minimum way, but not anywhere at the scale that I have seen in the US.
I go to the doctor, they make a medical determination about what my needs are, and we proceed from there. There is almost no fraud because the doctor has no real financial incentive to overtreat me, and since it is a single payer system, malicious patterns get picked up quickly and efficiently.
Keep in mind that each province administers their own medical system, so there is no such thing as the Canadian health insurance system.
> They still pay health care workers, but they don't have to have phone banks filled with people answering questions about claim denials. I'm not even sure if a claim denial is a thing here, or who I would call.
The Canadian system may be much cheaper to administer, but it isn't magical. There is still a need for staff to administer and adjudicate claims, and you still have to ration limited healthcare resources somehow.
Notice how all of the things that you found represent a single department in the provincial government instead of a significant part of national GDP spread across multiple billion dollar conglomerates.
The first link you submitted is actually showing how the automated system processes the huge majority of claims automatically without people in the loop. So not a good argument that BC has phone banks of people answering claims questions.
Yes the claim process exists, and the various appeals parts exist, but that part of MSP is just not the patient's problem. If you read through the reasons for denial that you linked, almost all of them are requests for better paperwork or missing information. The level of administrative overhead just doesn't exist on the scale that I have experienced living in the states.
What I have never had happen, or heard of happening, is a resident getting a bill for seeking medical care (which would happen if a claim was rejected). Or someone not receiving medical care due to inability to pay. Or having to doctor shop for a place that accepts their insurance. In fact, most people I know have never even had to contact MSP.
>The Canadian system may be much cheaper to administer, but it isn't magical. There is still a need for staff to administer and adjudicate claims, and you still have to ration limited healthcare resources somehow.
But it isn't just the Canadian system -- it's every other system too.[0]
There is a unique form of corruption occurring in the American health system and it is absolutely tied to the insurance industry.
This corruption causes the misallocation of resources in ways that are detrimental to the health of American citizens.
Medical bankruptcy and the cost that it has on a person's health isn't really a thing in Canada. Having to choose between paying for medical bills or healthy food isn't really a thing in Canada. People putting off minor medical issues until they grow into major issues because they can't afford routine checkups or treatments isn't really a thing in Canada.
This results in far less rationing of healthcare because people are able to make better choices that prevent the waste of medical resources.
Don't get me wrong, there are issues with Canadian healthcare -- the biggest being corrupt politicians and business people trying to import American healthcare practices for their personal gain but the issues that the average Canadian face in accessing healthcare are nothing compared to those that the average American faces.
> There is almost no fraud because the doctor has no real financial incentive to overtreat me
The vast majority of healthcare fraud does not come from corrupt dentists convincing you to get root canals you don't need.
The largest source is billing for services not rendered.
That is: some provider just makes up that you came to see them and charges the insurance company and you don't even know about it.
This is a non-trivial problem to solve.
Even in the NHS in the UK - where the entire system, including the providers, are public - there is STILL a large billing for services not rendered problem!
This seems trivially solvable. In BC, Canada, I had an old doctor renew a prescription over the phone. This must have triggered a fraud alert because my address was now in a different health management district. They sent me an automatic notice asking me to confirm that I had been helped by that doctor at that time. I believe I can also log onto a provincial portal and see activity related to my medical care.
Seems like a pretty low cost way to ensure that no fraud is happening. Set up triggers for confirmation like doctors treating people who don't live nearby, treating people who are concurrently seeing other doctors, or any number of other known fraud alerts, and follow up.
Since private practice isn't really allowed here, getting removed from the provincial insurance program means a career death sentence, so I think that it just isn't that big of a problem anyway.
I'm not a citizen of the UK so I can only speculate from a poorly informed position but I would imagine that it has to do with the starve the beast tactics that are being used to weaken the NHS to make it more susceptible to privatization.
I've proposed eliminating those jobs because they're bullshit jobs that have a net negative contribution to society because the American medical system is hopelessly inefficient and corrupt.[0]
It is a curious thing watching people defend the undefendable. What makes you so confident in this system that so many Americans loathe and feel betrayed by?
Because (1) most Americans are satisfied with their healthcare and (2) the CBO doesn't think that a public option would decrease costs much if at all: https://www.cbo.gov/publication/57125
"Hollywood accounting" only works because you're transferring the profits of one enterprise (ie. the movie itself) to something else (ie. the production/distribution company). Unitedhealth Group is a publicly traded company. Where are they funneling the profits to?
> The FTC’s administrative complaint alleges that CVS Health’s Caremark, Cigna’s ESI, and United Health Group’s Optum, and their respective GPOs—Zinc Health Services, Ascent Health Services, and Emisar Pharma Services—have abused their economic power by rigging pharmaceutical supply chain competition in their favor, forcing patients to pay more for life-saving medication. According to the complaint, these PBMs, known as the Big Three, together administer about 80% of all prescriptions in the United States.
What's the best way to solve the engineering issue of high load on any given system?
Reduce or eliminate the load.
Of course insurance will reduce their load with tactics such as deny, deny. But systemically, there's a better, good-faith way.
IMHO, without getting into all the nitty gritty details, the good-faith way to improve a ton of healthcare is to extend the efforts of fortification in common foods, expand people's consumption of healthier foods (more plants that provider fiber + minerals), improve people's abilities and motivation around healthier lifestyle choices (exercise, sleep), and significantly reduce or re-engineer illness-causing agents (plastics, VOCs) in our daily lives.
The challenge is how to implement these things in a balanced and sustainable manner, while keeping most industries relatively happy. Of course this would take a decade or more, but the knowledge is out there from some very competent healthspan PHds/MDs and a variety of scientists.
In my personal opinion, if all we did was increase consumption of sulfur, protein (especially collagenic sources), we would improve a tremendous amount of health outcomes drastically. Asian countries are a great example where the food actually has sulfur and collagenic sources built into their culture. Koreans consume cabbage 3x/day (cruciferous veggies with sulfur) and traditionally consume a bone-broth (collagenic) type of soup with 1-3 meals on the daily. I could outline the science here, but a huge amount of chronic illness, such as the shooter's mother may have seen some relief with some of my aforementioned efforts.
The way we can take for granted iodine deficiency because they added it to salt, we really need to do that for others. Omega 3s within milk these days is also a good path forward.
> If you take the CEOs salary and distribute it to healthcare patients, $50M worth of healthcare is not going to even minutely move the needle.
I have a hard time buying this. Really? You can't cover a few more cents of a few more claims if you reduce c-suite pay?
I don't pay my premium to just see it go directly to the c-suite and some retirement fund's coffers. I pay it to cover healthcare costs and to keep from being financially ruined by a chance illness or injury.
If the CEO is making a half-million a year and his company is coming to me telling me that there just isn't any money to cover my back injury surgery, they're negotiating in far better faith than if they're paying him ~5x the median lifetime earnings of the American male each year, every year.
>>$50M worth of healthcare is not going to even minutely move the needle.
>I have a hard time buying this. Really? You can't cover a few more cents of a few more claims if you reduce c-suite pay?
Nice job moving the goalposts from "moving the needle" to "a few more cents of a few more claims". UnitedHealth Group had 371.6 billion in revenue last year. $50 M means they can provide 0.01% more care to their customers. I think it's fair to describe that as "not going to even minutely move the needle".
The numerator might so up but so will the denominator, so it effectively cancels each other out. More to the point, I feel like this argument is over relative vs absolute. It might be noticeable" to a single person, but given that we're talking about the healthcare system as a whole, it's fair to say that it's not "noticeable".
Maybe instead of paying for the c-suite's bonuses, they need to be paying someone to air the dirty laundry of the health system that's charging $15 for an acetaminophen. When someone's f*cking both you and your customer like that, you go after them. But it's not about that, is it? It's about transferring value to shareholders, not reducing the costs of care. Hell, doing actual work to reduce the cost of care is expensive, and we can't possibly expect the retirement funds and major shareholders of America to pay for that.
> When someone's f*cking both you and your customer like that, you go after them. But it's not about that, is it? It's about transferring value to shareholders, not reducing the costs of care.
It's almost as if it's not an easy problem to solve, or some other health insurance company would do it and put all the other ones out of business.
It's not an easy problem to solve if you're not interested in solving the problem.
And they're not. Like I said, the goal of for-profit health insurance companies is not to maximize economic benefits for customers; it's to maximize economic benefits for shareholders. It's a lot easier to transfer value to shareholders by just denying the claim submitted by the customer for that pill than it is to actually (legally) beat the entity charging for the pill into permanent submission. So that's what they do.
> it's to maximize economic benefits for shareholders
Except health insurance is regulated, and you can only maximize profits to a small degree (which is the only reason UHC's profit margin is 6% instead of 40%).
This incentivizes health insurance companies to provide a good enough service that people want their insurance. Capturing a lot of the market is their ONLY way to make money.
They literally don't have the option to ask, "how do we just take more of our customers money and stuff it in our pockets?"
That's not really that terrible if the company is Apple and selling products that nobody NEEDS. It is terrible if you've only got a few choices and their selling something everyone needs - hence the regulation of profits.
It's almost as if our country isn't run by complete idiots.
Is it a perfect system? No.
Is there an obvious, far superior system? Also, no.
It's almost as if healthcare spending isn't the only variable that matters - and it matters how fat and sedentary your population is, and how much you pay doctors and nurses.
It's almost as if the world isn't so reductive complex issues can be reduced to cute little charts.
In an ideal world the insurance company would operate more like a fiduciary than a custodian. Their job should be to guide you towards the best possible outcome not just the outcome that suits their best interest. But, that would require everyone along the chain from physicians, pharmacies, nurses, back office, front office, billing and scheduling to all operate in that same manner -- which unfortunately doesn't lead to profit so we end up with the system we have.
I agree, but demonizing the profit motive isn't the ideal path. The system, as far as I can tell, needs work. The fiduciary model works in other places, it will probably work in insurance and healthcare as well.
Given insurance companies are not a necessary component of a functioning healthcare system why do we normalize debates around what level of resource extraction constitutes murder on their part?
The principle carries in so far as you hold up your contract for covered claims until bankrupt.
Or to use an analogy, which HN absolutely hates and will nitpick since an analogy is never the same thing: you do not get to trespass someone from your airplane while you are in flight. If the airplane catastrophically fails and someone is sucked out, then there is a pass.
It does not appear these denied claims are just people getting sucked out of a catastrophically failed aircraft.
Refusing to pay for medical care is hardly murder. It’s a standard monetary dispute, and we have a due process for these. If you think that so many claims are being unreasonably denied, why not start a company offering bridge loans, and funding legal challenges?
Maybe the courts are too inefficient to handle these disputes, but that’s an argument for reforming the courts, not for shooting executives.
> In some countries if you don't give care to someone who is in danger of dying you are yourself responsible for murder.
So everyone in said countries is guilty of murder because they're not donating 100% of their time and energy to helping cure cancer?
That's not at all how this works. You can't just legislate infinite resources into existence. And infinite resources is exactly what it would take to give everyone a 100% perfect standard of care.
Deciding what's covered and what isn't is literally the whole job of an insurance company. Otherwise we could just put money into a pot and let anyone take out any amount they feel like, whenever they feel like it, for whatever purpose they deem necessary at their sole discretion. (And if that sounds like a good idea to you, I'd urge you to think things through a bit more carefully before you waste your money by trying it.)
> In some countries if you don't give care to someone who is in danger of dying you are yourself responsible for murder.
Certainly not murder, involuntary manslaughter maybe. In any case, what is the basis for this obligation? You would concede that, as a consequence of imposing involuntary obligations on their citizens, these countries are less free? And you would also concede that reasonable people can disagree about the priorities of their values, and that valuing personal autonomy over collective well-being is a reasonable position?
> Murder by inaction and calling it anything else is playing in their hands.
What about doctors and nurses who refuse to work for free? Should we also shoot them? What about pharmaceutical companies that refuse to invest billions into drug development, or hospitals that refuse to purchase expensive facilities and equipment, without without a reasonable expectation of a return on their investment? Are they murderers too?
This worldview of holding people accountable for failing to intervene is simply not tenable. People are responsible for their direct actions. If you injure someone, you are responsible for your actions and the outcome they produced. If you simply come across an injured (or sick) person, you are in no way more obligated to them than you are to such a person on the other side of the world.
You also seem to be operating from the presumption that insurance companies do not add any value to the system, and that careful scrutiny of claims is motivated only by greed. I beg to differ. I want to be insured alongside other people with a similar risk profile to myself (eg. no drinking/drugs/smoking, daily exercise, good sleep, healthy body composition) to the exclusion of others. I want my insurance company to carefully scrutinize its applicants and claimants, on my behalf, to ensure that my interests are being well-represented. Insurance does not mean absolution from personal responsibility.
Not american. But how people will get to the ER in the first place? Not sure if true, but I heard people will run away from ambulances in the US because the costs are so high.
It’s not a standard monetary dispute - one party is under duress and holding a potential time bomb that the other party needs to defuse, but is arguing over.
The mess is deeper, but starting an insurance company is not easy either, one could blame the regulations. And then one cannot blame regulations either, it's the regulators/govt who are ultimately voted/allowed by the people. It's a case where every one passes the buck, and so no one single entity is responsible for the mess.
You're ignoring a litany of intentional efforts by powerful people to keep the system as broken as possible so that they can take advantage of it. Things didn't just get this bad on their own; this is the result of decades of strategizing, billions of dollars in lobbying, and intentional efforts to profit off of the sickness and death of others. It's not like there's a lack of responsibility to go around.
What you say is true, but collectively people are ultimately to blame for their non-vigilance when their rights are slowly eroded.
Look at even small groups of common people, the most power hungry get to the top, common people vote for the most charismatic/popular, not the most competent. Blaming the powerful evil people is self defeating and absolves personal responsibility.
Common people are also a divided lot. Petty issues, bickering and entertainment keep them engaged. As the saying goes: divide and rule.
"When all are guilty, no one is; confessions of collective guilt are the best possible safeguard against the discovery of culprits, and the very magnitude of the crime the best excuse for doing nothing."
> Refusing to pay for medical care is hardly murder. It’s a standard monetary dispute, and we have a due process for these.
> Maybe the courts are too inefficient to handle these disputes, but that’s an argument for reforming the courts, not for shooting executives.
You do realize that these companies lobby to make sure that it stays inefficient, right?
In the cases where they don't use the court system, they use arbitration, which is usually tilted in the favor of insurance companies.
If you want a fair shake at getting the benefits you paid for, you have to go through the courts. Given the nature of the subject of the lawsuit, there's a real chance that you'll be dead or bankrupt before you get your day in court. That's not a system that works. And when there are systems that don't work, there are on occasion people who will go outside the system to make their own. There is no scenario in which vigilantism is completely eliminated when you have people making massive sums of money off of refusing to do business in good faith.
More people need to read the cautionary tale of Ken Rex McElroy and the town of Skidmore, MO.
> If you want a fair shake at getting the benefits you paid for, you have to go through the courts.
Maybe I’m in the minority, but my health insurance makes it very clear what the benefits I paid for are. There’s guidance after guidance and tool after tool to help minimize any surprise costs.
Good for you, but there's an entire branch of the law profession dedicated to cases where that's not true and insurance companies have to be held to the letter of the contracts that they came up with.
> Maybe I’m in the minority, but my health insurance makes it very clear what the benefits I paid for are. There’s guidance after guidance and tool after tool to help minimize any surprise costs.
...and how has it gone when you tried to use them? Just as a personal anecdote: I once tried to get UHC to partially reimburse me for an out-of-network mental health expense. My policy explicitly covered such reimbursement (at a lower rate, of course). I tried for months to get the claim reimbursed. My employer at the time retained the services of a "healthcare concierge", and one of the main things they did was fight insurance companies on your behalf. That concierge service tried for six months to get a single claim reimbursed.
We all gave up.
It was such a small dollar amount; UHC likely spent more time and effort denying the claim than it would have cost to reimburse. It boggles my mind, to this day.
Just because your health insurance "makes it very clear what the benefits I paid for are" has no relation to whether or not they will actually pay those benefits out to you. If you haven't really experience this yet in America, I can only conclude that you are either rather healthy (and haven't used the benefits much), very lucky, or possibly both.
> Refusing to pay for medical care is hardly murder.
This is crazy. Maybe it's not "murder" in the traditional sense but you are making a choice on whether someone gets life-saving care, or lives in immense pain for the rest of their lives until they commit suicide. Again, this kind of normalized violence is justified when it's a business making choices to increase profits. We are so disconnected from our humanity that rounding errors in an Excel sheet mean actual lives are being ended, but that's okay.
> you are making a choice on whether someone gets life-saving care, or lives in immense pain
Is the care life-saving or pain-preventing?
There is an additional option: the person pays for it. Or someone else pays for it. Since the 1980s U.S. emergency rooms have been required to provide life-saving care regardless of whether someone can pay.
> normalized violence
It is not violence to fail to reimburse someone.
If someone cannot pay his bills, then he declares bankruptcy, the debts are wiped out, his creditors take a haircut and he moves on with his life. In many/most states he will get to retain his home and perhaps his vehicle. It’s not the end of the world?
Is it ideal? No, of course not. It’s better than dying, and of course it’s not murder.
Those can be the same thing for some people. Chronic pain patients have a dramatically worse mortality rate.
> If someone cannot pay his bills, then he declares bankruptcy, the debts are wiped out, his creditors take a haircut and he moves on with his life.
I’ve done this. Due to medical expenses, in fact. It costs money up front, and was difficult to navigate as a well educated person with family support.
The idea that this is an easy option for a single person with no supports and a disabling condition is insane.
Many doctors won’t see you after, either. Bankruptcy doesn’t mean people you burned have to keep doing business with you.
Most Americans get their health insurance through their employers. You are technically free to not sign up for this and purchase your own health insurance, but when you consider that you then give up the employer subsidy to your monthly premium, and that said subsidy often amounts to thousands of dollars each year, it does not make financial sense to participate in the market.
Most health insurance (and the lowest cost insurance) in the US is tied to a person's employer, a system that shifts the balance of power substantially to large corporate employers over workers and small companies.
Furthermore, absent major life events (job change, marriage, new child, etc) there is only one time of year when health insurance changes can be made, a time of year called Open Enrollment.
Finally, if you are self employed and you don't live in a state with a well functioning Obamacare market, your health insurance options are often quite limited.
Well, in the US, most people get insurance through their employer, who pays part of the cost. Switching would mean having to pay all the cost yourself, which would be economically painful.
And why doesn't the employer switch? Because health care plans typically have doctors that they like more than other doctors ("in network" vs "out of network"), so most people gravitate toward the preferred doctors. ("Like" means "cover better", so the patient pays less.) If your company changes health care insurers, then many people would have economic pressure to switch away from their current doctors, which is a hassle.
TL;DR: There's a lot of friction in various forms here. That's why. Yes, people can switch, but it's expensive and painful, so most don't, even though the option is technically there.
