Hopefully it can materialize into something that can have an impact on the healthcare industry, but it's disheartening seeing no doctors or anyone with medical expertise in the mix.
I think you have more faith in doctors than me. The way the California Medical Association (and the AMA) resist expanding the role of nurses really damaged their reputation for me.
Rising medical costs and increased consumption of medical services is good for physicians.
Freakonomics did a pretty good podcast[1] on the subject.
Indepdent healthcare providers like IPAs / MSOs provide a large chunk of healthcare in the US. I wouldn't be surprised if they are looking to partner with these groups directly.
Unless the business model looks more like Amazon Prime Video than AWS. And looks exactly that way to me: fixed-rate subscription fees, upselling add-ons, heavy bespoke negotiation with suppliers, etc.
> they plan to collaborate on a way to offer health-care services to their U.S. employees.
Is it clear that they will be offering these services to outside clients? Or is this just a way to keep down Healthcare costs across their organizations?
I don’t know. But a quick Google search indicates that these 3 companies have over 1 million employees. But that’s world wide. Still that’s an impressive number.
It's market participants, with a huge stake, trying to fix a disastrously broken government-corporate healthcare system that has gradually failed for about a dozen big reasons over the last 20 years.
It depends on whether or not you view healthcare as a basic right for citizens (in the same sense as education and law enforcement etc.)
The free market coming up with a co-op approach that may only benefit the handful of companies involved only benefits me if I’m in one of those companies.
Any one who is arguing that this is the free market at work doesn't believe that healthcare is a right. You can have access to healthcare, but that doesn't guarantee that you will.
>Any one who is arguing that this is the free market at work doesn't believe that healthcare is a right. You can have access to healthcare, but that doesn't guarantee that you will.
This country has socialism for the rich, rugged individualism for the poor. - MLK
I wish you were able to get the opportunity to die from undertreated diabetes complications (probably attributable to lack of health insurance coverage) in your 40s instead of my buddy. I mean, I'd rather you both have had coverage and lived long healthy lives, but if one had to go I wish it was the one that supported the cause.
I do think it's very odd for any company to be making big bets on private health insurance when that system isn't going to exist in another 5-10 years. The ACA was the last stab at leaving private insurers in charge of a somewhat more regulated system, and it failed.
Personally I'd be surprised if it doesn't still exist within the next 20 years. I don't think that much has changed in regards to how much political power this industry has. Just because the people are starting to get on board with single payer doesn't mean the politicians are going to care.
I think most people see ACA's failure as a failure of government regulation, not as a failure of private insurers. If anything the pendulum is going to swing the other way, and we'll see more privatized healthcare in the near future (5-10 years).
I've always wondered what's stopping someone from creating a non-profit and just having people join it in order to give the non-profit ability to negotiate lower prices.
I imagine there's a cost to set this up, but is that cost less than the marginal cost of each employee and the savings they would (presumably) receive if enough people joined?
Some regional BCBS are nonprofit; Anthem BCBS isn't.
Even so, your main point is taken. There's a broad directorship problem with many non-profits, higher eduction, and mutuals. General users of these public services either have no say -or- have no reasonable way to exercise their limited authority. For example, State Farm Mutual permits its subscribers to show up in person on a particular day once per year in order to vote from a set of directors that was selected by... the previous directors. I'm curious what sort of legal/social/technology solutions could be put to use in addressing this administrative capture.
Many BlueCrosses (they're not one company, they're all independent) are _non-for-profits_ which is totally different from a _non-profit_ or 501(c)(3). They can still lobby as a non-for-profit and the whole model is pretty much weird legal bullshit anyway.
Also another reason you couldn't start a big non-profit is because insurance companies are limited in reach by state/region. Sadly, that's one of the few things keeping them in check. If that regulation was removed, you'd see all the Blues and other companies start to merge into only two to three mega companies, similar to cell phone providers.
The US healthcare system worked for the majority of people until roughly the last 15 years, and then it began failing gradually up the income ladder. So if you look more recently, the last ten years in particular, that would be the window where something like this would especially begin to matter. It wasn't done before, because it didn't make sense for large entities to bother; things have gotten bad enough that now it makes sense.
The average annual premium for families for health insurance was $5,791 in 1999. The median was even lower. Today it's closer to $18,000.
The system worked at $5,791, the average family could afford that without much problem. At $18,000 the system breaks apart and fails for the typical family. Wages for the US were even further beyond comparable nations back in ~1999. With very modest real wage growth since 1999, especially at the median, that $18,000 cost essentially represents money in the economy that should have in part gone into wage growth.
These large companies now have a powerful incentive - for several different reasons - to begin hammering down the cost of healthcare. Their action on this front is a positive fortunately, these companies are extraordinarily powerful, both politically and economically. If they're dead set on bringing down the cost of healthcare, that's exactly what will happen, and they'll gather other very willing partners and the momentum will likely roll.
Do you happen to know the sources of inflation? Are we consuming a lot more services? Are healthcare providers being paid more? Are healthcare companies getting rich?
It'll require more than a one-word answer to explain why that Koch-affiliated (https://www.charleskochinstitute.org/educational-programs/pa...) libertarian think-tank didn't think to chart other rising healthcare costs, like the costs of prescription drugs.
According to that chart there were 1-2 years in the 90s where the headcount of health care bureaucracy quadrupled, but the trendline for price did not change at all (maybe the smoothing is too aggressive? I couldn't find the source data). How do you conclude that the problem is administrators if an increase of 300% in # of admin doesn't produce a proportional change in the price?
That article is a terrible oversimplification of the issue. As you said, the two trend lines of number of administrators and cost aren't even correlated.
As the other comment noted, there has been a vast expansion of administrative bullshit cost in the system.
Pharma drug costs have gone up a lot (that's around 10% to 15% of the $1.x trillion cost problem the US has). The US is spending about ~20% of its GDP on healthcare, or roughly twice the OECD average (~70-80% more than countries like France or Belgium). That's up from 12.x% in 1990, and 14% in 2000 (that 6% representing an added $1.x trillion in cost). That 12% figure in 1990, is comparable to what nicer developed nations spend today.
US wages are high, healthcare workers typically earn far above the median (eg US nurses and doctors are very well paid), and we've hired a lot of healthcare workers in the last 20 years. The number of healthcare workers has roughly doubled since 1990 from eight million to around 15-16 million today. A near 100% increase vs a population increase of about 30% or so over that time. That is guaranteed to generate a massive cost spike for that part of the problem, and that cost isn't being distributed across a further 100% larger population base. Healthcare workers have also seen their wage growth exceed the median wage growth, they've mostly done ok. So the net cost per capita for each healthcare worker in the US, has soared.
Insurance companies have done exactly what you'd expect. They push prices as high as they can get away with, adding more cost bloat to the system.
The American diet deteriorated dramatically since ~1980. Obesity particularly soared from around the mid 1980s to 2015. That brought with it a lot of added healthcare costs, around cancer, diabetes, and so on. These people weren't/aren't dying so much as they are requiring expensive routine care for various health consequences of the obesity. Conceptually it's like the battlefield cost of having a vast number of wounded soldiers, rather than those soldiers simply dying instead; in this case the battlefield is the economy or society generally speaking.
And then the US population has aged quite a bit in the last 20-30 years. The boomer generation is going to be extraordinarily expensive from a healthcare standpoint. For now that's getting worse by the year as with most developed nations.
> The boomer generation is going to be extraordinarily expensive from a healthcare standpoint.
When I log in to check my 401(k) status, there's a button that will tell me my projected income and expenses down the road. Today, I'm 47 and spend very, very little on healthcare. However, when I'm 87, they project I will be paying more than $10,000 per month for healthcare. How is that possible?
As a 10 year engineer in the medical device industry I've slowly come to believe the root cause is not greed for more profit, but actually runaway altruism.
All across healthcare, providers, scientists, administrators are faced with millions of tiny choices every day: should we spend more money to improve outcomes. Should we add that extra feature to this device - costs more but improves care a little. Should we use this more expensive material - costs more but is probably safer. Should we do additional testing - costs more but we'll be more sure it's safe. The calculus of incremental value vs. cost is subconsciously seen as inhumane across the industry -- it's seen as starting down that slippery slope that ends with a "dollars per life" number which feels wrong to everyone. Nobody wants to be the person who traded someone's health for a buck.
I'm not necessarily condemning it, I want the best possible care for my children, but I do think that (like a lot of big socioeconomic problems) this comes back to incentives.
Well that's kind of truism. Good food, good education, good car, good house and so on, none of them have to be expensive, but more often than not they are.
> The calculus of incremental value vs. cost is subconsciously seen as inhumane across the industry -- it's seen as starting down that slippery slope that ends with a "dollars per life" number which feels wrong to everyone. Nobody wants to be the person who traded someone's health for a buck.
That's not what's going on though, is it?
All across healthcare you have groups trying to provide an evidence base, and other groups trying to decide whether that evidence base means something is value for money or not. In England that's going to be NICE, in the US it's insurance companies.
The US has a serious problem of over-testing. The reason isn't because they think it improves outomes. They know it doesn't, they know it makes things worse. They over-test because it means they're less likely to get sued. The cost of the test is lower than the cost of getting sued, even though too much testing is causing harm.
So by this reasoning, you're saying virtually every other country on Earth that spends less than half as much per capita as the U.S., has no such concept as medical bankruptcies, and covers a greater percentage of citizens must be LESS altruistic than America?
I never understood the fear of public funded healthcare in America. An annual premium of $18,000 is insane. My mother in law spent 1 month at the hospital and she had two surgeries. Cost? Zero.
I've thought about this before as well. It seems like there would be room for something like Mozilla—a non-profit arm for healthcare insurance, perhaps with car, home and other types of insurance as for-profit. Then again, I know little about how these companies operate. That and I'm sure it requires a large amount of capital to start such a company.
In my area on the individual exchange they were one of two providers available with the other being a for profit insurance company. At every level of plan the for profit had cheaper premiums, co-pays and lower deductibles.
At least in my area Kaiser also likes to centralize certain specialties at a single one of their health clinics. For instance mental health providers are only available in one location. I live in a large metro area with severe traffic issues. The clinic mental health services are provided out of may be the worse location for the majority of the service area to reach. For me an appointment would have involved a 45 minute to hour drive each way.
A couple of years ago Kaiser decided not to renew their contract with the non-profit hospital system which dominates this area and instead signed a contract with a for profit hospital system. This means there is a single hospital within a reasonable drive of me which I would be able to utilize. Even then there are 3 hospitals in the non-profit system which are closer or equal distance. It gets worse if for some reason I would have had to use the next closest hospital Kaiser will cover. There are 5 hospitals in the non-profit system that would be closer. Also the non-profit system is nationally recognized as the top or a top 5 care provider for several specialties. The for profit is not.
I have no love for Aetna, Cigna, United Health, Anthem or any of the other large health insurance companies, but Kaiser also doesn't seem to be the model to follow.
> I've always wondered what's stopping someone from creating a non-profit and just having people join it in order to give the non-profit ability to negotiate lower prices.
Likely the fact that many of these prices are basically standardized because of CMS. Providers basically look to what the Medicare/Medicaid standard is as a benchmark for pricing.
As a provider why accept a lower price from insurance when the gov't is providing a backlog of people at predetermined prices?
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Unless these companies are also looking to enter the provider space, they will likely only competing on marginally better insurance rates.
Amazon is basically about vertical integration. I'd be surprised if they do not enter the provider space. Don't forget the rumors that Amazon is planning to offer its own branded generics.
> As a provider why accept a lower price from insurance when the gov't is providing a backlog of people at predetermined prices?
This isn't even an option on the table. Private insurers are generally required by law to pay more than Medicare does.
And besides, Medicare reimburses rates that are below COGS, so providers charge private insurers more in order to make up the difference. Otherwise, they wouldn't be able to accept Medicare patients at all; they'd literally lose money on a per patient basis.
This is so important and so little understood: Medicare can demand the prices that it does because other payers will be making up for it. Their low prices create externalities in the rest of the insured market.
The cost of insurance is largely driven by the underlying cost of what you are insuring. Unless they are able to lower the cost of care significantly, the price difference between a non-profit and for-profit is marginal.
Actually, I'll go one step further. Why don't we set up a non-profit/cooperative to aggregate people to get all the group benefits that full time employees receive (e.g. Retirement, Health and other insurance, and other discounted perks)?
Heck, we could even create a HN-cooperative that any of us could join, sign up and pay a nominal membership fee. Then we could off and all be independent contractors etc. without fear of losing benefits.
> The three companies said they plan to set up a new independent company "that is free from profit-making incentives and constraints."
I wonder if they will be setting it up as a health insurance cooperative, an organizational structure in which the primary goal is to serve its members, rather than to generate value for external shareholders: https://en.wikipedia.org/wiki/Health_insurance_cooperative
It's not at all unprecedented for publicly traded companies to create cooperatives for their employees. Employee credit unions are one example.
As a fan of distributism https://en.wikipedia.org/wiki/Distributism, I would love to see an increase in health insurance cooperatives, and cooperatives in general. Under a cooperative structure, the members/policyholders fully own the company, so it's not beholden to outside shareholders seeking to profit at the expense of its members. Any profits that a cooperative generates are returned back to the members/policyholders in the form of lower premiums, or improvements to services.
One of the benefits a profit motive brings to insurance companies is pushing back on improper billing by providers (doctors/hospitals) and negotiating lowest possible care and drug rates. Tech-focused insurers like Oscar also invest heavily to help guide members toward better care paths, which if done well lead to better care at less expense (for both the member and insurer).
Unrelated: one of the worst parts of insurance is the customer service quality. How does an internal, non-profit insurer staff itself to do this well? If they commit to this even at the risk of it being unprofitable, that would be most awesome —- but I’m skeptical.
You're correct that a profit motive leads for-profit health insurance companies to push back on improper billing and negotiate prices, because whatever profit they are able to eek out goes to its shareholders.
But the same motive applies to co-ops. The member-owners of a co-op don't want their costs to be inflated by improper billing or inflated prices, because if they are able to reduce their expenses, then the member-owners benefit in the form of lower premiums.
In both cases, the shareholders want to get their money's worth, it's just that in the case of a for-profit company, those shareholders are often external investors, but in the case of a cooperative, all shareholders are also members.
For companies like Amazon, JP Morgan, Berkshire, it's blatantly clear they have a massive financial incentive to beat down the run-away cost of healthcare. They've got a million employees all up and down the economic tiers. It's a very big boon to their business, to have a smaller share of cost going into healthcare, where they can instead redirect that money into eg competing for labor with higher wages (especially relevant with the U3 at 4.1%).
Healthcare costs are so bad they're now a large, direct competitor to the Amazons and Berkshires and JP Morgans in a business well-being sense, as resources are finite. I like having these giants stepping up to the plate and targeting the healthcare system on cost. They tend to get their way; if a political rock (eg insurance companies) gets in the way, it'll get moved out of the way.
It reminds me of the 450 hospitals getting together to set up a not-for-profit generic drug company recently -
A non-profit ensurer staffs itself to have high quality customer service by pushing back on improper billing by providers and instead of returning that savings to its members investing it into higher quality employees, more training, and better systems to ensure that hospitality is a paramount concern.
> One of the benefits a profit motive brings to insurance companies is pushing back on improper billing by providers (doctors/hospitals) and negotiating lowest possible care and drug rates.
The ACA requires insurers to spend 80% of the premiums they take in on direct healthcare costs for their members. Inflated billing and high drug costs are actually helpful if they want to make a nice big profit. To a point, at least - they've gotta find the right balance between profit and people being unable to pay their premiums.
Actually systemic higher costs do help. An older industry analysis found insurance to be competitive so they only way to grow profits for the industry was to grow costs. The trick is for insurance companies to find ways to get other insurance companies to pay more even if they have to also carry those costs.
AKA, 10% of 2 trillion is more than 10% of 1 trillion.
Medicare is relatively simple compared to most insurance companies and their rules.
Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates.
Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
> Medicare is relatively simple compared to most insurance companies and their rules.
As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D.
> Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself.
> There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
Yes, that's true. And that would be true even if you only looked at Medicare patients.
It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare.
Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers.
A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance.
Medicare isn't simple, it's just a small piece of a very big shit sandwich.
> A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar.
This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous.
> Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich.
As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.
This thread reads like you two are talking past each other, are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?
> are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?
I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.
>
It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare.
They are actually overlapping problems, since some of those private lines are Medicare Part C or D plans (and some are Medicaid managed care plans, and some are both Medicare Part C and Medicaid managed care plans.)
> Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.
Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly.
The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.
I think the causality flows the other way: the system being so complicated to navigate creates huge barriers to entry, which result in huge profits for whoever can navigate the whole system.
Whenever I want to feel sad, I think about how the most brilliant minds of our times are probably making a fortune at such zero sum transactions as gaming the health system and tax code.
It's both. But there are also laws that limit an insurer's ability to push back. For example, ALL out-of-network emergency services must be covered, including all follow-up work that occurs as part of being admitted due to an emergency.
Out of network means the insurer and provider have not previously negotiated a rate. And emergency services are among the most expensive bills out there.
This is diametrically opposed to the facts. People need to stop making arguments like this about profit driven insurance when our system has the US spend the most per capita amongst modern nations with mediocre results.
That’s in large part because the costs of healthcare are crazy high, not the cost of insurance.
They are interrelated, yes. But fundamentally we are at a place where providers, especially hospitals, are billing insanely high rates for services compared to other countries.
It's nutty to me that yours is the first comment that I'm reading in this thread that has mentioned that. The provider part of this shit sandwich (to steal a phrase used elsewhere in this thread) is by far the more problematic piece.
When you use a service without paying for it (e.g., television, radio, Yoogle, Facepage, and so on), you are not the customer but the vector to get to the real customer who is paying. No, buying a TV or paying your ISP is not paying for the services you are accessing.
What Americans think of as “health” “insurance” fits this model. Providers are in the business of soaking their customers the various tax-favored third-party payers for all they can. Of course prices rise continually. People are stirred into a frenzy about rising costs and demand that politicians just do something! The insurers get more tax-favored money that providers happily mop up.
This feels like a setup for a broader push into healthcare by these companies. The sector is still growing, Amazon is already working out the pharmacy space. "[F]ree from profit-making incentives and constraints" sounds like the strategy they've used so far to dominate sections of online retail.
I think it would be irresponsible at best for Amazon to tackle the medical supply/device market before they can get their counterfeiting problem under control.
Presumably they wouldn't allow literally-anybody comingled inventory for that. It's trivial for them to regulate requiring first party or trusted party sales for that.
It would be irresponsible at best for Amazon to tackle the medical supply/device market before they can learn to ship 20 items from the same fulfillment center on the same day in the same box instead of in 20 oversized but mostly empty boxes.
Fulfillment centers are large enough that shipping them in individual boxes may actually be the cost-effective method at times.
I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
> Fulfillment centers are large enough that shipping them in individual boxes may actually be the cost-effective method at times.
You missed half of what I wrote, "instead of in 20 oversized but mostly empty boxes." The context was in a single order from a single supplier, whose product was already at the warehouse, shipping on the same date, to the same address, for the same delivery date, using the same delivery carrier, of almost identical items that almost assuredly are on the warehouse shelves right next to each other.
> I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
That may be the case, but I am referring to the incorrect packing of boxes not trucks.
It may not be incorrect. It seems that if it was significantly affecting their bottom line it’d be a low-hanging optimization that they’d have tackled by now.
FWIW this issue infuriates me also - to a degree
Hard to say without knowing the supplier's volume, the nature of the products, etc., but it's entirely possible given the nature of Amazon's warehouses that those "almost identical items" could be scattered all over.
They could have arrived from the supplier in small batches (or even one-by-one) over time if it's a low-volume sort of thing. Amazon might intentionally spread them throughout the fulfillment center in some situations to expedite packing and reduce the distances their robots have to travel.
They might have just needed twenty boxes to finish the tetris puzzle to send a truck out the door.
From Amazon's point of view, they're doing both correctly.
Their algorithm apparently optimises for packing completely filled tucks leaving the warehouse first, then optimises for minimal packaging second.
If they need a few more boxes of a particular size, to completely fill an outgoing truck, they will split some orders appropriately so that those boxes appear on the conveyor at the right moment.
This means that sometimes you receive an SD card in an A4 size box, because that was the only item that was available when they needed an A4 box to fill a truck - and the algorithm decided that the trade-off was worth it.
I have some medical supplies that Amazon will sell me without a prescription. I used them last time because I neglected to order far enough ahead of time, and the game of tag between my doctor and my pharmacy would have taken too long - Amazon Prime to the rescue! Today I pick up a new prescription at my pharmacy, and I'm curious to know if my insurance copay is less than what Amazon charged. I'm guessing it could go 50-50 either way.
This is something I've been thinking about for a while - what would insurance companies (and even other companies in every vertical) look like with some incentive other than profit? Paying good salaries is one thing, but doing it for the sake of external shareholders is a different case.
Newman's Own is one interesting (and successful) example I can think of that's an otherwise for-profit company acting effectively as a charity. Are there papers/books about how effective this would be in practice?
Perhaps Vanguard is an example of a mass mutual company that owes part of its success through its formation due to its ability to pass cost savings back to its customers in the form of lower fund fees?
Vanguard took decades to gain any traction and it was managed well enough to ensure it didn't prematurely burn out, and not only that but Jack Bogle spent his entire life evangelizing low-cost in an environment where "cost is no object" was a common mantra.
Not only that but the healthcare industry has extraordinarily high financial and legal barriers to entry.
There are extraordinarily high expectations in the finance industry but the only barriers are regulatory compliance (with regards to fiduciary duty) and convincing people to throw money at you.
Considering their already extensive ground in insurance and JP Morgan's financial acuity, Amazon is in good hands. I know I'm hoping they encounter some success.
My personal (unproven) theory is that the non-profit model works well for ventures that require very little entrepreneurial judgment, but poorly otherwise. Vanguard basically follows that: they mainly sell index funds, which a well-trained monkey can run.
Similarly, it makes more sense to have a non-profit coffee-buying employee group to buy coffee (at places that don't provide it for free) rather than pay a vendor to bring it in. But that's not because profit-making is an inherent drain on efficiency, but because the "judgment" that those profits are "buying" ... doesn't add much value.
Absolutely. So based on what I know their financial products and customer service is awesome but I doubt if it comes at a price which is lower than the market (even after considering what they give back to its members).
Their insurance risk pool is far more favorable - those in the military are generally more healthy than the general population, and they have pretty much guaranteed income.
From ehealthinsurance.com:
Kaiser Permanente is composed of Kaiser Foundation Health Plans (nonprofit, public-benefit corporations), Kaiser Foundation Hospitals (a nonprofit, public-benefit corporation), and the Permanente Medical Groups (for-profit professional organizations).
Our family have been members for over 20 years. I'd rate their health care as "good", but the real benefit is that we have NEVER had a billing dispute, because almost NOTHING is "out of network". On the rare occasions we've needed non-Kaiser health care (such as ER visits while traveling), we just give the bill to Kaiser, and they take it from there.
When the insurer owns the hospitals and contracts all the doctors, customer billing is almost friction-free.
I would think the actual care would be the highest priority for most people. These companies are so closely watched that billing disputes are extremely rare.
Not only that, but Kaiser Permanente was formed for similar reasons. It was to provide healthcare for the employees of the Kaiser shipyards, a major industrial employer.
The way to change the game in healthcare is to eject the legacy bullshit. Own the experience as a vertical, don’t accept Medicare/Medicaid and the price controls that come with it and you slice out a lot of the overheads.
Most of the Blues are already "non-profits." That really isn't the issue. The biggest issue is regulation--I've worked in healthcare IT and it sucks due to the regulatory burden and fears that are associated with it. You can't innovate, management won't let you.
The second biggest issue is that they are using archaic technology such as AS/400 systems and trying to ship data around using "file drop." File drop--in 2018! They doubled down on stupid technology choices years ago and continue to fail because of it.
The third biggest issue is revenue. You can't even run a non-profit without revenue. Employees don't work for free!
A related problem is that the company I worked for failed to promote people like me who could solve some of their problems for them. I lost the political battle as a tech lead. Had I been someone with more clout, things might have gone differently. Companies promote all the wrong people, though.
BTW, cooperatives are bullshit--even grocery coops have to have revenue, it's not magic. Coops fail because there's "no one in charge" and without decisive action there is failure.
Credit unions work because they extend credit based on typical fractional reserve models. Members of credit unions own shares based on their deposits.
You can't do use a credit union model with insurance because of how insurance underwriting works. Just look at the healthcare costs of any small company--if one person gets sick, everyone's rates go up. There's no magic as to how this all operates. There's no pool of people size n where n is large enough to fix the problem--which is why universal or single-payer systems are merely an illusion of prosperity while taxes rise to 80% and up! It becomes punitive taxation! Which means no freedom for any of the people living under such a system, and eventually the resultant economic collapse--yes, even in Europe.
Thank you for giving a name to something I have been pondering a lot. I have come to this conclusion by thinking about automation and technological unemployment. If people own land, or productive tools, they can be self reliant and exist without jobs from corporations, or help from the state. Naturally people would organise as a cooperative or a market of services, exchanging services for services, because they have little money and no corporate jobs. Yet they can work, so they can create a kindergarten for children of the neighbourhood, or a medical clinic, or a mechanic repair-shop, or a construction company, and so on.
By combining these skills a neighbourhood, or a city could be self reliant. In the future, with the advent of solar energy, agro-bots, 3d-printing and other empowering technologies it will be even easier to be self reliant. I see this as a better solution to UBI which depends on the state, which is corruptible and the corporations, which are greedy. People would retain their agency, unlike in the UBI scenario, where they would be wards of the state.
There is no purpose to automation that does not exist in the service of humanity at large, but only for a few. Automation must be owned by the people directly. We need to have the means of production in our hands in order to survive. There is one single job the advancement of automation can't take from us - the job of taking care of ourselves! And that's hard work.
I can't say if it's better or not, but we do know that human organizations function poorly at scale. The larger the group, the more difficult it is to communicate, the easier it is to feel powerless, the more the problems of a large chunk of the group are remote and abstract (and thus ignored/missed/downplayed/deprioritized)
I suspect that you also have more corruption and/or abuse of power because (a) the previous entries all empower sociopathic individuals, (b) you have a larger pool from which to find such sociopaths, and (c) you have more positions of power for said sociopaths to fill.
You have all of these problems in small groups, but many of our policing/accountability systems don't function well in very large groups.
I'm not sure any of your claims are backed up by data. Is our larger society more corrupt? Is it more difficult to communicate?
I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy, which might lead to more wars. I have no idea if that's true, but it sounds plausible to me.
In the end, actually examining data is what's needed. Until there are facts to assess, we're just spouting wild conjecture.
> I'm not sure any of your claims are backed up by data.
https://en.wikipedia.org/wiki/Dunbar%27s_number has a decent collection of the research I know of. There is a little hand-waving involved when it comes to "why", but it's notable that multiple researchers over decades disagree about the number, not the base concept. Likewise, studies related to the base concept of the non-technical Brooks Law support the non-linear impact on communication as a group grows (off hand I can't find a study on that, but I know I've read of multiple).
Anecdotally, plenty of governing and/or economic systems (e.g. communism) have historical success in small groups and no examples of success in large groups, but that's a completely different kind of evidence.
The corruption/abuse item is not part of the research, which is why I separated that as "I suspect" Given the above, and what we know about leaders (executives, politicians) and how sociopathic tendencies are an asset to personal success I find it very plausible but I have no actual evidence, thus "I suspect".
> I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy
You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences. That's orthogonal to my point though, as I was only addressing internal workings, not interactions between groups.
> The corruption/abuse item is not part of the research, which is why I separated that as "I suspect"
My main point was that the theory was labeled as something you suspect, but the evidence you listed to back up that theory sounded like it was being presented as fact. You've provided resources to back up the claim, at least to some degree (as you note), which is what I was looking for, so thanks. :)
> You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences.
I don't have any, but I also would be interested to see it. I was using it as an example of something that sounded true and that I suspected was true that I had no real evidence of, and thus should be hesitant to assert as true. Unfortunately, by its nature that makes it interesting to a certain type of person, so it ends up teasing us. :/
I'm upvoting you just for engaging in this conversation, even though I thoroughly disagree with you. :-)
The "distributism" described above is the dream of virtually every rural community. People choose to live in rural communities because it's a little piece of heaven for them: they are surrounded by people they know, they have clean air, the earth is right beneath their feet, the stars are bright, the pace is slow, and so on. They want to serve their neighbors and receive services from their neighbors. How is that mindset pathological?
I am always encouraged by innovations that help rural folks be more self-reliant so they can work toward their dream of self-sustaining, independent communities.
Certainly. There will always be interdependence and rural communities understand that; that's why they drive modern pickup trucks rather than horse-drawn carriages. Still, they are always looking for ways to reduce their dependence on cities.
Well, at least until we reach the science fiction utopian dream of nanoassemblers that can make nanoassemblers. Then rural communities could truly be independent.
Although that independence would be like a group of proto humans that knew about fire and how to use it, but not how to make it, and thus carefully guarded it and kept it fed, lest it go out.
Do you think that we'll be able to escape making this tradeoff in the future? I don't think it's unreasonable to think that sanitation and healthcare technology will advance to the point that they can be implemented in smaller communities at similar levels of quality that could be seen in big cities.
I hope we will have healthcare services that don’t require advanced knowledge or infrastructure to operate, but we’ll still need advanced tech to produce them.
I don’t see a way around this, since you always have to start from the same raw materials.
Distributism includes the principle of subsidiarity, it doesn't exclude the fact that you need large organisations to produce some technology, just that you should tend towards the smallest organisation that can achieve what you need. Capitalism seems to be tending towards the opposite where the winner takes all.
Wouldn't it also be possible to see that as rural residents putting on a brave face? The general trend has been towards urbanization globally for the past century or more, and relatively few young people growing up in rural communities seem to be interested in staying in them in the US[1].
While your experience might tell you that the reality is that is simply not true. You're countering a statistically sourced statement with an anecdote.
There are two actually statistics underlying the discussion here, and from my reading both points are right (though disagreeing that we're urbanizing is incorrect)...
1) Our general trend is towards urbanization, humanity is now more urban than rural, and every quality of life index shows cities give more good to more people better.
2) Millennials, hipsters in particular, in American markets with crushing real estate prices have recently begun reverse-migrating away from the cities and to more rural areas with romanticized lifestyles creating some new demographic, and real estate, trends.
In terms of pure statistics we're looking at a sub-group with a different trend than the overall group. Most potatos aren't from my backyard, but those potatoes are only getting prettier while the many thousands at the market are getting uglier ;)
I'm totally in the camp who wants to move back to the Midwest and buy some acreage- my point was mainly that the person I responded to flat out stated that the parent commenter was wrong which is not the case.
Statistical significance aside, blanket statements such as what I responded to are simple, not true when compared to reality. I do not believe that humans can be unbiased when interrupting data to form a conclusive hypothesis. This is why the scientific community has a peer-review process to filter out biases.
However, I will agree that my initial response was lacking and would have been better if not stated at all.
Isn't that just a reflection of where jobs are, which is in turn a reflection of our increasing specialisation. I know there are almost no jobs for computer science graduates within ten miles of the village I live in. The choice is to move to the city or work in the local supermarket.
I think GP is referencing a type of Commune, where potentially services, possessions, and responsibilities are shared amongst those who live there. America has had communes as well
Communism is where all property is publicly owned and each is given what they need.
A commune is a self-reliant community, likely to be small - individuals need each other. A communist state is still a state, it is not decentralized like a commune, but very centralized. Instead of relying on each other everyone relies entirely on the state.
From a certain perspective I agree, and though I am a free market capitalist to my core, the free market doesn't preclude an organization behaving in a communist fashion; the free market simply doesn't require it. I very much encourage things like this.
You see it in my locality, none of the local farmers own their harvesting machines, as a group they own the machinery collectively. This is still a long way from communism though.
> There is no purpose to automation that does not exist in the service of humanity at large, but only for a few.
There certainly is, to the few that are served. Increased productivity that doesn't require manpower/hours has been captured for centuries.
A capitalist economy provides many incentives to privately hold productivity gains from automation, while providing virtually none to relinquish them to the public.
> [people] can be self reliant and exist without jobs from corporations, or help from the state. Naturally people would organise as a cooperative or a market of services, exchanging services for services, because they have little money and no corporate jobs. Yet they can work, so they can create a kindergarten for children of the neighbourhood, or a medical clinic, or a mechanic repair-shop, or a construction company, and so on.
How is that self-reliant? It’s different from most of the current developed economies, but it’s still division of labour and relying on others for some things.
> Distributism (also known as distributionism or distributivism) is an economic ideology that developed in Europe in the late 19th and early 20th century based upon the principles of Catholic social teaching, especially the teachings of Pope Leo XIII in his encyclical Rerum novarum and Pope Pius XI in Quadragesimo anno.
> According to distributists, property ownership is a fundamental right, and the means of production should be spread as widely as possible, rather than being centralized under the control of the state (state capitalism), a few individuals (plutocracy), or corporations (corporatocracy). Distributism, therefore, advocates a society marked by widespread property ownership.
> Distributism has often been described in opposition to both socialism and capitalism, which distributists see as equally flawed and exploitative. Thomas Storck argues: "both socialism and capitalism are products of the European Enlightenment and are thus modernizing and anti-traditional forces.
So not to be snarky, but how is this anything more than simple "Marxism, minus the parts that don't work with Catholic religion, plus Catholic religion"?
Properly understood, Distributism is capitalism limited by an understanding of the purpose of capital. Just as there is no mathematical system that can prove all of its first principles, so there is no system of capital that can within itself articulate a just distribution of that capital.
The assertions of Distributism are that:
* Everyone has a right to private property (ad contra of Marxism)
* That right to private property is not absolute (ad contra of laissez faire capitalism)
* Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means (ad contra of if-it-is-not-100%-it-is-not-a-monopoly capitalism)
This is inspired by Catholic principles and promoted by Catholic thinkers, but it is certainly something one can come to without being Catholic.
>Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means
Won't you just get run out by others who are focused on productivity and can beat you in trade and undercut your prices while delivering higher quality?
By a lot of accounts nomadic life was much better than early farm life. Didn't help the nomads in the end though.
Well, achieving the Marxist utopia involves forcing the genuine owners of capital goods ("the means of production") to surrender those to the state, in practice usually requiring imprisonment, execution, and initially a certain amount of genocide to avoid revolt.
Clumsily named, the aspects of "distributism" being lauded here only seem to involve convincing people to partly own instutitions rather than simply transacting with them as a third party. Seems to me that this reading of "distributism" is just capitalism plus a social norm of a bias toward involvement and ownership, rather than just employment and consumption.
> Well, achieving the Marxist utopia involves forcing the genuine owners of capital goods ("the means of production") to surrender those to the state, in practice usually requiring imprisonment, execution, and initially a certain amount of genocide to avoid revolt.
No, it's the Marxist part that makes it not work, doesn't matter which inspired party adds their flavour. If you want Marx's society (not saying his analysis, especially of his surroundings, was wholely incorrect), it can only be had by force.
I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't,
comfortably boiled frogs as the record shows them.
> I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't, comfortably boiled frogs as the record shows them.
a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
b) Your view of history is perverse, and insulting to the many people that resisted and were killed off by Lenin & Co when they took power.
> the many people that resisted and were killed off by Lenin & Co when they took power.
Show me the scores of people taking a stand while being placed under arbitrary arrest. Yeah, sure some people resisted, a whole lot more memorable than the millions who walked with their captors straight to the grave. It's not like they didn't resist because they were bad people or something, they just had no tools to deal with any of this, who on earth did?
For the most part, you're taken by night or in transit, and they show up to dig up your trash to find your cherished letters or the wrong souvenir, you're still wondering if all the other people who were arrested did what they were accused of. What does resisting that even look like?
This was all to prove some fantasy of a man with a weak spirit and infinite capacity to look outside himself for fault; and for Lenin and Stalin it was just their ticket into town.
> a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
I didn't say you had one, really, I said that if one were to be instituted, it seems it could only happen by force. Marx's conclusions are the fundamental source of the most inhumane behaviours of the USSR, the specifics are just gory decoration. It doesn't matter if the dissidents happen to be suppressed by genocide, imprisonment, or exile; only by suppressing the dissidents can you institute the envisioned solution. There is a considerable proportion of society which will simply not agree to have their life's work taken from them. Tell me what the important difference is between a solution which passively requires genocide, and a realized implementation of that solution.
Granted I'm underslept right now, so say whatever, I'll see it when I'm back on earth.
This is a type of utopia that many of us yearn for, but never appears to have worked at the level of large nation-states. I mean, here are some things that are not taken into account:
- People who can not work because they simply can't hold down a job, period.
- Externalities such as neighboring (or even distant) communes dumping wastewater into rivers etc., or polluting the ground, or air... you get the idea. What about natural calamities, such as earthquakes, tsunamis, volcanic eruptions, and such?
- Conflicts over scarce resources. Water, for example. Communes that rely on a common source of water will likely have conflicts. How are they resolved?
- Any commune is exceedingly unlikely to be good at producing all the things it needs. Trade will need to develop. Does 'self-reliance' exclude the possibility of trade?
- How large should a commune be, to enable innovation? Without innovation, there will be stagnation that will harm the commune in the long run.
- How would a commune handle people that are 'different'? How about criminals within and without?
This is not at the expense of the large nation state, it just limits the power of the nation, preferring to push down the responsibilities to the lowest level possible, rather than aggregating up the moment that any benefits can be found from that aggregation.
We live in a world where (to quote GKC [1]):
> Lancashire merchants whenever they like
> Can water the beer of a man in Klondike
> Or poison the meat of a man in Bombay;
> And that is the meaning of Empire Day.
The advantage of centralization is that we can stop the poisoning all at once (because there is only one place doing the poisoning). However, when the meat is poisoned many more people suffer food poisoning than would if the food packaging were distributed.
Probably best to distinguish between "self-reliant economically, but connected to the world economy" vs "closed system". Trying to be self-reliant in terms of physical inputs doesn't work in the oil age. Whereas the various small and micro-states manage to be economically self-reliant while importing staples.
I don't think distributism requires a closed system.
How familiar are you with distributism? It certainly does not advocate for communes! Distributism is merely an (admittedly aspirational) economic system where the ownership of productive property is widespread.
A few of its guiding principles may answer your concerns:
* Subsidiarity teaches that things should be handled at the lowest or least centralized level that is competent to handle them. That doesn't mean that small organizations should be expected to bite off more than they could handle. It may very well be that a giant, multinational corporation is the lowest-sized organization that can handle operating something like an airline, and that is not inconsistent with distributist principles.
* Distributism, as an economic system, is not at all incompatible with things like a strong social safety net. However, it is worth pointing out that if the ownership of productive property were to become more widespread, the need for such a safety net would be decreased.
There are Kibbutzim, full blown cooperative communities spread across the country (which were the initial backbone of the country but have decline over time). They share income depending on the Kibbutz, but some of these communities are very productive and very well off.
There are also Moshavs that aren’t quite as collective but still cooperative. Everyone in the Moshav shares a fixed piece of land in the community but production and income is controlled by the individual laborer. However, the community will still share costs together, like machinery, supplies, marketing of output.
Both are 70 year+ running models and proven to be successful no reason they can’t everywhere else.
The earth can't physically support the existing human population without great cooperative ventures such as the production of electricity and nitrogen fertilizer. It can't support life at anywhere close to the present day level of prosperity without additional great ventures such as transportation, medicine, telecommunications, money systems, and electronics manufacturing. All known means of operating those ventures depend on the state, including the entitlements granted to corporations.
Giving up these ventures would require such a massive reduction to the quantity and quality of human life, that it would be unacceptable to the vast majority of people.
The Haber process ended humanity's hopes of creating a society based on self reliance.
I hope I wasn't predicting a population bomb. What I was suggesting was that the existing population level is sustained by organized human activity at a scale that can't be managed by independent individuals or small groups. Thus a proposed restructuring of society requires a credible plan for maintaining or replacing some specific activities such as the Haber process.
It's interesting to see your thoughts on UBI, how you connect it necessarily to the state. I think this doesn't have to be the case:
https://joincircles.net
I am also very much in favor of distributed, self reliant communities. Yet I want to preserve the advantages of a global linked economy.
I hope that Blockchain technology will help us to achieve this.
I limit my comment to that. Truth is that..
1. Your military secure the borders of what all knows as USA. 2. You have defined land area.
3. And you have a certain number of people living there within.
Now divide your lanarea with number of people, and see how much land everybody has the right to.
You cannot OWN land. You can secure it.
To OWN lan you have to have a proof of origin of the land.
Nobody has. As the land is much older than your relatives way way back.
People try to avoid this and manipulate "laws" to be able to own land, which is just criminal.
Your land should be owned by all of you.
It is a fedaral issue.
A State defines often as something evil. Thats the rich 1%'ers propaganda and thei dreams.
A State in you case is Federal USA. And it should keep records of the land, and everybode should arrend, hire, their birth right. It is simply only that way you can "own" land.
You may find this rediculous... but it is the truth.
In my country there is 9 million people on a secured land of 445000km2. Gives me about 10 footbolls field side by side of land. I also have kid and a wife that has the same as I.
It's quite possible they are simply setting up a captive third party administrator company. All of the companies will fund health insurance which will then have benefits designed for employees and care overseen by this third entity which would be a not for profit. This entity would then have to go out and negotiate contracts with providers, drug companies, lab testing facilities etc. Given the size of these entities, they would have significant negotiating power with providers and hospital systems which could keep costs down for members.
A large problem with this system I can see is it doesn't help those who either 1) don't work there or 2) want to switch jobs. This merely pushes back on health insurance companies which is great but it doesn't fix the general issues that occur when access to healthcare is tied to employment.
Would having an Amazon Prime "Membership" likely count enough to expect to see Amazon offer this to consumers (possibly at enough of a discount to make it competitive with employer insurance)? I would think that having access to medical records to determine that someone needs a few more OTC allergy med suggestions might make this a long term goal of the project. In that same vein, fully expect to see an Amazon Credit Union someday as well and possibly part of a complete "Amazon Member Benefits" bundle.
Here's what this is about. Large successful companies contract out their health insurance and care to external companies. Most of those companies are profit centers- they provide a service, but they take a very large profit on it. Much of that profit is just waste- it's money that goes to people who aren't innovating, or providing value, just acting as gatekeepers (note: this is just my opinion, not provable fact).
Companies like Amazon know they can provide that same service- or a simplified version of it that focuses on effective treatments that don't cost a lot of money- far more cheaply, because they have willingly forgone short-term profits.
Whether this saves money and provides adequate care remains to be seen.
Insurance companies, by and large, are gate keepers to capital. The "best" have a lot of highly innovate algorithms, machine learning, and data collection, but they're all designed to maximize the profit of the company by accurately pricing premiums. An accurately priced premium means customers who don't their services less pay less; in effect, they're using data to increase premiums for the customers who actually use their service, while increasing revenue in order to fund their massive, inefficient bureaucracy.
The companies involved in this new venture were already self insured. They were paying for employee health care via third-party administrators, not buying insurance.
The last few insurance companies Ive delt with seem to act more like banks giving loans. Twice now, they have priced premiums for our company policy low in the first year before increasing them the following year based on how much was claimed. One agent actually admitted it was to "recoup costs".
We joked that the meme where actuaries were being replaced by machine learning was actually just the insurer firing actuaries because they figured out they could just demand the money back from the client after a claim.
I'd call this liberal-communism. We just have to put our trust in benevolent billionaires to solve our problems for us with no oversight or democratic controls whatsoever. The idea that this is anything but an attempt to squeeze even more money out of the system for quite literally the richest people on Earth is naive. In Ohio, 10% of Amazon employees are on food stamps[1] while Bezos is worth over 100 billion dollars.
Isn't that just conservative-capitalism? Specifically the US Republicans? Get rid of regulations, lower taxes on corporations and billionaires and put our trust in benevolent billionaires to solve our problems for us with no oversight or democratic controls whatsoever.
I'm neutral on the particulars of this venture (it's probably positive). But how can anyone argue that the market is efficient when it is possible for companies that "is free from profit-making incentives" to exist? Just curious. How does this example fit into that framework?
> how can anyone argue that the market is efficient when it is possible for companies that "is free from profit-making incentives" to exist?
"Commoditise your complements" is an old and true business mantra. It's the reason it's good business for Google to promote an open web or investment banks to promote mutually-owned, virtually profitless settlement & clearing organizations like the DTCC and SWIFT. Much of the robber baron era's drama centred around steel trying to commoditise railroads, railroads steel, and oil the whole lot.
I always think that it's only a matter of time before some company with vast capital (looking at you Apple) finds their own way to set up a city/country with their own ecosystem (healthcare, transport etc.), with less bureaucracy and more efficiently.
I think this is what a lot of politicians think, also. They don't want government run healthcare because it's only a matter of time before the market fixes healthcare.
Edit: I think Apple is only interested in medical devices.
> Could this problem be attacked by a goodwill billionaire with a long-term plan? Open several private medical schools that will offer "free" med education in exchange for multi-year contracts. Open many small copycat clinics. Manufacture your own generics if possible, import whatever is cheapest, focus on things you can do cheap, be transparent about pricing, build awareness and brand. McDonaldize/Amazonize American healthcare.
It's not just the cost. It's the incredible inefficiency of the operations, and, the gerrymandering of coverage. Under the ACA, I had to choose between allowing my family to continue to see their lifetime care givers, or, paying in network rates, for the full year, because the insurance company I chose gave me incorrect information when they were trying to get my business (my wife is less kind in evaluating their motives). I paid $30,000 in health care expenses out of pocket that year for what was essentially a healthy family. I was not permitted to change insurance companies once I learned they had misled me.
Buffet calls them a tapeworm, I call it the next, ongoing rape of the American middle class.
> Isn't this just for the 900k employees and isn't it just focusing on wearable tech?
I believe it's initially for the employees of those companies. If they can make it work for them, they have a great team (ecommerce, finance, insurance) to back a larger rollout. The announcement says it's about providing healthcare at lower cost with better results, which sounds like a lot more than wearables.
>It sounded more like fitbit with cloud services than insurance.
If there are healthcare providers involved giving direct healthcare, there will need to be systems and development around medical records. That could easily be sold as a product to hospitals and providers outside of the AMZN/JPM/BRK company down the road.
Taking a "beginner's mindset" to me sounds like they plan on writing their own stuff, except for interoperation like HL7, which is great because most of the stuff from EPIC/Allscripts/Cerner is drowning in technical debt.
"beginner's mindset" was my favorite line in the article. Classic Bezos. Yes, it might indicate building their own stuff. I also interpret it that sometimes the experts are too stuck in their ways.
Buffet is the same guy that "fixed" other insurance markets by driving them away from mutual ownership to privately owned companies - a massive wealth transfer away from the common man. He shouldn't be commenting on tapeworms.
I'm genuinely fascinated by this comment. You're saying that mutuals offer lower prices (not typically true), but they were out-competed by private companies? I'm not sure that makes sense. In my sector (life insurance), there's no real pattern to mutual vs public company pricing, but maybe it's different in auto insurance, for instance.
It goes beyond pricing. Mutual insurance policy owners were paid dividends based on principle investment. Berkshire pays dividends to shareholders, i.e. Warren Buffet, while policy holders get nothing but insurance coverage.
Not only has Berkshire never paid dividends, as another comment noted, Buffett decided three decades ago to give all of his wealth away to the benefit of less fortunate people.
In the abstract, giving away the proceeds to a cause you support isn't really a tremendous excuse for bad behavior.
I'm not evaluating Buffett either way with that statement, just pointing out that it is possible and probably necessary to evaluate his behavior without giving consideration to his pledge.
I was wrong, replace dividends with stock buybacks and buying up other companies, it's the same impact on the policy holder, who will still see no financial gain from holding the policy. Did you consider that some of those less fortunate people that he donates to might be less fortunate because they've been paying into an insurance system that for 40+ years years has provided them no return?
If you want an investment you can invest, if you want insurance you can get insurance. I'm not sure why you think overpaying for insurance and getting a dividend back sounds like a great way to do both. If you pay for insurance for 40+ years you certainly got something out of it--you have been insured for 40+ years!
>> If you want an investment you can invest, if you want insurance you can get insurance.
Most people used to do both at the same time and it seemed to work pretty well before Buffett came along. And there's a good analogy to your last point - someone who rents an apartment for 40 years when they could have bought an equivalently valued home two times over. They shouldn't complain when they die with a net worth of zero, they had a roof over their head for 40 years!
Also, mutual policy holders don't "overpay" for insurance as all dividends are returned to them. Only a private insurance company policy holder could overpay. Just thinking about it now, Buffett wouldn't be so rich if his policy holders weren't overpaying, as you're implying.
Buffet decoupled investments from insurance, because he thought (IMO rightly) they should be different products. And his companies only win to the degree that consumers choose them.
Consumers don't as a group "choose" anything independently in the sense that their biases and psychological faults and the structure of incentives in our society are all used to make consumers act against their own interests and the interests of the whole. When our "best and brightest" are only committed to profit, we cannibalize ourselves. It isn't progressive. There is no scenario where shitting on the masses to help yourself results in a win for humankind. Not at this stage in history.
All involved players are mainly interested in lining their own pockets. The question if this will come at the expense of patients or other players in health care.
There is nothing wrong with “lining your own pockets” as a motivation. It is the fundamental driver of capitalism and the motivation for most entrepreneurs.
Doesn't it? America is unapologetically a capitalist nation with a few notable and infuriating exceptions (looking at you, ISPs).
I mean if you want to make an anti-capitalist argument on a message board owned by a venture capital firm, feel free. But by definition "profit = good"
I don't think there's anything necessarily anti-capitalist about BI, especially if it could be shown that a given level of BI substituting certain social programs was more cost-effective. Increasing benefits while lowering taxes without raising the deficit or incurring debt would be a pretty easy sell to both sides of the aisle, I'd think.
Yes however oligarchs don't want 99% of wealth to be in the hands of the 1%. Right now its something like 40% of the wealth in the hands of the 1%. If it shifts much more they will have total war on their hands. The rich will always be encouraged to keep that number down to prevent war - which is also convenient as those efforts can make them look like our lord and salvation.
true true, yesterday I saw someone make the argument "If popularity doesn't make something moral, what does" And on this thread it's "if capitalism doesn't make it moral, what does"..
There's an entire college course called Philosophy I that basically goes over 7 to 10 different moral compasses. The only one that seems to win out (aka the only one people remember after the class is Moral Relativism).
I think in healthcare, there is a problem with profit as a motivation, at least insofar as the ability to receive care. I think healthcare professionals should be paid, and paid well. But a for-profit company (or whether or not one can pay the premiums or deductible of any insurance company) should not be a gatekeeper to whether or not one can receive care at all. Inevitably, someone will be left out in the cold, or will end up paying inordinate amounts to receive care due to bureaucracy (or malice), as has been experienced by people elsewhere in this thread.
This is why I believe single payer healthcare is generally the best solution.
However, in the current situation, I think this idea to create a healthcare company dedicated to serving their employees, "free from profit-making incentives and constraints," is a great idea, one which I hope others will attempt if it ends up a success.
Single payer healthcare is the best soln. Agreed, However I can’t see it working more than a presidential term. America is too politically unstable.
What i’d love to see is a commercial business having vertical integration. Insanely cheap basics like X-rays, mris, and other checks. Heavy use of AI based diagnosis confirmed by doctors, and a big insurance pool where profits go back into scaling healthcare.
Basically current American healthcare is not scalable. Period.
Why wouldn't you make a profit? You sell that technology to hospitals and such the world over.
You just might not have the option of telling someone it's 10 grand (with ridiculous profit margins) to get an earlier diagnosis and a chance at actually living.
> Single payer healthcare is the best soln. Agreed, However I can’t see it working more than a presidential term. America is too politically unstable.
I'm not too sure about that. It's taken an entire year for the GOP to start to actually succeed at chipping away at the ACA, and they have legislative and executive control. If we could get sweeping reform in a more favorable political climate, something not plagued with the implementation issues the ACA has labored under, it might stand a chance. The next administration might find it politically untenable to take it away if it actually works well.
Did anyone read the article? It’s going To be set up as an independent company without profit as the motive.
They know all their companies will earn more money if there is more money in everyone’s pockets. Look at how much some people are spending per year on healthcare. Someone in this thread mentioned $30k for his family in a year just for insurance. If he even saved a third of that, it’d end up being spent somewhere. A good economy benefits all those big companies. The losers in this are the healthcare companies.
Sorry, it seemed like others were making that assumption without reading the article.
As long as this company doesn’t go public, it seems like it will be able to stay away from that. It will be extremely competitive against companies trying to raise profits.
Also, the number of employees these three companies have, put together, mean that setting up a non-profit health provider and using it to provide employee coverage saves them money in their normal businesses.
Amazon might decide to make their own networking hardware or their own power generation for their datacenters to save money, but they spend more money on headcount than on datacenters, and a huge chunk of the headcount expense goes to health insurance companies.
That's how you get healthcare lobbyists to get laws passed that screw over patients and how you end-up with medicine that rises 100x in price.
Healthcare should be nationalized. Then the government would also have other positive incentives meant to lower healthcare costs, like reducing pollution, sugar in foods, other dangerous foods on the market, and so on.
I believe that insurance companies welcome legislation and regulation. It requires them to hire more people and buy more equipment and services. All of that cost then gives them added justification to raise prices, because ‘we are a public company and have a duty to return profit to our shareholders.’ All of that regulation is expensive to start with, and needs a profit on top of it.
Another true story, even with a Health Care provider and insurance company I don’t hate: after a routine visit, I had to spend more time on the phone with both of them than I spent in front of the Dr In order to have the service code corrected so the payment would count towards my deductible. The administrators I had to work with are paid employees, their costs not only have to be covered, but profitable. Very polite, capable and professional and completely unnecessary. I dare any non-American to come into our system and figure out in-network vs. out of network, co-payment, co-insurance, personal deductibles, family deductibles, lifetime maximums, deductible vs. non deductible services... and then write an App that compares plans, even within the same insurer’s portfolio and tells me which is the better plan.
Intentional value obfuscation, unnecessarily complex, adds to the bottom line.
My girlfriend is a doctor and says that working for the private care system she spends more time fighting with the insurance companies that treating patients - they want to pay for the cheapest drugs she wants to prescribe what is best.
Fortunately we have the option of publicly funded health care here in Europe which is what she recommends for anything serious.
I'm as much a capitalist as the next man, but lining your pockets when you're already a billionaire, at the expense of middle class, is downright pathetic.
If you profit off sick people, are you motivated to move toward a world with no sick people? If you profit from prisons, then you need to fill you prisons. Problem is, that as a society, we should aim toward not needing prisons at all. Therein lies the rub.
If I profit off of you being sick, then I need to keep you sick.
Normally that would be true, but under ACA profits are capped at 25% of premiums. They can increase profits only by increasing premiums, which can be justified by rising costs. Private insurance companies in America have no incentive to lower healthcare costs.
Well, that's true if they hit the cap and have no competition. If they don't have a 25% profit margin yet, they can still try to increase profits by cutting costs. There is also the strategy of lowering prices to increase market share.
The downside I was hinting at is that as a patient, cutting costs isn't always what you want. If it means more prevention or paying less, it's good. Otherwise it'll probably mean worse service.
As a European I would disagree. We have helathcare for the purpose of keeping people healthy rather than for profit. It seems to work out a whole lot better than your system in the states.
Given that Buffett pledged to donate 90% of his wealth to charities, I'm not sure you can characterize him as "mainly interested in lining his own pocket."
To me he is a character like Gates, Rockefeller or Carnegie. Ruthless, ever greedy businesspeople who get as much as they can out of business at any cost. Then they give a big part of it away. The question is whether the health care thing is part of the making money activities or part of the giving away activities.
You can always hope for the best so let's see what happens. Looking at the American health system I am not very optimistic.
I don't know. I don't pretend to be an expert in these things, but the impression I get of Buffett is a world away from Al "Chainsaw" Dunlap (CEO, more so than owner, I know), or even the Carl Icahn's of the world.
Why do you think this? His public and private actions generally seem to support the idea that he is ethically grounded, and I'm unaware of questionable behavior at any point in his earlier career. But I'm not that old, so I don't know who he was in the 70s.
I have nothing against Buffet. I just think that you can't become a multi-billionaire by being a nice guy. You have to be ultra (pathologically?) competitive and ambitious to get that far.
Buffet seems like a good-hearted person, but nothing about Amazon or JPMorgan leads me to believe this will be an altruistic enterprise. Also, Buffett is 87 and not likely to be involved for too many more years.
Buffet I'll give you, but Bezos clearly is not in this to help anyone out. One only has to look at the negotiations with the guild at the Washington Post to see that.
let's see, in a battle between employers pushing down on insurance costs and the morass of corruption on the healthcare side, who is the least politically organized? it would be a miracle if individuals don't get screwed.
Do you believe hospital Executives/VPs (which are more likely than not physicians) are not interested in lining their own pockets? Take a look at who sits on which boards and the rather obvious conflicts of interest within HC. The entire system is designed for billing. You realize clinicians make bonus on seeing as many patients as possible. See a patient for 15 mins bill for 1 hour.
I had the same unfortunate experience that in angers me to even think about it.
- I leave my last employer on July 21, 2017
- My old employer rols me off system on last day of July 2017
- On June 2017, they switch HR providers from TriNET to Namely and now the payment processor is Discovery Benefits and the Dental/Vision are now in Guardian. (So it went from Aetna to Aetna/Guardian and two other companies).
Since my wife is high-risk and I have thyroid issues, our best bet was COBRA ($1,000 / mo) because the new startup I joined did not offer group health coverage.
What followed next was this:
- The HR person who was handling my COBRA papers left during all of this. Switched jobs.
- Thanksgiving break
- Weeks of "the system will update this weekend with your information."
- "They were suppose to process your dental, but they never did"
My wife and I tried using our new AETNA IDs once we had gotten them and they still told us that it did not work. I had to have an expensive thyroid blood test pushed back. Multiple dentist appointments postponed. Everything.
FINALLY, once I got my SSN and ID for my coverage on AETNA, I had to pay back premiums all the way back to August 2017 just to keep using my coverage. So that's $4,000 USD for services I could not essentially render. $4000 of my hard-earned money. Gone. For nothing -- basically.
They had the gall to tell me (AETNA did) "Sir, if you paid for anything out of pocket during the time of your retroactive coverage, we can pay you back any cost you incurred."
The whole reason we get insurance is to avoid those high prices.
I'm so spent. I'm not an angry man but these health insurance companies really drove it home for me.
"The whole reason we get insurance is to avoid those high prices."
But only for unpredictable, irregular events. Anything else is uninsurable. If someone sells you "insurance" for wellness checkups[1], regular, scheduled screenings ... or tires on your car ... you can be absolutely assured that they are taking from you as much, or more, in premiums than the cost of those services.
What you are looking for is socialized, state sponsored medical care. There is no problem in looking for that and I make no value judgement here on that.
The first step would be to stop mischaracterizing this as "insurance". It's not. It can't be.
[1] Yes, certainly wellness checkups and things like them can be enormously economically beneficial for the provider since they spend up front preventative dollars instead of emergency, acute dollars later but it still doesn't change the fact that those are not underwriteable as they are regular, on-going expenses - very much like the tires on your car.
Your comment seems to overlook the fact that insurance companies negotiate better rates on many (most?) services than an individual would get going at it alone. From that perspective, I think it's reasonable to say that in our current system, insurance can allow you to essentially avoid high prices even for things that are predictable/regular.
That is because providers can't refuse healthcare to someone that needs it and can't afford it, so those costs get inflated just to be able to get a fraction of it. As rsync says, it's still not insurance, it's just the ability to be part of a group large enough to negotiate pricing, and has enough credibility for providers to trust them to be able to pay.
Yes, of course. I meant to convey that for the providers that can't refuse, like hospitals or ambulances, sticker prices not realistic because the provider is having to gamble on which portion of the people they treat can and cannot pay, and how much, so they inflate their prices extremely high. And also to negotiate with insurers.
This is not clear, in that "concierge doctors" or cash only doctors to some, seem to have rates that are lower than what the insurance companies claim they are billed for a service. That would suggest they are lousy negotiators.
I don't disagree, but I observe that if the interests of getting the lowest cost were aligned with the insurance company, and if the complexity of billing was a significant cost factor, it should be well within the capabilities of the insurance company to simplify the billing (by simplifying the requirements) in order to lower overall costs. And yet here we are :-)
I don't think this is true at all. The doctors have to justify their costs and the insurance companies have to validate that they are worth covering. Neither of those seem simple unless the insurance companies simply said, "Whatever the doctor wants to do, and whatever they charge is fine."
How do you come to that conclusion? I've seen a number of articles and cases like [1] where a company decides to charge apparently "what ever it wants" and the insurance company said "fine" and paid it. This article[2] talks about the wide range of prices for the exact same procedure within the same area. Is it your understanding that each of those different doctors justified their costs and the insurance company validated them?
Each doctor offers hundreds of services/procedures. Each one has a different price. The insurance company needs a certain number of doctors in the network to be competitive and they can't really have hard cutoffs for every single item. It's not that surprising that there are outliers.
Additionally, lots of doctors often bill incorrectly on purpose so that a particular services/procedure gets covered, so I am not sure we should keep "justified" and "validated" in these discussions.
I worked in health care and saw so much money wasted. The ACA was suppose to bring the same risk factors to everyone, so you got the same premiums based on age, gender and smoking status. Big companies got big breaks for employees and the rich paid less.
This might have worked if everyone was required to buy from the market place and there were no employer plans. Obama's famous "You can keep your existing health coverage" was a terrible, terrible decision.
I watched the Medicare/Medicate group for my company and they might have complained about not getting enough money, but I really think they did. Things had fixed prices and there'd be plenty of money if BlueCross didn't spend money on advertising, useless wellness programs and shitty IBM technology.
Everyone should just get Meidcare/Medicade. The government won't control healthcare, it will just get contracted out to providers. They'll have to cut costs and not waste so much money (they waste A LOT!)
Capitalism + Health care is a failed experiment. Socialized health care does work, in every high income country that's not the United States. Australia fought against the Abbot government when they wanted to introduce copays. That's right, Australians don't have doctor co-pays (they kinda do now, but wavers are in place and the plan was effectively defeated).
The fact that the US government requires us to buy private health insurance at insane rates is absolutely insane and the Supreme Court should have struck it down. You are not a car. Your body shouldn't have a fee for existing.
How high are your taxes in your socialized medicine nation? What are the knock-on effects of those high taxes in terms of economic stagnation, poverty, etc? I am so sick of the "but muh socialized medicine rocks" while others are paying for your problems and having their mobility curtailed by YOU without any acknowledgment regarding the real situation.
In the US we have historically enjoyed economic mobility and very loose class structure. That corporations have gamed the system is something that needs to be addressed. But to have prosperity and real freedom means that we aren't working via "collective" rights and aren't just a bunch of dumb Matrix cucks fooling ourselves like Europeans seem to be.
You can also negotiate on your own. I've occasionally had medical bills that for whatever reason were not covered. I call the provider and if I owe $1,000 I'll say I can pay $500 today to settle it. That's more than they will get selling the debt to a collector so they will take it.
You generally can't negotiate in advance though, because most providers seem unable or unwilling to tell you what anything is going to cost.
It's rather entertaining to see the fallout of costs becoming more transparent in America's healthcare system. There is a reason why the medical field is so lucrative in the US, and it's because for decades it's been subject to extreme price obfuscation. This is great for the merchants (pharmaceuticals, doctors, hospitals, medical software providers, nurses, etc), especially for such inelastic goods such as healthcare.
Now that organizations in the US have reached a breaking point, those costs are becoming clear to the consumers and they don't like it. You're absolutely right that the term insurance is bastardized in the healthcare setting, but people will have no choice but to understand.
If people want to blame somebody, they can start with the doctors union that restricts the number of residency positions open.
Residency programs are more restricted by funding for residency spots, not by the AAMC. Funding is, very weirdly, provided by Medicare. It's all a tangled mess with lots of weird stakeholders, but saying "doctors are using rent seeking behavior to limit new entrants to the field" is a bit disingenuous.
Doesn't the AAMC regulate the number of nurse practitioners? My understanding was that increasing the pool of nurse practitioners would help alleviate the cost of treatment for basic ailments, but that number is capped by an administrative body.
I explained it to someone recently as this: "This biggest problem with the healthcare industry is that incentives are terribly misaligned and patchwork. Because most of the market is formed by accreted law rather than naturally, even incentives for a given participant (e.g. an insurance company) are usually different than what you'd expect."
Allow foreign doctors to work in the us with a reasonable, attainable testing period of one year, and you will find no shortage of doctors in the us within the year.
Not sure I get you. "But only for unpredictable, irregular events." But if I went into the Doctor's office without insurance, could they turn me away? The bill would be too high?
We looked into ACA... but we thought that the process of switching over from AETNA to COBRA would be painless (weeks at most). So we just went through with it. We did not know it would end up like it has.
The operations for insurance is a daunting, slippery rope. Can you not lay some fault onto insurance and its operations?
What would you characterize this as? People slipping up? That's how the "system has always worked"? People forgetting to process paperwork needed so people can get to their appointments?
I think the parent is objecting to the use of the word "insurance". By definition, insurance is a form of risk management, to protect yourself against unexpected cost or loss. You can't be "insured" for regular wellness checkups and screenings; that word just doesn't make sense there, as those are expected, regular costs. Coverage for that is more like a "health plan", which is, in reality, what we have, despite the industry's insistence on calling it insurance.
I believe OP is talking more generally about insurance (not just health). Insurance covers you for unusual unexpected large-cost events at the cost of regular, predictable payments. They are useful in capping your risk exposure.
But if the events are rather certain, then the insurer can only act as a payment plan on the events. The risk is 100%, so at least 100% is priced into your premium (profits, a overhead, etc take it over 100).
Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs.
Even covered wellness care probably comes out a bit less than it would otherwise cost, because not everyone uses it even though it's covered. Some people, like me, just don't go to the doctor.
This is why the poster called it a socialized system. You are literally spreading the costs to the society of individuals in the plan. That is not insurance.
Now, it is common for "socialized" to be a scary word. So that people try and name it other things. But you aren't spreading the risk here. You are only spreading the costs.
Well, I'd also argue that you are spreading the benefits. Which is a good thing to me. Point being, though, it is not insurance.
"Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs."
This is why I used wellness checks and tire changes as examples - they are regular and universal.
I'd say that healthcare is just one of the fields where bureaucratic incompetence is horrifying. There are many others, like the legal system confusing two people with the same name in the same town.
This isn't quite correct for American health care. It is absolutely cheaper to pay insurance premiums than to pay directly for medical bills. The insurance company takes in more premiums than benefits that they pay out but the price that insurance companies negotiate for a procedure is dramatically lower than what you would be able to get if paying directly.
That's the way COBRA works though: you have 2 months to elect it, but if/when you do, you have to pay premiums starting from the moment you lost your original coverage (and have retroactive coverage).
Yep. And I elected ASAP. One of the first things I did starting new job.
But the I continuously got the "we have you down for this provider" when my COBRA admin told me that that provider could no longer give me coverage. I needed to AETNA to file me under a new provider.
Then I called AETNA and they still said "so and so" is listed as my provider. I told them to change it. "It's gonna be at least a week to update your information, sir."
Call back next week, "sir, you are still listed on 'so and so' provider."
No, Cobra rules are all defined in Federal law. The OP could have gotten care at the time and asked the doctors to defer billing until the insurance resolved (or just submitted to the insurance company anyway and followed up later). If the doctor/hospital balks you can show them your Cobra paperwork to confirm it. But yes you have to pay the premiums.
In retrospect this is probably what I should have done.
edit: but the thing was, I trust them to give me good advice. The HR providers. I figured, well if they haven't said anything about deferred payments, it might not be applicable to my situation so I never brought it up...
Already have, thanks. Actually bought another house after the 3 year mark when I was eligible for an FHA loan. Luckily, my credit score is pretty excellent.
This was back in the early 2000's just before the actual market crash. It was insane to me that banks were willing to work with people that bought houses they couldn't afford but that they wouldn't work with me on a loan modification because I wasn't delinquent.
I don't understand why it should take days to "update" a system. Now, I now next to nothing about how their current system works but information updated should not take so long.
The insurance industry needs a technological overhaul but I doubt it will happen.
I encourage you to contact your state's insurance commissioner. Further, in my state, they admin the COBRA program. In my experience, the state has been very supportive, helpful. Whereas the insurers and payers will do very little to help.
People feel that politics are tedious, but this is exactly the reason to pay attention. Look farther than your case and systematically review overall national stats of healthcare costs in the US vs other nations. We pay the most of any developed nation, double on average other developed nations, almost triple the best run healthcare of other nations. We not only pay much much more, people die sooner and go bankrupt more under this system for completely preventable reasons.
Edit: And great that there might be a new value conscious private competitor out there - but I'd note that all those other developed nations that are individually, collectively, and vastly outperforming our health system all have some form of government control on drug and procedure prices. And a single private company would be very hard pressed to replicate the negotiation leverage of a government. I'd also note that I'd trust JPMorgan about nil to be concerned about customer value over company profits. Other nations have a health system, and at the end of the day we have a health market.
One of the nastiest things in the failed TPP from my perspective were provisions to make illegal a government agency in my country that successfully keeps costs of medication down by forcing competition and negotiating strongly.
The numbers are small by world standards but I guess the drug companies are paranoid of this idea catching on in, say the US.
I’m sure it will be regarded as communism, but hey, it makes the market actually work for us here.
I think it would have been incredibly foolish and costly for your government to sign onto that provision. It's funny that the arguments seem about single or multi or hybrid public private billing arrangements here - but if you look across the national stats, all of those arrangements perform better - because a root cause that I think there are in those nations, a regulation of cost by medical experts in that nation vs efficacy of various drugs and/or procedures. The dream that somehow laymen off the street can shop for medical care like shopping for a pair of socks and that would balance the market in price or knowledge of derived value is really naive in my eyes.
I've also had lots of weird and frustrating insurance and doctor issues, but am surprised COBRA was your best bet or that your wife being high-risk was relevant. In the current system your preconditions shouldn't be a factor in the price.
I am also high-risk and have always found that the Obamacare market had prices close to or lower than the unsubsidized cost of an employer provided plan.
The most frustrating for me is that the doctors can't even guess how much their facility will charge for the treatment they decide is necessary, much less how much the bill will be after insurance gets their cut. It is a major barrier for me to get MRIs and blood tests. Especially blood tests, which seem to range in cost from practically free to thousands of dollars for a single blood test panel.
It's infuriating, and no matter how closely I read the insurance fine print I still cannot guess what the hospital and insurance plan negotiated ahead of time. Kaiser was way better, at least there the incentives were aligned to sane billing procedures.
You’re right, but respectfully, in the long term, “I want this specific provider at any cost” is somewhat of an edge case. A lot of (most?) people just want good healthcare and a low cost. That’s a complex but solveable problem.
No, its not an edge case. If you have a rapport with a doctor/care provider, you would want to stay with them. I have a genetic disease and an endocrinologist who helps me manage it. I wouldn't want to leave that doctor, who has seen me multiple times, has my charts, understands what Im working with, and so much more.
But isn't that OP's point? By nature of your specific disease/condition you are a bit of an outlier no?
Obviously the ideal would be you have a system that accommodates "my kid has a fever/fell out of a tree and broke their arm" majority of medical issues who could be helped by basically anyone trained in basic medicine while also accommodating people who need a rapport with a highly trained/expensive specialist.
That's how I took the comment...apologies in advance if this comes off as insensitive to your condition, definitely not my intention.
People want to believe that their medical condition(s) are a special, one-in-a-billion mix requiring years or decades of rapport-building and conversations. That's not the case for the vast majority of people, even with very complicated medical histories and diagnoses.
"Has seen me in the past" and "has my charts" are not indicative of medical efficacy. There are doctors I have rapport with, absolutely. I still have lunch occasionally with the physician who was my family doctor as a child and still sees my parents. But that doesn't mean his medical treatment is going to be any better than a doctor seeing me for the second or third time.
Given the tiny slices of time doctors seem to have for each patient, it would seem that having time and history to have actually spent time with patients and their medical background would seem to be a common sense advantage. It's good to see that borne out in evidence.
There's also clinical evidence in favor of placebo usage, that doesn't mean that placebos increase medical efficacy, it means sometimes people just need to feel good about what's happening. And people - myself included - would probably prefer seeing the same physician long term.
Wait...except the decrease in care when transferring a patient to a new doctor is the EXACT reason health care professionals say we can't put a cap on working hours and introduce more doctors to help with the work-load.
They always says it hurts the patient's care. I think there is some truth to both sides, but we'll probably never know. Too many people are making out like bandits in the current health care system.
I bet that health outcomes are improved with longer term patient-physician relationships - Imagine having a new family doctor every year vs. a doctor who has known you for the last 15 years.
edit: This (quite extensive and longitudinal) study would suggest that it's true. Check out the sources on the paper for other studies with similar findings:
Indeed - I am familiar with people who were misdiagnosed by a GP (in England) for over a decade before a visit to a different doctor yielded the correct diagnosis and treatment.
Each rare disease is rare, but it is not very rare to have a rare disease. There are just thousands of rare diseases. For example, it is estimated that 6-8% of the EU population has a rare disease: https://en.wikipedia.org/wiki/Rare_disease#Prevalence
Thanks, it's great to know (also that 80% has a genetic component).
I have a rare disease (shortness of breath caused by air pollution, especially when lying down or excercising), but all pulmonology doctors are sure that I'm just depressed after the usual check-ups are unable to show the disease (and I'm not coughing which is unusual for most similar diseases). I'm trying to find blood tests and gene tests that help me find the disease I have, as I've given up on doctors. I also know multiple people with BRCA gene who weren't taken seriously by doctors before they had the gene test.
I've had great luck with just using whatever specialist is in network by default, and just calling or emailing my old doctor for a second opinion if something weird happens. I assume not all doctors are so communicative, but I think many are happy to help as long as it doesn't take much time.
The OP reports the insurer misrepresenting their in-network coverage. I've had this experience with BCBS -- the list of in-network doctors on the website was wrong. Hard to prove incompetence vs. malice, but there seems to be zero accountability for this sort of thing.
> “I want this specific provider at any cost” is somewhat of an edge case
Not really. I want someone I can trust. For my primary care needs, I have established trust with someone and know their capabilities, their business practices, and their character. I don't want to roll the dice with someone new when I can still go to them.
Example 1: My primary care provider(been seeing him for 10 years.
Example 2: My dentist (been seeing him or his predecessor for 30 years)
It's a bit of an aside, but this whole issue, the bare knuckle fight about health care brings about an interesting deeper rooted issue that clearly and uniquely differentiates the two primary perspectives; one side always tends towards the heavy handed, imposing, authoritarian approach to force things they deem self-evident as desirable or have determined to be "good" and are thereby inherently inefficient and wasteful due to it's centrally planned, waterfall type approach ... and the other side tends to want to set up incentive structures that create pressures for efficiency and allows for free will and self-determination and discrimination to both succeed or fail on their own accord.
It is an eternal struggle of authoritarianism and imposition trying to subdue self-determination and self-governance.
Let's tear down on the government restrictions on the sell side of the market before we champion the glory of the market.
Repeal EMTALA. No patents. No certificates of need. Make Medicare and Medicaid fully opt in for providers. Create a path for additional private organizations to certify medical schools.
Anyone refusing to do all that stuff and face the political consequences for it just wants to pay less taxes.
I wasn't getting as specific as "championing the glory of the market". But in a general sense, what you are referring to the "market" is really the origin of control. Who is in control over your life and decisions in it and the consequences from it ... are you in control or some other party like politicians or bureaucrats who lord and decree and impose what you can choose if you have a choice at all, which invariably must include the ability to exclude oneself from matters that are not a common expense and value, which cannot be individually separated out like defense or cost of core governmental functions.
It's the age old question, who is a better person to make decisions for yourself, you yourself, or some person somewhere that believes they know better what is best for you in your particular set of circumstances. Some call it communism, some marxism, some authoritarianism, some totalitarianism ... but ultimately they are simply differing degrees and characteristics of the same question ... who controls your life?
Okay, lets start by repealing limited liability for investors.
If the government has no place simplifying the process of buying insurance (by making sure products are available, comparable and reliable), then the government has no place protecting people from legal consequences related to their investments.
If my employer buys health insurance for me, neither they nor I pay taxes on the premium cost.
If I buy the exact same policy for myself, it is fully taxable to me.
The amount of taxes is not small, about $1000 per month.
So, the government is already imposing a very strong centrally planning effect on how health care works by tax policy.
But to be real here, the main motivation for creating this new venture is employer cost.
Some people might not be aware that the vast majority of large employers in the U.S. that offer health insurance are self funded (i.e. they collect premiums from themselves/employees and take on all the insurance risk), so anything they can do to lower any direct/indirect cost with plan administration, claims, drug cost (big one), healthcare utilization, etc. will save them billions easily.
>Only about 26 percent of employers with between 100 and 499 employees self-insure, compared with more than 82 percent of employers with 500 or more employees, according to data from the U.S. Department of Health and Human Services.
That being said, they don't usually take on ALL the insurance risk, they typically purchase stop gap insurance for very large claims.
I wonder if we could collectively use civil disobedience and refuse to pay for healthcare and insurance until major changes are made to the system. Non violent civil disobedience. Essentially a strike against the system.
You could until someone gets sick and needs medical services, hoping they don't go bankrupt due to their lapsed coverage due to non-payment.
The biggest problem I see are the costs. The healthcare industry can't even tell you why costs differ on so many levels of services. The industry isn't transparent and they'll fight this because it's too profitable for them.
Your desires are mutually incompatible. Imagine you’re contracting for cloud hosting services, and you start with the premise you’re not going to switch away from your existing provider. How do you achieve cost efficiencies in that situation?
Rolling their own health care company might solve only part of the issue. I think the largest driver of healthcare costs right now is price gouging by providers with their charge masters, needless exams and procedures.
Three large employers, realising that for-profit healthcare is expensive and inefficient, create a non-profit that pools healthcare and is driven by its member's interests.
This is terrible if it works.
Imagine if other employers want to join it. And then even more employers... and what if the scheme becomes so large and covering so much of the population that it ... gasp... looks almost like a government-run non-profit health insurance scheme! You know, like what those Marxists in Europe have.
And where it would it end - soon people would be demanding cheaper drug prices and being able to negotiate prices for drugs! Insane
(In case its not clear, the above is written ironicly. I am all for a well funded government-run health service)
There will be economies of scale. The bigger the pool of employees the lower the costs, so yes there are options but they could get fewer if this takes off.
What we oppose is being forced by the government to accept a 1 size fits all plan, and not being allowed to buy the healthcare plan we want.
It is the difference between everyone using Facebook because they like the product and the network effect, vs everyone using governmentBook because the government outlawed all competing social networks.
If the US only allowed one grocery store to exist, that would have economies of scale as well.
Shouldn't we then give everyone "food insurance" which you pay for with taxes, and then are able to use that food insurance to get food from the store for free? (well, not really free, paid for by your taxes). You'd pay a predetermined amount of money no matter what you got from the store, but your options would be limited by the government food insurance committee.
If you don't support this single payer food insurance solution to all of your caloric needs, then my question for you is why do you hate poor people?
Government provision does NOT stop the private sector from providing options. It is not an either government OR private. But both. Your example does not exist anywhere, nor is it what it is being advocated.
To be realistic your example would be as follows: what if the US provided a grocery store that provided the basic necessities, free at the point of provistion and paid for by common taxation. People are free to buy the nice wine from the private provider next door BUT if you fall on hard times and you need to put food on the table, the rest of your fellow citizens help pay to make sure you, your partner, and your children have food to eat, and retain a semblance of human dignity, until you can get back on your feet and pay taxes that provide for someone else who needs help.
Where does it stop? If "healthcare is a right" and "food is a right" and "shelter is a right" who is going to pay for all of these services for all of these people when they have no vital need to go out and support themselves? Who's going to maintain the sewers and take care of the trash and all of the jobs that most people don't want to do?
Based on the results of the last few election cycles, I think you are being overly optimistic but I hope you are right. We could not even get the Medicare age lowered to 55 because it required a super majority in the Senate and that failed when Democrats has 60 votes because there's always someone holding out, in that case Joe Lieberman. When Democrats adopted the healthcare plan advocated by conservative thinktanks into ACA/Obamacare, the conservatives moved farther to the right - every time what we see is the Democrats triangulate and the Republicans move the goal posts.
I read it as "Apple, Berkshire and JPMorgan" at first, and I was very excited to see such a customer-first company finally taking on healthcare.
Then I read the top comment and saw Bezos. Oh. It's Amazon.
I do not want my medical provider and experience to be optimized to the point of insanity.
Healthcare needs to be fixed, but I'm pretty sure these three companies will create a monster worse than the one we currently endure. (Profits or not.)
I feel there will be a series of HC acquisitions ranging from unicorn startups to major HC providers. I don’t have to name the qualified startups, they are too well known... Great time to join an insurance startup!!!
One reason this is likely to be less expensive is that the employees of those companies tend to be well paid and to have had ongoing access to health care. Essential tasks ordinarily done by the working poor are usually outsourced. In the case of Amazon, it's not just things like facilities maintenance and janitorial workers that won't fall under its health care umbrella, it's all those warehouse workers engaged in physical work.
Essentially, the costs will be lower because the new company will cherry pick. And again in the case of Amazon, the tendency to hire young workers also works in favor of lower costs. This is disruption in the same sense that Amazon's pillaging the public purse for its new headquarters is disruption.
I’d join that company. First thing I’d do is properly line item every coded expense and expose it to the end user, and compare it with averages of other providers. Expose people to where they are being ripped off and where they can get better prices.
After my wife giving birth last year, I would say there is quite a bit of room for improvement. The whole billing process is such a mess when you receive different bills from doctors, the hospital, labs, etc. It seemed like the bills rolled in for months afterward, some going through insurance and some not even being billed to insurance.
Happy to have insurance after I saw the total bill, but man is it a huge headache.
I hope they figure something out if we never make it to a single payer type system.
It's worse if you get the surprise "Out of Network" doctor that assisted in the delivery. Nothing like getting a surprise $1,200 bill when you're sleep deprived. Long story short, we didn't have to pay any of that $1,200. But the last thing we needed with a new born was more stress.
It is a welcoming move. I hope they make it available for public sector as well. I would be more than happy to have my prescriptions delivered using Amazon Prime same day/2nd day service.
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[ 3.7 ms ] story [ 455 ms ] threadRising medical costs and increased consumption of medical services is good for physicians.
Freakonomics did a pretty good podcast[1] on the subject.
[1]: http://freakonomics.com/podcast/nurses-to-the-rescue/
EDIT: Do downvoters care to explain their views?
Is it clear that they will be offering these services to outside clients? Or is this just a way to keep down Healthcare costs across their organizations?
Others might argue this is free market at work.
The free market coming up with a co-op approach that may only benefit the handful of companies involved only benefits me if I’m in one of those companies.
This country has socialism for the rich, rugged individualism for the poor. - MLK
I imagine there's a cost to set this up, but is that cost less than the marginal cost of each employee and the savings they would (presumably) receive if enough people joined?
Even so, your main point is taken. There's a broad directorship problem with many non-profits, higher eduction, and mutuals. General users of these public services either have no say -or- have no reasonable way to exercise their limited authority. For example, State Farm Mutual permits its subscribers to show up in person on a particular day once per year in order to vote from a set of directors that was selected by... the previous directors. I'm curious what sort of legal/social/technology solutions could be put to use in addressing this administrative capture.
Also another reason you couldn't start a big non-profit is because insurance companies are limited in reach by state/region. Sadly, that's one of the few things keeping them in check. If that regulation was removed, you'd see all the Blues and other companies start to merge into only two to three mega companies, similar to cell phone providers.
The average annual premium for families for health insurance was $5,791 in 1999. The median was even lower. Today it's closer to $18,000.
The system worked at $5,791, the average family could afford that without much problem. At $18,000 the system breaks apart and fails for the typical family. Wages for the US were even further beyond comparable nations back in ~1999. With very modest real wage growth since 1999, especially at the median, that $18,000 cost essentially represents money in the economy that should have in part gone into wage growth.
These large companies now have a powerful incentive - for several different reasons - to begin hammering down the cost of healthcare. Their action on this front is a positive fortunately, these companies are extraordinarily powerful, both politically and economically. If they're dead set on bringing down the cost of healthcare, that's exactly what will happen, and they'll gather other very willing partners and the momentum will likely roll.
Do you happen to know the sources of inflation? Are we consuming a lot more services? Are healthcare providers being paid more? Are healthcare companies getting rich?
[1] https://fee.org/articles/the-chart-that-could-undo-the-us-he...
Administrator salaries don't seem to explain this: https://www.statnews.com/wp-content/uploads/2016/03/ASPE1.pn...
Nor this: http://static3.businessinsider.com/image/556494646da8110d29e...
This sort of thing probably doesn't help, either: http://www.foxnews.com/us/2018/01/30/drug-companies-flooded-...
One could argue drugs cost too much, but you can't argue they are a major reason for soaring healthcare costs.
https://www.statista.com/statistics/184914/prescription-drug... says we've gone from $121B/year in 2000 to 360B/year in 2017.
As the other comment noted, there has been a vast expansion of administrative bullshit cost in the system.
Pharma drug costs have gone up a lot (that's around 10% to 15% of the $1.x trillion cost problem the US has). The US is spending about ~20% of its GDP on healthcare, or roughly twice the OECD average (~70-80% more than countries like France or Belgium). That's up from 12.x% in 1990, and 14% in 2000 (that 6% representing an added $1.x trillion in cost). That 12% figure in 1990, is comparable to what nicer developed nations spend today.
US wages are high, healthcare workers typically earn far above the median (eg US nurses and doctors are very well paid), and we've hired a lot of healthcare workers in the last 20 years. The number of healthcare workers has roughly doubled since 1990 from eight million to around 15-16 million today. A near 100% increase vs a population increase of about 30% or so over that time. That is guaranteed to generate a massive cost spike for that part of the problem, and that cost isn't being distributed across a further 100% larger population base. Healthcare workers have also seen their wage growth exceed the median wage growth, they've mostly done ok. So the net cost per capita for each healthcare worker in the US, has soared.
Insurance companies have done exactly what you'd expect. They push prices as high as they can get away with, adding more cost bloat to the system.
The American diet deteriorated dramatically since ~1980. Obesity particularly soared from around the mid 1980s to 2015. That brought with it a lot of added healthcare costs, around cancer, diabetes, and so on. These people weren't/aren't dying so much as they are requiring expensive routine care for various health consequences of the obesity. Conceptually it's like the battlefield cost of having a vast number of wounded soldiers, rather than those soldiers simply dying instead; in this case the battlefield is the economy or society generally speaking.
And then the US population has aged quite a bit in the last 20-30 years. The boomer generation is going to be extraordinarily expensive from a healthcare standpoint. For now that's getting worse by the year as with most developed nations.
When I log in to check my 401(k) status, there's a button that will tell me my projected income and expenses down the road. Today, I'm 47 and spend very, very little on healthcare. However, when I'm 87, they project I will be paying more than $10,000 per month for healthcare. How is that possible?
All across healthcare, providers, scientists, administrators are faced with millions of tiny choices every day: should we spend more money to improve outcomes. Should we add that extra feature to this device - costs more but improves care a little. Should we use this more expensive material - costs more but is probably safer. Should we do additional testing - costs more but we'll be more sure it's safe. The calculus of incremental value vs. cost is subconsciously seen as inhumane across the industry -- it's seen as starting down that slippery slope that ends with a "dollars per life" number which feels wrong to everyone. Nobody wants to be the person who traded someone's health for a buck.
I'm not necessarily condemning it, I want the best possible care for my children, but I do think that (like a lot of big socioeconomic problems) this comes back to incentives.
The US spends 2-3 times what the rest of the OECD countries spend on a per-capita basis. https://data.oecd.org/healthres/health-spending.htm
For all that spending, we have lower life expectancy and worse stats in a variety of outcomes. http://www.commonwealthfund.org/publications/press-releases/... http://www.latimes.com/nation/la-na-healthcare-comparison-20...
Not only does healthcare not have to be expensive, it isn't (comparatively speaking) in the rest of the developed world.
That's not what's going on though, is it?
All across healthcare you have groups trying to provide an evidence base, and other groups trying to decide whether that evidence base means something is value for money or not. In England that's going to be NICE, in the US it's insurance companies.
The US has a serious problem of over-testing. The reason isn't because they think it improves outomes. They know it doesn't, they know it makes things worse. They over-test because it means they're less likely to get sued. The cost of the test is lower than the cost of getting sued, even though too much testing is causing harm.
Look at cancer outcomes. People that live 5 years with cancer consume a lot more medical care than people that die quick.
And all sorts of other things are similar. Trauma care is better, etc.
It's clearly not the only factor but I'm pretty sure it is a factor.
http://slatestarcodex.com/2017/02/09/considerations-on-cost-...
See more on payer breakdowns vs quality at http://costatlas.iha.org
A full rewrite of this app with more data and better mobile design launches in February.
At least in my area Kaiser also likes to centralize certain specialties at a single one of their health clinics. For instance mental health providers are only available in one location. I live in a large metro area with severe traffic issues. The clinic mental health services are provided out of may be the worse location for the majority of the service area to reach. For me an appointment would have involved a 45 minute to hour drive each way.
A couple of years ago Kaiser decided not to renew their contract with the non-profit hospital system which dominates this area and instead signed a contract with a for profit hospital system. This means there is a single hospital within a reasonable drive of me which I would be able to utilize. Even then there are 3 hospitals in the non-profit system which are closer or equal distance. It gets worse if for some reason I would have had to use the next closest hospital Kaiser will cover. There are 5 hospitals in the non-profit system that would be closer. Also the non-profit system is nationally recognized as the top or a top 5 care provider for several specialties. The for profit is not.
I have no love for Aetna, Cigna, United Health, Anthem or any of the other large health insurance companies, but Kaiser also doesn't seem to be the model to follow.
Likely the fact that many of these prices are basically standardized because of CMS. Providers basically look to what the Medicare/Medicaid standard is as a benchmark for pricing.
As a provider why accept a lower price from insurance when the gov't is providing a backlog of people at predetermined prices?
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Unless these companies are also looking to enter the provider space, they will likely only competing on marginally better insurance rates.
This isn't even an option on the table. Private insurers are generally required by law to pay more than Medicare does.
And besides, Medicare reimburses rates that are below COGS, so providers charge private insurers more in order to make up the difference. Otherwise, they wouldn't be able to accept Medicare patients at all; they'd literally lose money on a per patient basis.
Heck, we could even create a HN-cooperative that any of us could join, sign up and pay a nominal membership fee. Then we could off and all be independent contractors etc. without fear of losing benefits.
I wonder if they will be setting it up as a health insurance cooperative, an organizational structure in which the primary goal is to serve its members, rather than to generate value for external shareholders: https://en.wikipedia.org/wiki/Health_insurance_cooperative
It's not at all unprecedented for publicly traded companies to create cooperatives for their employees. Employee credit unions are one example.
Co-ops were part of an early proposal while the ACA was still shaping out, but unfortunately, due to pressure from for-profit health insurers, they were later shot down: http://www.nytimes.com/2009/08/17/health/policy/17talkshows....
As a fan of distributism https://en.wikipedia.org/wiki/Distributism, I would love to see an increase in health insurance cooperatives, and cooperatives in general. Under a cooperative structure, the members/policyholders fully own the company, so it's not beholden to outside shareholders seeking to profit at the expense of its members. Any profits that a cooperative generates are returned back to the members/policyholders in the form of lower premiums, or improvements to services.
Unrelated: one of the worst parts of insurance is the customer service quality. How does an internal, non-profit insurer staff itself to do this well? If they commit to this even at the risk of it being unprofitable, that would be most awesome —- but I’m skeptical.
But the same motive applies to co-ops. The member-owners of a co-op don't want their costs to be inflated by improper billing or inflated prices, because if they are able to reduce their expenses, then the member-owners benefit in the form of lower premiums.
In both cases, the shareholders want to get their money's worth, it's just that in the case of a for-profit company, those shareholders are often external investors, but in the case of a cooperative, all shareholders are also members.
Healthcare costs are so bad they're now a large, direct competitor to the Amazons and Berkshires and JP Morgans in a business well-being sense, as resources are finite. I like having these giants stepping up to the plate and targeting the healthcare system on cost. They tend to get their way; if a political rock (eg insurance companies) gets in the way, it'll get moved out of the way.
It reminds me of the 450 hospitals getting together to set up a not-for-profit generic drug company recently -
https://www.cnbc.com/2018/01/18/hospitals-plan-to-create-the...
The ACA requires insurers to spend 80% of the premiums they take in on direct healthcare costs for their members. Inflated billing and high drug costs are actually helpful if they want to make a nice big profit. To a point, at least - they've gotta find the right balance between profit and people being unable to pay their premiums.
Higher medical expenses don’t help. It only creates higher premiums, which members then blame on greed.
There are plenty of legitimate problems with providers, drug laws, and insurers. But insurers definitely don’t benefit from higher expenses.
AKA, 10% of 2 trillion is more than 10% of 1 trillion.
And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies.
Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.
Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates.
Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D.
> Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself.
> There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
Yes, that's true. And that would be true even if you only looked at Medicare patients.
Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers.
A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance.
Medicare isn't simple, it's just a small piece of a very big shit sandwich.
This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous.
> Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich.
As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.
I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.
They are actually overlapping problems, since some of those private lines are Medicare Part C or D plans (and some are Medicaid managed care plans, and some are both Medicare Part C and Medicaid managed care plans.)
Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly.
The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.
Whenever I want to feel sad, I think about how the most brilliant minds of our times are probably making a fortune at such zero sum transactions as gaming the health system and tax code.
Out of network means the insurer and provider have not previously negotiated a rate. And emergency services are among the most expensive bills out there.
They are interrelated, yes. But fundamentally we are at a place where providers, especially hospitals, are billing insanely high rates for services compared to other countries.
What Americans think of as “health” “insurance” fits this model. Providers are in the business of soaking their customers the various tax-favored third-party payers for all they can. Of course prices rise continually. People are stirred into a frenzy about rising costs and demand that politicians just do something! The insurers get more tax-favored money that providers happily mop up.
They already sell it: https://www.amazon.com/Professional-Medical-Supplies/b?ie=UT...
I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
You missed half of what I wrote, "instead of in 20 oversized but mostly empty boxes." The context was in a single order from a single supplier, whose product was already at the warehouse, shipping on the same date, to the same address, for the same delivery date, using the same delivery carrier, of almost identical items that almost assuredly are on the warehouse shelves right next to each other.
> I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
That may be the case, but I am referring to the incorrect packing of boxes not trucks.
They could have arrived from the supplier in small batches (or even one-by-one) over time if it's a low-volume sort of thing. Amazon might intentionally spread them throughout the fulfillment center in some situations to expedite packing and reduce the distances their robots have to travel.
They might have just needed twenty boxes to finish the tetris puzzle to send a truck out the door.
From Amazon's point of view, they're doing both correctly.
Their algorithm apparently optimises for packing completely filled tucks leaving the warehouse first, then optimises for minimal packaging second.
If they need a few more boxes of a particular size, to completely fill an outgoing truck, they will split some orders appropriately so that those boxes appear on the conveyor at the right moment.
This means that sometimes you receive an SD card in an A4 size box, because that was the only item that was available when they needed an A4 box to fill a truck - and the algorithm decided that the trade-off was worth it.
Newman's Own is one interesting (and successful) example I can think of that's an otherwise for-profit company acting effectively as a charity. Are there papers/books about how effective this would be in practice?
Not only that but the healthcare industry has extraordinarily high financial and legal barriers to entry.
Unlike Amazon and Berkshire, two of the best managed companies humanity has ever created?
> Extraordinarily high financial and legal barriers to entry
Unlike financial companies?
If there is a company with enough muscle to force themselves into the business, it's Berkshire.
Similarly, it makes more sense to have a non-profit coffee-buying employee group to buy coffee (at places that don't provide it for free) rather than pay a vendor to bring it in. But that's not because profit-making is an inherent drain on efficiency, but because the "judgment" that those profits are "buying" ... doesn't add much value.
Our family have been members for over 20 years. I'd rate their health care as "good", but the real benefit is that we have NEVER had a billing dispute, because almost NOTHING is "out of network". On the rare occasions we've needed non-Kaiser health care (such as ER visits while traveling), we just give the bill to Kaiser, and they take it from there.
When the insurer owns the hospitals and contracts all the doctors, customer billing is almost friction-free.
Healthcare: https://en.wikipedia.org/wiki/Bupa
Media: https://en.wikipedia.org/wiki/Scott_Trust_Limited
Retail: https://en.wikipedia.org/wiki/John_Lewis_Partnership
Finance: https://en.wikipedia.org/wiki/Nationwide_Building_Society
Lots of stuff: https://en.wikipedia.org/wiki/The_Co-operative_Group
The way to change the game in healthcare is to eject the legacy bullshit. Own the experience as a vertical, don’t accept Medicare/Medicaid and the price controls that come with it and you slice out a lot of the overheads.
The second biggest issue is that they are using archaic technology such as AS/400 systems and trying to ship data around using "file drop." File drop--in 2018! They doubled down on stupid technology choices years ago and continue to fail because of it.
The third biggest issue is revenue. You can't even run a non-profit without revenue. Employees don't work for free!
A related problem is that the company I worked for failed to promote people like me who could solve some of their problems for them. I lost the political battle as a tech lead. Had I been someone with more clout, things might have gone differently. Companies promote all the wrong people, though.
BTW, cooperatives are bullshit--even grocery coops have to have revenue, it's not magic. Coops fail because there's "no one in charge" and without decisive action there is failure.
Credit unions work because they extend credit based on typical fractional reserve models. Members of credit unions own shares based on their deposits.
You can't do use a credit union model with insurance because of how insurance underwriting works. Just look at the healthcare costs of any small company--if one person gets sick, everyone's rates go up. There's no magic as to how this all operates. There's no pool of people size n where n is large enough to fix the problem--which is why universal or single-payer systems are merely an illusion of prosperity while taxes rise to 80% and up! It becomes punitive taxation! Which means no freedom for any of the people living under such a system, and eventually the resultant economic collapse--yes, even in Europe.
Thank you for giving a name to something I have been pondering a lot. I have come to this conclusion by thinking about automation and technological unemployment. If people own land, or productive tools, they can be self reliant and exist without jobs from corporations, or help from the state. Naturally people would organise as a cooperative or a market of services, exchanging services for services, because they have little money and no corporate jobs. Yet they can work, so they can create a kindergarten for children of the neighbourhood, or a medical clinic, or a mechanic repair-shop, or a construction company, and so on.
By combining these skills a neighbourhood, or a city could be self reliant. In the future, with the advent of solar energy, agro-bots, 3d-printing and other empowering technologies it will be even easier to be self reliant. I see this as a better solution to UBI which depends on the state, which is corruptible and the corporations, which are greedy. People would retain their agency, unlike in the UBI scenario, where they would be wards of the state.
There is no purpose to automation that does not exist in the service of humanity at large, but only for a few. Automation must be owned by the people directly. We need to have the means of production in our hands in order to survive. There is one single job the advancement of automation can't take from us - the job of taking care of ourselves! And that's hard work.
I suspect that you also have more corruption and/or abuse of power because (a) the previous entries all empower sociopathic individuals, (b) you have a larger pool from which to find such sociopaths, and (c) you have more positions of power for said sociopaths to fill.
You have all of these problems in small groups, but many of our policing/accountability systems don't function well in very large groups.
I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy, which might lead to more wars. I have no idea if that's true, but it sounds plausible to me.
In the end, actually examining data is what's needed. Until there are facts to assess, we're just spouting wild conjecture.
https://en.wikipedia.org/wiki/Dunbar%27s_number has a decent collection of the research I know of. There is a little hand-waving involved when it comes to "why", but it's notable that multiple researchers over decades disagree about the number, not the base concept. Likewise, studies related to the base concept of the non-technical Brooks Law support the non-linear impact on communication as a group grows (off hand I can't find a study on that, but I know I've read of multiple).
Edit: Also https://www.psychologytoday.com/blog/how-risky-is-it-really/... points out some research about the distance/abstractness I mentioned.
Anecdotally, plenty of governing and/or economic systems (e.g. communism) have historical success in small groups and no examples of success in large groups, but that's a completely different kind of evidence.
The corruption/abuse item is not part of the research, which is why I separated that as "I suspect" Given the above, and what we know about leaders (executives, politicians) and how sociopathic tendencies are an asset to personal success I find it very plausible but I have no actual evidence, thus "I suspect".
> I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy
You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences. That's orthogonal to my point though, as I was only addressing internal workings, not interactions between groups.
My main point was that the theory was labeled as something you suspect, but the evidence you listed to back up that theory sounded like it was being presented as fact. You've provided resources to back up the claim, at least to some degree (as you note), which is what I was looking for, so thanks. :)
> You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences.
I don't have any, but I also would be interested to see it. I was using it as an example of something that sounded true and that I suspected was true that I had no real evidence of, and thus should be hesitant to assert as true. Unfortunately, by its nature that makes it interesting to a certain type of person, so it ends up teasing us. :/
The "distributism" described above is the dream of virtually every rural community. People choose to live in rural communities because it's a little piece of heaven for them: they are surrounded by people they know, they have clean air, the earth is right beneath their feet, the stars are bright, the pace is slow, and so on. They want to serve their neighbors and receive services from their neighbors. How is that mindset pathological?
I am always encouraged by innovations that help rural folks be more self-reliant so they can work toward their dream of self-sustaining, independent communities.
So, you either choose total independence and low technology or interdependence with other groups and advanced tech.
Although that independence would be like a group of proto humans that knew about fire and how to use it, but not how to make it, and thus carefully guarded it and kept it fed, lest it go out.
I don’t see a way around this, since you always have to start from the same raw materials.
1: https://www.bloomberg.com/view/articles/2017-06-20/rural-ame...
1) Our general trend is towards urbanization, humanity is now more urban than rural, and every quality of life index shows cities give more good to more people better.
2) Millennials, hipsters in particular, in American markets with crushing real estate prices have recently begun reverse-migrating away from the cities and to more rural areas with romanticized lifestyles creating some new demographic, and real estate, trends.
In terms of pure statistics we're looking at a sub-group with a different trend than the overall group. Most potatos aren't from my backyard, but those potatoes are only getting prettier while the many thousands at the market are getting uglier ;)
However, I will agree that my initial response was lacking and would have been better if not stated at all.
Communism is where all property is publicly owned and each is given what they need.
A commune is a self-reliant community, likely to be small - individuals need each other. A communist state is still a state, it is not decentralized like a commune, but very centralized. Instead of relying on each other everyone relies entirely on the state.
There certainly is, to the few that are served. Increased productivity that doesn't require manpower/hours has been captured for centuries.
A capitalist economy provides many incentives to privately hold productivity gains from automation, while providing virtually none to relinquish them to the public.
How is that self-reliant? It’s different from most of the current developed economies, but it’s still division of labour and relying on others for some things.
> According to distributists, property ownership is a fundamental right, and the means of production should be spread as widely as possible, rather than being centralized under the control of the state (state capitalism), a few individuals (plutocracy), or corporations (corporatocracy). Distributism, therefore, advocates a society marked by widespread property ownership.
> Distributism has often been described in opposition to both socialism and capitalism, which distributists see as equally flawed and exploitative. Thomas Storck argues: "both socialism and capitalism are products of the European Enlightenment and are thus modernizing and anti-traditional forces.
https://en.wikipedia.org/wiki/Distributism
So not to be snarky, but how is this anything more than simple "Marxism, minus the parts that don't work with Catholic religion, plus Catholic religion"?
The assertions of Distributism are that:
* Everyone has a right to private property (ad contra of Marxism) * That right to private property is not absolute (ad contra of laissez faire capitalism) * Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means (ad contra of if-it-is-not-100%-it-is-not-a-monopoly capitalism)
This is inspired by Catholic principles and promoted by Catholic thinkers, but it is certainly something one can come to without being Catholic.
Won't you just get run out by others who are focused on productivity and can beat you in trade and undercut your prices while delivering higher quality?
By a lot of accounts nomadic life was much better than early farm life. Didn't help the nomads in the end though.
Clumsily named, the aspects of "distributism" being lauded here only seem to involve convincing people to partly own instutitions rather than simply transacting with them as a third party. Seems to me that this reading of "distributism" is just capitalism plus a social norm of a bias toward involvement and ownership, rather than just employment and consumption.
That is Communism, not Marxism.
I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't, comfortably boiled frogs as the record shows them.
a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
b) Your view of history is perverse, and insulting to the many people that resisted and were killed off by Lenin & Co when they took power.
Show me the scores of people taking a stand while being placed under arbitrary arrest. Yeah, sure some people resisted, a whole lot more memorable than the millions who walked with their captors straight to the grave. It's not like they didn't resist because they were bad people or something, they just had no tools to deal with any of this, who on earth did?
For the most part, you're taken by night or in transit, and they show up to dig up your trash to find your cherished letters or the wrong souvenir, you're still wondering if all the other people who were arrested did what they were accused of. What does resisting that even look like?
This was all to prove some fantasy of a man with a weak spirit and infinite capacity to look outside himself for fault; and for Lenin and Stalin it was just their ticket into town.
> a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
I didn't say you had one, really, I said that if one were to be instituted, it seems it could only happen by force. Marx's conclusions are the fundamental source of the most inhumane behaviours of the USSR, the specifics are just gory decoration. It doesn't matter if the dissidents happen to be suppressed by genocide, imprisonment, or exile; only by suppressing the dissidents can you institute the envisioned solution. There is a considerable proportion of society which will simply not agree to have their life's work taken from them. Tell me what the important difference is between a solution which passively requires genocide, and a realized implementation of that solution.
Granted I'm underslept right now, so say whatever, I'll see it when I'm back on earth.
- People who can not work because they simply can't hold down a job, period.
- Externalities such as neighboring (or even distant) communes dumping wastewater into rivers etc., or polluting the ground, or air... you get the idea. What about natural calamities, such as earthquakes, tsunamis, volcanic eruptions, and such?
- Conflicts over scarce resources. Water, for example. Communes that rely on a common source of water will likely have conflicts. How are they resolved?
- Any commune is exceedingly unlikely to be good at producing all the things it needs. Trade will need to develop. Does 'self-reliance' exclude the possibility of trade?
- How large should a commune be, to enable innovation? Without innovation, there will be stagnation that will harm the commune in the long run.
- How would a commune handle people that are 'different'? How about criminals within and without?
We live in a world where (to quote GKC [1]):
> Lancashire merchants whenever they like > Can water the beer of a man in Klondike > Or poison the meat of a man in Bombay; > And that is the meaning of Empire Day.
The advantage of centralization is that we can stop the poisoning all at once (because there is only one place doing the poisoning). However, when the meat is poisoned many more people suffer food poisoning than would if the food packaging were distributed.
I don't think distributism requires a closed system.
A few of its guiding principles may answer your concerns:
* Subsidiarity teaches that things should be handled at the lowest or least centralized level that is competent to handle them. That doesn't mean that small organizations should be expected to bite off more than they could handle. It may very well be that a giant, multinational corporation is the lowest-sized organization that can handle operating something like an airline, and that is not inconsistent with distributist principles.
* Distributism, as an economic system, is not at all incompatible with things like a strong social safety net. However, it is worth pointing out that if the ownership of productive property were to become more widespread, the need for such a safety net would be decreased.
https://www.ers.usda.gov/webdocs/publications/74672/60298_ei...
It doesn't clearly state how many farmers lease land, but 39% of acreage is rented.
The 98% statistic appears in the follwing item, but concerns white vs black land ownership, not rental vs. ownership:
https://inequality.org/research/owns-land/
There are Kibbutzim, full blown cooperative communities spread across the country (which were the initial backbone of the country but have decline over time). They share income depending on the Kibbutz, but some of these communities are very productive and very well off.
There are also Moshavs that aren’t quite as collective but still cooperative. Everyone in the Moshav shares a fixed piece of land in the community but production and income is controlled by the individual laborer. However, the community will still share costs together, like machinery, supplies, marketing of output.
Both are 70 year+ running models and proven to be successful no reason they can’t everywhere else.
Giving up these ventures would require such a massive reduction to the quantity and quality of human life, that it would be unacceptable to the vast majority of people.
The Haber process ended humanity's hopes of creating a society based on self reliance.
People have predicted the population bomb many times for hundreds of years, and every time they have been wrong.
Scientists predict human population to peak in 2040 anyway. I think that we can make it till then.
The world supports the current population quite well, right now.
I am also very much in favor of distributed, self reliant communities. Yet I want to preserve the advantages of a global linked economy.
I hope that Blockchain technology will help us to achieve this.
I tried to capture some of the thought vectors here: https://gist.github.com/AndreasS2501/2dc6c5813f5fd8abc79aad4...
I limit my comment to that. Truth is that.. 1. Your military secure the borders of what all knows as USA. 2. You have defined land area. 3. And you have a certain number of people living there within.
Now divide your lanarea with number of people, and see how much land everybody has the right to.
You cannot OWN land. You can secure it. To OWN lan you have to have a proof of origin of the land. Nobody has. As the land is much older than your relatives way way back. People try to avoid this and manipulate "laws" to be able to own land, which is just criminal.
Your land should be owned by all of you. It is a fedaral issue. A State defines often as something evil. Thats the rich 1%'ers propaganda and thei dreams.
A State in you case is Federal USA. And it should keep records of the land, and everybode should arrend, hire, their birth right. It is simply only that way you can "own" land.
You may find this rediculous... but it is the truth. In my country there is 9 million people on a secured land of 445000km2. Gives me about 10 footbolls field side by side of land. I also have kid and a wife that has the same as I.
If the world would be managed by the truth.
Companies like Amazon know they can provide that same service- or a simplified version of it that focuses on effective treatments that don't cost a lot of money- far more cheaply, because they have willingly forgone short-term profits.
Whether this saves money and provides adequate care remains to be seen.
Also, the companies aren't particularly inefficient, because that gets in the way of making profit.
We joked that the meme where actuaries were being replaced by machine learning was actually just the insurer firing actuaries because they figured out they could just demand the money back from the client after a claim.
[1] https://www.policymattersohio.org/press-room/2018/01/05/more...
What's next? Anarcho-Capitalism?
https://en.wikipedia.org/wiki/Anarcho-capitalism
Are you really going to argue that for profit insurance providers are more deserving of that money?
"Commoditise your complements" is an old and true business mantra. It's the reason it's good business for Google to promote an open web or investment banks to promote mutually-owned, virtually profitless settlement & clearing organizations like the DTCC and SWIFT. Much of the robber baron era's drama centred around steel trying to commoditise railroads, railroads steel, and oil the whole lot.
https://www.joelonsoftware.com/2002/06/12/strategy-letter-v/
Edit: I think Apple is only interested in medical devices.
Actually, health is the only "tech company" benefit you get as an employee there, since they won't even give you free food or a nap pod.
Your idea was first attempted in the 1880's :)
> Could this problem be attacked by a goodwill billionaire with a long-term plan? Open several private medical schools that will offer "free" med education in exchange for multi-year contracts. Open many small copycat clinics. Manufacture your own generics if possible, import whatever is cheapest, focus on things you can do cheap, be transparent about pricing, build awareness and brand. McDonaldize/Amazonize American healthcare.
CVS is sorta trying to do that (acquisition of Aetna is a big pointer)
Buffet calls them a tapeworm, I call it the next, ongoing rape of the American middle class.
It sounded more like fitbit with cloud services than insurance.
I believe it's initially for the employees of those companies. If they can make it work for them, they have a great team (ecommerce, finance, insurance) to back a larger rollout. The announcement says it's about providing healthcare at lower cost with better results, which sounds like a lot more than wearables.
If there are healthcare providers involved giving direct healthcare, there will need to be systems and development around medical records. That could easily be sold as a product to hospitals and providers outside of the AMZN/JPM/BRK company down the road.
Taking a "beginner's mindset" to me sounds like they plan on writing their own stuff, except for interoperation like HL7, which is great because most of the stuff from EPIC/Allscripts/Cerner is drowning in technical debt.
They can't fix the entire HC market, but they can have a great start.
Berkshire has never paid a dime of dividends to anybody.
What's your next premise?
I'm not evaluating Buffett either way with that statement, just pointing out that it is possible and probably necessary to evaluate his behavior without giving consideration to his pledge.
Most people used to do both at the same time and it seemed to work pretty well before Buffett came along. And there's a good analogy to your last point - someone who rents an apartment for 40 years when they could have bought an equivalently valued home two times over. They shouldn't complain when they die with a net worth of zero, they had a roof over their head for 40 years!
Also, mutual policy holders don't "overpay" for insurance as all dividends are returned to them. Only a private insurance company policy holder could overpay. Just thinking about it now, Buffett wouldn't be so rich if his policy holders weren't overpaying, as you're implying.
That’s a great thing.
I mean if you want to make an anti-capitalist argument on a message board owned by a venture capital firm, feel free. But by definition "profit = good"
There's an entire college course called Philosophy I that basically goes over 7 to 10 different moral compasses. The only one that seems to win out (aka the only one people remember after the class is Moral Relativism).
This is why I believe single payer healthcare is generally the best solution.
However, in the current situation, I think this idea to create a healthcare company dedicated to serving their employees, "free from profit-making incentives and constraints," is a great idea, one which I hope others will attempt if it ends up a success.
What i’d love to see is a commercial business having vertical integration. Insanely cheap basics like X-rays, mris, and other checks. Heavy use of AI based diagnosis confirmed by doctors, and a big insurance pool where profits go back into scaling healthcare.
Basically current American healthcare is not scalable. Period.
You just might not have the option of telling someone it's 10 grand (with ridiculous profit margins) to get an earlier diagnosis and a chance at actually living.
I'm not too sure about that. It's taken an entire year for the GOP to start to actually succeed at chipping away at the ACA, and they have legislative and executive control. If we could get sweeping reform in a more favorable political climate, something not plagued with the implementation issues the ACA has labored under, it might stand a chance. The next administration might find it politically untenable to take it away if it actually works well.
They know all their companies will earn more money if there is more money in everyone’s pockets. Look at how much some people are spending per year on healthcare. Someone in this thread mentioned $30k for his family in a year just for insurance. If he even saved a third of that, it’d end up being spent somewhere. A good economy benefits all those big companies. The losers in this are the healthcare companies.
As long as this company doesn’t go public, it seems like it will be able to stay away from that. It will be extremely competitive against companies trying to raise profits.
Amazon might decide to make their own networking hardware or their own power generation for their datacenters to save money, but they spend more money on headcount than on datacenters, and a huge chunk of the headcount expense goes to health insurance companies.
Healthcare should be nationalized. Then the government would also have other positive incentives meant to lower healthcare costs, like reducing pollution, sugar in foods, other dangerous foods on the market, and so on.
Another true story, even with a Health Care provider and insurance company I don’t hate: after a routine visit, I had to spend more time on the phone with both of them than I spent in front of the Dr In order to have the service code corrected so the payment would count towards my deductible. The administrators I had to work with are paid employees, their costs not only have to be covered, but profitable. Very polite, capable and professional and completely unnecessary. I dare any non-American to come into our system and figure out in-network vs. out of network, co-payment, co-insurance, personal deductibles, family deductibles, lifetime maximums, deductible vs. non deductible services... and then write an App that compares plans, even within the same insurer’s portfolio and tells me which is the better plan.
Intentional value obfuscation, unnecessarily complex, adds to the bottom line.
Fortunately we have the option of publicly funded health care here in Europe which is what she recommends for anything serious.
If I profit off of you being sick, then I need to keep you sick.
But this has other problems. Incentives are tricky.
The downside I was hinting at is that as a patient, cutting costs isn't always what you want. If it means more prevention or paying less, it's good. Otherwise it'll probably mean worse service.
They profit much more if you pay them money but never use their service.
You can always hope for the best so let's see what happens. Looking at the American health system I am not very optimistic.
Berkshire is a holding company, all the not so nice decisions are made by the CEOs of the companies Berkshire owns.
Fortunately they have plenty of lobbyist which can be put to good use.
Outragous, I paid $10,000 in fire insurance for a house THAT WAS NOT BURNING!
- I leave my last employer on July 21, 2017
- My old employer rols me off system on last day of July 2017
- On June 2017, they switch HR providers from TriNET to Namely and now the payment processor is Discovery Benefits and the Dental/Vision are now in Guardian. (So it went from Aetna to Aetna/Guardian and two other companies).
Since my wife is high-risk and I have thyroid issues, our best bet was COBRA ($1,000 / mo) because the new startup I joined did not offer group health coverage.
What followed next was this:
- The HR person who was handling my COBRA papers left during all of this. Switched jobs.
- Thanksgiving break
- Weeks of "the system will update this weekend with your information."
- "They were suppose to process your dental, but they never did"
My wife and I tried using our new AETNA IDs once we had gotten them and they still told us that it did not work. I had to have an expensive thyroid blood test pushed back. Multiple dentist appointments postponed. Everything.
FINALLY, once I got my SSN and ID for my coverage on AETNA, I had to pay back premiums all the way back to August 2017 just to keep using my coverage. So that's $4,000 USD for services I could not essentially render. $4000 of my hard-earned money. Gone. For nothing -- basically.
They had the gall to tell me (AETNA did) "Sir, if you paid for anything out of pocket during the time of your retroactive coverage, we can pay you back any cost you incurred."
The whole reason we get insurance is to avoid those high prices.
I'm so spent. I'm not an angry man but these health insurance companies really drove it home for me.
I feel taken advantaged of and it really stinks.
But only for unpredictable, irregular events. Anything else is uninsurable. If someone sells you "insurance" for wellness checkups[1], regular, scheduled screenings ... or tires on your car ... you can be absolutely assured that they are taking from you as much, or more, in premiums than the cost of those services.
What you are looking for is socialized, state sponsored medical care. There is no problem in looking for that and I make no value judgement here on that.
The first step would be to stop mischaracterizing this as "insurance". It's not. It can't be.
[1] Yes, certainly wellness checkups and things like them can be enormously economically beneficial for the provider since they spend up front preventative dollars instead of emergency, acute dollars later but it still doesn't change the fact that those are not underwriteable as they are regular, on-going expenses - very much like the tires on your car.
[1] https://www.law360.com/articles/940691/fla-compounding-pharm...
[2] https://www.usatoday.com/story/news/politics/2016/04/27/huge...
Additionally, lots of doctors often bill incorrectly on purpose so that a particular services/procedure gets covered, so I am not sure we should keep "justified" and "validated" in these discussions.
This might have worked if everyone was required to buy from the market place and there were no employer plans. Obama's famous "You can keep your existing health coverage" was a terrible, terrible decision.
I watched the Medicare/Medicate group for my company and they might have complained about not getting enough money, but I really think they did. Things had fixed prices and there'd be plenty of money if BlueCross didn't spend money on advertising, useless wellness programs and shitty IBM technology.
Everyone should just get Meidcare/Medicade. The government won't control healthcare, it will just get contracted out to providers. They'll have to cut costs and not waste so much money (they waste A LOT!)
Capitalism + Health care is a failed experiment. Socialized health care does work, in every high income country that's not the United States. Australia fought against the Abbot government when they wanted to introduce copays. That's right, Australians don't have doctor co-pays (they kinda do now, but wavers are in place and the plan was effectively defeated).
The fact that the US government requires us to buy private health insurance at insane rates is absolutely insane and the Supreme Court should have struck it down. You are not a car. Your body shouldn't have a fee for existing.
In the US we have historically enjoyed economic mobility and very loose class structure. That corporations have gamed the system is something that needs to be addressed. But to have prosperity and real freedom means that we aren't working via "collective" rights and aren't just a bunch of dumb Matrix cucks fooling ourselves like Europeans seem to be.
You generally can't negotiate in advance though, because most providers seem unable or unwilling to tell you what anything is going to cost.
Now that organizations in the US have reached a breaking point, those costs are becoming clear to the consumers and they don't like it. You're absolutely right that the term insurance is bastardized in the healthcare setting, but people will have no choice but to understand.
If people want to blame somebody, they can start with the doctors union that restricts the number of residency positions open.
https://economix.blogs.nytimes.com/2013/12/17/how-medicare-s...
https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html
https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...
https://www.aafp.org/news/practice-professional-issues/20120...
Good for the doctors though, at least they're smart enough to bargain in their own interest.
We looked into ACA... but we thought that the process of switching over from AETNA to COBRA would be painless (weeks at most). So we just went through with it. We did not know it would end up like it has.
The operations for insurance is a daunting, slippery rope. Can you not lay some fault onto insurance and its operations?
What would you characterize this as? People slipping up? That's how the "system has always worked"? People forgetting to process paperwork needed so people can get to their appointments?
(But yes, admittedly, this is just pedantry.)
But if the events are rather certain, then the insurer can only act as a payment plan on the events. The risk is 100%, so at least 100% is priced into your premium (profits, a overhead, etc take it over 100).
Even covered wellness care probably comes out a bit less than it would otherwise cost, because not everyone uses it even though it's covered. Some people, like me, just don't go to the doctor.
Now, it is common for "socialized" to be a scary word. So that people try and name it other things. But you aren't spreading the risk here. You are only spreading the costs.
Well, I'd also argue that you are spreading the benefits. Which is a good thing to me. Point being, though, it is not insurance.
This is why I used wellness checks and tire changes as examples - they are regular and universal.
But the I continuously got the "we have you down for this provider" when my COBRA admin told me that that provider could no longer give me coverage. I needed to AETNA to file me under a new provider.
Then I called AETNA and they still said "so and so" is listed as my provider. I told them to change it. "It's gonna be at least a week to update your information, sir."
Call back next week, "sir, you are still listed on 'so and so' provider."
It was exhausting.
edit: but the thing was, I trust them to give me good advice. The HR providers. I figured, well if they haven't said anything about deferred payments, it might not be applicable to my situation so I never brought it up...
Have you been able to find a workable alternative or are you still stuck with AETNA?
- Bank of America messes up my loan because the person doing my paperwork was a newbie. No biggie, right?
- Branch manager offers to fix the issue and prioritize it so that we can close in time.
- Branch manager is unable to fix it in time so offers to pay our closing costs and re-finance the loan afterwards.
- Branch manager leaves the company after our loan is completed.
- Don't qualify for re-fi because we owe more than the house is worth.
- Don't qualify for loan modification because we've never been late on our payments.
- Reported to FHA. Got in touch with local news station. Immediate response from BofA's Office of the President.
- Rep from Office of the President that was "assisting" quits 2 weeks later.
- Get another rep and they start a "forced" loan modification. Assign me another, lower rep and promise follow-up in 2 weeks.
- Repeat ad nauseum until I literally can't even and decide to foreclose because it's such a cluster.
Your last few sentences really strike a chord here. I totally feel for you.
This was back in the early 2000's just before the actual market crash. It was insane to me that banks were willing to work with people that bought houses they couldn't afford but that they wouldn't work with me on a loan modification because I wasn't delinquent.
I don't understand why it should take days to "update" a system. Now, I now next to nothing about how their current system works but information updated should not take so long.
The insurance industry needs a technological overhaul but I doubt it will happen.
Edit: And great that there might be a new value conscious private competitor out there - but I'd note that all those other developed nations that are individually, collectively, and vastly outperforming our health system all have some form of government control on drug and procedure prices. And a single private company would be very hard pressed to replicate the negotiation leverage of a government. I'd also note that I'd trust JPMorgan about nil to be concerned about customer value over company profits. Other nations have a health system, and at the end of the day we have a health market.
The numbers are small by world standards but I guess the drug companies are paranoid of this idea catching on in, say the US.
I’m sure it will be regarded as communism, but hey, it makes the market actually work for us here.
https://en.wikipedia.org/wiki/Pharmac
I am also high-risk and have always found that the Obamacare market had prices close to or lower than the unsubsidized cost of an employer provided plan.
The most frustrating for me is that the doctors can't even guess how much their facility will charge for the treatment they decide is necessary, much less how much the bill will be after insurance gets their cut. It is a major barrier for me to get MRIs and blood tests. Especially blood tests, which seem to range in cost from practically free to thousands of dollars for a single blood test panel.
It's infuriating, and no matter how closely I read the insurance fine print I still cannot guess what the hospital and insurance plan negotiated ahead of time. Kaiser was way better, at least there the incentives were aligned to sane billing procedures.
Obviously the ideal would be you have a system that accommodates "my kid has a fever/fell out of a tree and broke their arm" majority of medical issues who could be helped by basically anyone trained in basic medicine while also accommodating people who need a rapport with a highly trained/expensive specialist.
That's how I took the comment...apologies in advance if this comes off as insensitive to your condition, definitely not my intention.
"Has seen me in the past" and "has my charts" are not indicative of medical efficacy. There are doctors I have rapport with, absolutely. I still have lunch occasionally with the physician who was my family doctor as a child and still sees my parents. But that doesn't mean his medical treatment is going to be any better than a doctor seeing me for the second or third time.
https://www.newyorker.com/magazine/2017/01/23/the-heroism-of...
They always says it hurts the patient's care. I think there is some truth to both sides, but we'll probably never know. Too many people are making out like bandits in the current health care system.
edit: This (quite extensive and longitudinal) study would suggest that it's true. Check out the sources on the paper for other studies with similar findings:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4226774/
I have a rare disease (shortness of breath caused by air pollution, especially when lying down or excercising), but all pulmonology doctors are sure that I'm just depressed after the usual check-ups are unable to show the disease (and I'm not coughing which is unusual for most similar diseases). I'm trying to find blood tests and gene tests that help me find the disease I have, as I've given up on doctors. I also know multiple people with BRCA gene who weren't taken seriously by doctors before they had the gene test.
We truly live in the darkest timeline.
Not really. I want someone I can trust. For my primary care needs, I have established trust with someone and know their capabilities, their business practices, and their character. I don't want to roll the dice with someone new when I can still go to them.
Example 1: My primary care provider(been seeing him for 10 years.
Example 2: My dentist (been seeing him or his predecessor for 30 years)
It is an eternal struggle of authoritarianism and imposition trying to subdue self-determination and self-governance.
Your naked partisanship is ugly and unhelpful.
Repeal EMTALA. No patents. No certificates of need. Make Medicare and Medicaid fully opt in for providers. Create a path for additional private organizations to certify medical schools.
Anyone refusing to do all that stuff and face the political consequences for it just wants to pay less taxes.
It's the age old question, who is a better person to make decisions for yourself, you yourself, or some person somewhere that believes they know better what is best for you in your particular set of circumstances. Some call it communism, some marxism, some authoritarianism, some totalitarianism ... but ultimately they are simply differing degrees and characteristics of the same question ... who controls your life?
If the government has no place simplifying the process of buying insurance (by making sure products are available, comparable and reliable), then the government has no place protecting people from legal consequences related to their investments.
Healthcare is a horribly overexpensive market precisely because of those things you mentioned.
The many healthcare systems generally described as "socialist" are more cost-efficient than the American system.
Some people might not be aware that the vast majority of large employers in the U.S. that offer health insurance are self funded (i.e. they collect premiums from themselves/employees and take on all the insurance risk), so anything they can do to lower any direct/indirect cost with plan administration, claims, drug cost (big one), healthcare utilization, etc. will save them billions easily.
Something can be good for the bottom line and good for society. It’s not one or the other!
>Only about 26 percent of employers with between 100 and 499 employees self-insure, compared with more than 82 percent of employers with 500 or more employees, according to data from the U.S. Department of Health and Human Services.
That being said, they don't usually take on ALL the insurance risk, they typically purchase stop gap insurance for very large claims.
The biggest problem I see are the costs. The healthcare industry can't even tell you why costs differ on so many levels of services. The industry isn't transparent and they'll fight this because it's too profitable for them.
This is terrible if it works.
Imagine if other employers want to join it. And then even more employers... and what if the scheme becomes so large and covering so much of the population that it ... gasp... looks almost like a government-run non-profit health insurance scheme! You know, like what those Marxists in Europe have.
And where it would it end - soon people would be demanding cheaper drug prices and being able to negotiate prices for drugs! Insane
(In case its not clear, the above is written ironicly. I am all for a well funded government-run health service)
What we oppose is being forced by the government to accept a 1 size fits all plan, and not being allowed to buy the healthcare plan we want.
It is the difference between everyone using Facebook because they like the product and the network effect, vs everyone using governmentBook because the government outlawed all competing social networks.
Incidentally, a one-size fits most plan works great for alot of people.
Shouldn't we then give everyone "food insurance" which you pay for with taxes, and then are able to use that food insurance to get food from the store for free? (well, not really free, paid for by your taxes). You'd pay a predetermined amount of money no matter what you got from the store, but your options would be limited by the government food insurance committee.
If you don't support this single payer food insurance solution to all of your caloric needs, then my question for you is why do you hate poor people?
To be realistic your example would be as follows: what if the US provided a grocery store that provided the basic necessities, free at the point of provistion and paid for by common taxation. People are free to buy the nice wine from the private provider next door BUT if you fall on hard times and you need to put food on the table, the rest of your fellow citizens help pay to make sure you, your partner, and your children have food to eat, and retain a semblance of human dignity, until you can get back on your feet and pay taxes that provide for someone else who needs help.
[1] https://www.cnbc.com/2018/01/18/hospitals-plan-to-create-the...
Solid start-up tips
Then I read the top comment and saw Bezos. Oh. It's Amazon.
I do not want my medical provider and experience to be optimized to the point of insanity.
Healthcare needs to be fixed, but I'm pretty sure these three companies will create a monster worse than the one we currently endure. (Profits or not.)
Amazon is much more customer-first than Apple is.
Essentially, the costs will be lower because the new company will cherry pick. And again in the case of Amazon, the tendency to hire young workers also works in favor of lower costs. This is disruption in the same sense that Amazon's pillaging the public purse for its new headquarters is disruption.
Happy to have insurance after I saw the total bill, but man is it a huge headache.
I hope they figure something out if we never make it to a single payer type system.