I was just thinking the other day. Every job I've had has offered health insurance through the state BCBS. Those plans are ways a little over $100/m (for a single worker)
Meanwhile, I've had people brag to me about paying $10/ for damn to near full coverage. I'm starting to wonder if BCBS employer plans are just garbage
The average health insurance monthly premium for individuals is a couple hundred dollars ($321 in 2017 per https://www.cnbc.com/2017/06/23/heres-how-much-the-average-a... ; it'll be higher now). $10 or $100/month both mean the employer is chipping in a bunch, they're subsidized via the exchange due to low income, or they've got absolutely garbage coverage that won't actually pay for anything significant.
This is why the linkage to employers for coverage is so insidious - it hides the true cost of the system in lowered salaries. People look at an unsubsidized exchange plan like mine, with its $2,144/month premiums, and go "holy shit, I only pay $10/month for mine at work, that's horrible!"
I was just looking up individual insurance rates the other day. You can probably find health insurance for $321/mo, and really don't cover all that much outside of catastrophic problems. If you want decent coverage you're looking at $600-$1000+/mo.
My wife just took a job at a place that has a 'good' health insurance plan.
If she opted into it, her contribution would be ~$300/month, her employer's contribution would be $900/month.
If she wanted to cover me with it, her contribution would be $1,500/month, and her employer's would be $900/month.
Unsurprisingly, we did not take advantage of this, and she remains on my insurance (Since my employer handles 90% of the premium for both of us.)
When we were still dating, I had a good look at what the $300/month health plans provided. Absolutely flippin nothing. Deductibles of $8,000/year, and co-pays of 25%. If all you can afford is a $300/month plan, there's no way in hell you can afford an $8,000/year + 25% medical bill.
Meanwhile, Canada provides universal healthcare for $5,200 USD/year/person, with similar health outcomes.
Edit: fixed a typo in the employer's contribution.
Coinsurance is paid only until the out of pocket maximum is met, no?
I have a plan on the state exchange for around $300/month and an out of pocket max around $8k (I'm 34 years old).
I just budget $12k/year for healthcare and move on. This seems reasonable for people who can afford to take the risk of potentially having to pay anywhere from $4-12k/year.
In a lot of instances, the employers subsidize some or all of the premiums. BCBS has a lot of different plan structures too, depending on the size of the organization or association involved in purchasing the policies.
Does anyone know the extent to which this is happening faster or slower than the background increase of medical care costs? I know that historically medical care costs have been outpacing inflation. So it's not altogether surprising that, in an unsubsidized environment, the costs to the end-user of that care would also increase, by roughly the same amount.
I hear this statement all the time...but what does it mean?
If employers didn't provide health insurance to employees wouldn't we just wind up with 40% of the insured uninsured? Its not like Corporate America is going to make up the difference and start paying cash to compensate for the lost benefit, at least thats what happened as pensions got stripped away from the workplace. Even if the employer's did make up the cash difference, its not like that will bring pricing down, individuals can't negotiate individual insurance rates, pools of employees can negotiate group rates, so if anything costs would probably go up.
How will this help: 1) insured more people; or 2) bring costs down?
> individuals can't negotiate individual insurance rates, pools of employees can negotiate group rates, so if anything costs would probably go up
This is why the exchanges exist. They're huge pools of people on a group rate. New York state negotiates with insurers on my behalf, and is additionally able to regulate their premium increases each year.
And the nice, healthy white collar lived are locked away in employer group health plans, resulting in fewer insurance companies being able to offer insurance on healthcare.gov, resulting in higher premiums for lives on healthcare.gov.
Another advantage for big businesses over small businesses.
Who is in charge of negotiating for this pool? Just as an example between 2017-2018 the average silver plan went up 32% and the average gold plan 20%, who the hell negotiated that?
At least with the employer provided insurance the employer is negotiating, and you know who that is and you know they have a self-interest in keeping costs down.
The price of insurance jumped massively every year from the start of Obamacare to 2018. The fact that this has apparently mostly stopped now is the unusual thing; 2017-18 was a pretty typical year despite Trump's meddling. The article you linked suggests that this is because insurers have finally increases the cost of insurance to be in line with how much it actually costs them.
Sure the employer negotiates the plan, but they are not negotiating on behalf of their employees, they are negotiating based on how much the employer is willing to spend. When the squeeze happens, the employer pays the same amount for a slimmer plan and the employees pay more in the form of wages and deductibles.
We would do what every other country does and offer healthcare as a basic right? The whole point of "Medicare for All" is to divorce employers from their employee's healthcare. The gov't negotiates on behalf of everyone.
MFA is a single-payer option but there are plenty of multi-payer healthcare systems in the world which achieve universal coverage and contain costs. Germany would be the prime example, but see also Switzerland and France.
I like single payer, but I haven't had the luxury of living under either system of universal care.
I think in the US we have different issues than face Germany/Switzerland/France, and for the US to contain costs my opinion is we would have to rip private insurance out completely.
Our main Government provided system (Medicare for the elderly) is a combination of government and private, and to put that system in perspective, Germany spent 375B (not sure if $ or Euro) in healthcare total in 2017, and US Medicare spent $609B in 2017. Germany covered an entire country (82M people) Medicare covered 15% of the US (44M people).
I am a U.S. citizen. Yes, cost is a huge issue. We would not have to rip out private insurance, but we would probably have to regulate pricing, which is how it works in Germany. Folks should be welcome to buy supplemental insurance as they do with Medicare. There's basically four models[1] for providing health care, and the US has all of them:
The Bismarck model like Germany with multiple payers, but they are non-profit and pricing is regulated. Doctors and hospitals are private, and there is still supplemental private insurance. Financing is a combination of employer and taxes, where the government takes over the employer portion if the person is unemployed. This is sorta what the U.S. has for those with employer subsidized health care except for the insurers being for-profit and unregulated pricing.
The Beveridge model like in the U.K. financed through taxes and where the government provides care. This is so-called socialized medicine. In the U.S. we have this system for veterans in the form of the V.A.
The national health insurance model, with private doctors and hospitals but the government is a single-payer. Canada. Medicare.
And lastly, out-of-pocket.
We use all of these in the U.S. and it's insane.
We could in theory adopt a Bismarck system. Force the insurers to be non-profit. Make everyone work off Medicare pricing. Supposedly existing Medicare pricing is too low. Fine, let the doctors and hospitals negotiate that with Medicare. Allow supplemental insurance for those who want it.
MFA polls badly when you ask Americans what if they had to give up their current insurance. But I think this is misleading. Of course it's going to poll poorly if you ask someone to give something up. That's basic loss aversion. Turn the question on its head and ask a bunch of 65+ year olds how they'd feel about giving up Medicare in return for their Medicare withholdings back to buy their own private insurance. Guessing that wouldn't poll too well.
I don't think MFA is necessarily the best option. Americans value choice. But it seems to be the universal care option with the most political momentum right now. I'll take it. But I'd be happy with a Bismarck-type system too.
As long as people are covered it would be a good start (I won't bother engaging further on the single payer/private insurance/hybrid systems, not enough room and not the right forum)...it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured. I know that is not attributable to you, and you seem optimistic we get there anyway, I hope you are right.
One last thing I will note, is there are all kinds of hidden costs through other insurance that hopefully would come down under a single payer (maybe even under a public/private hybrid like Medicare Part D) , take car insurance one reason premiums and deductibles are so high is because a lot of that goes towards personal injury claims (medical costs). The same can be said for odd things like homeowners insurance for example. A lot of these insurance policies people already pay for in some ways supplement health care coverage.
Well in response to my questions about why people want to divorce insurance from employment before universal care becomes a law/right/option, one commented answered:
>>Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America.
$375B for 82M people (~$4,500 per person) for Germany. Versus $609B for 44M people (~$13,800 per person) for Medicare.
FYI, USA currently spends about $10,800 per person on healthcare, roughly $3.5 trillion.
IMO, the discussion should revolve purely around pricing and efficiency. Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system.
I would like to see basic pricing reforms demonstrate that year-over-year price can be held constant. That would be a nice start.
> Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system
Of course it could. It works in Germany! And France! And Switzerland! Why not here?
Look, I don't know how this can possibly work with our current system. It cannot be solved by the market alone. There's no transparency in the current system. Insurers can just keep passing price increases along. And many Americans want "the best" and "right now" and that ends up increasing costs for all of us.
People will argue that the American system is so expensive because: reasons. e.g. we subsidize the rest of the world. Or we are overweight. Or we don't get enough exercise. Or we want the best of everything. Or health insurance profits and CEO salaries. Or fraud.
We also keep saying: America is exceptional. None of what other countries do will work here.
So what do you propose? At the end of the day, doctors, hospitals, and the payer or payers need to negotiate reasonable pricing for decent care. And that cost needs to be spread equally across all Americans. I'd favor doing it with cost-sharing from paychecks like we do now for Medicare, with the government picking up the bill for the unemployed, and with tax credits to offset income differences. I like the system than France has, where you have a co-pay, but it gets reimbursed. This makes the consumer at least aware that there is cost to using the system. Then allow supplemental insurance for people who want better.
And Americans will somehow need to realize that not every medical problem has to be solved right away. And that you don't need the most expensive treatment option for every issue.
We cannot continue to ration health care by ability to pay. It's immoral.
1) We cannot provide the same services with the same mechanisms, processes, and infrastructure at 50% of the current price. The margin simply isn’t that high. Everything from the design of the hospital, to the regulations around the equipment provisioned in each room, to the processes followed by staff throughout a given patient visit need to change, along with the specific tools and techniques used to perform procedures, before we even get into how and what procedures are chosen to treat or manage a given symptom or disease, whether acute or chronic.
2) Even with all of the above, a system that optimizes for price will absolutely have to make trade-offs in other areas to achieve that. Understanding where, when, and how those trade-offs are made and if they are being made fairly and uniformly based on malady, procedure, patient population, etc. is not a minor detail.
These are massive structural, policy, and economic changes which will impact a double-digit percentage of GDP. Why should anyone have any faith that this will be done in any semblance of a sane, reasonable, compassionate, let alone fair, efficient, or effective manner?
If the government has shown it’s entirely incapable of passing effective legislation to manage the cost of healthcare, why should government be granted an order of magnitude greater role in the provisioning of care?
And yet it manages Medicare. Poll Medicare recipients and ask them what they think of it. It also manages Social Security. And provides for the national defense. The government is entirely capable passing effective legislation, or at least half of it is.
In any case, the current system is both unfair and unsustainable. Something has to give.
Just to be clear, Medicare costs are roughly 50% higher again per person than the current average US cost per person. Patient population being a major confounder in that comparison, of course.
US defense spending is by far the highest of any other country in the world, and renowned for its wastefulness.
Social Security is going bust whenever we talk about it, and is merely a program which confiscated money today, in order to hand it out tomorrow, and doesn’t even invest it in the meantime.
And which half of government is it that’s capable of passing legislation again?
>Medicare costs are roughly 50% higher again per person than the current average US cost per person.
The numbers speak for themselves and it is ridiculous the US spends 100% more for half the people (e.g. Medicare) than Germany spends to cover 2x as many people and their entire country.
That said keep in mind Medicare patients are the most expensive patients in that they have the highest rate of chronic diseases of any other demographic. Its not apples to apples, but more importantly a Universal coverage could probably be extremely effective in preventing untold millions of chronic conditions through preventative care. What happens now is millions of people reach Medicare eligibility who had no coverage before and as a result have all these untreated chronic conditions, and then boom Medicare has to cover the tab when they become eligible. Its such a stupid system, there are even cases of heart surgery's and cancer treatments that are delayed until a patient hits medicare age, making the issue worse and more expensive to treat.
It may sound like I am taking a devils advocate position, but I 100% agree with you on governmental waste.
The government negotiating rates on behalf of all citizens is not the same as the government paying 100% of all citizens' costs. "Medicare for All" is the latter; but all we really need is the former. Basically the government could do on behalf of all citizens what it already does on behalf of government employees and elected officials: negotiate with providers to come up with a menu of plans, and then let each person/family select the plan from the menu that works best for them. Who pays what part of the premiums and costs is a separate question.
"Medicare for all" does not mean free healthcare. It's paid for by taxes. You taxes become your "premium" under that system. The concept of "private health insurance" outside of supplemental insurance would not exist under that system.
> "Medicare for all" does not mean free healthcare. It's paid for by taxes.
I didn't say "free healthcare". I said "government pays 100% of costs". Yes, that means ultimately we all pay them through taxes.
> The concept of "private health insurance" outside of supplemental insurance would not exist under that system.
Under Medicare, "government pays 100% of costs" also means "government is the only provider of health insurance". But my whole point is that you don't need to do that in order for the government to use its negotiating leverage to negotiate better rates; the government can do that even if the rates it's negotiating are with private insurance providers. That's basically what the government does now for Federal employees and elected officials; they aren't on Medicare, they have a selection of private insurance plans that have negotiated rates with the government. My suggestion is to simply extend this to all citizens, so the government can negotiate even better rates since they now have a much larger pool of people to negotiate for.
Getting insurance as an individual is expensive because you’re not part of a group plan. With a group plan the insurance company has some reason to believe you’re not collectively a bunch of dying people committing moral hazard, you’re just one of a generally similar looking company workforce.
If employers stopped providing it, I think it is presumed that the mentality towards individual plans would change
Sort of. This is true if everyone is required to participate in the system. And there’s only one provider. If you imagine there being a cheap plan and an expensive plan, you would probably expect that the expensive plan is a way better return on the dollar because there are fewer poor people on it weighing it down (because poor people are likely to have more health issues).
True meaning it averages out to a reasonably healthy person
>you would probably expect that the expensive plan is a way better return on the dollar because there are fewer poor people on it weighing it down
It is unfortunately true in the US (probably everywhere) there is worse health/higher incidences of chronic conditions in the poor (mostly because all chronic conditions are diet related). However, in the US the biggest weight would be the elderly who have chronic conditions at a higher rate than any other demographic (generally due to a lifetime of poor diet combined with irregular care over their life to treat the conditions until they are Medicare), but thats the irony these are the people already covered by Government healthcare (and they seem fairly happy with it. Its time to extend it to everyone.
> Getting insurance as an individual is expensive because you’re not part of a group plan.
I see people say this constantly. Insurance by definition is literally always a "group plan"—everyone who buys insurance is in the same group. That's literally the point of insurance. It's why it exists. That's what it is. That is fundamentally how insurance works. All insurance, in every category, of every type. There are no exceptions.
Insurance always pools risk across all payers (everyone is in the "group"), and then you expect only a fraction (but we don't know which fraction, of course) to require a payout in any given payment period.
If you're selling something that doesn't work like that, then it's not insurance—by definition.
You see it constantly because it is true. A group plan is a thing. Yes you’re still in a “group” when you register as an individual, but it is an “individual plan” and semantics doesn’t really help you out.
The difference is that if I know the mean and variance of expected health costs for the group, I can offer a lower premium to every individual member because the variance of total actual cost goes down by n^(-1/2) and I don’t need to cover my butt as much. Especially since almost all group plans are centered around relatively healthy working age people. The privilege of group plans is you’re in a healthier subset.
Individual plans are for people not on those plans and they suck dickballs. There is a high chance of moral hazard. There’s more retired old people. You offer little value to the insurance company so you don’t get to negotiate like a group plan does.
Medicare is mandatory in the US for retired old people. It's universal, it's mandatory, and it covers everything. They're literally not in the insurance pools, so I don't know what you're talking about.
As for the "group plans", those "groups" are too small for insurance purposes—they do not spread risk effectively. The entire "group plan" thing is a scam, and it would be trivial for gov't to just outlaw them entirely in the US, and force individual pricing on business-purchased health insurance like we do for every other kind of insurance we have. Costs would go down for everyone, and individual plans would no longer "suck dickballs".
That said, that is not how I would "fix" the health insurance issues we have. But it's at least better than what we do now...
> Medicare is mandatory in the US for retired old people. It's universal, it's mandatory, and it covers everything. They're literally not in the insurance pools, so I don't know what you're talking about
How about everyone who retired before 65?
As for your other points, I mean yeah, we shouldn’t have employers provide it. But they do, and you need to recognize it. There are definitely group plans large enough to spread risk.
That's all fine in theory, but do some shopping-around and you'll see it's simply untrue.
Personal anecdata:
2018, my employer didn't offer insurance. I signed up for a "silver" tier individual plan ($1250 deductible, good coverage) on the ACA marketplace and paid $170-something/mo. (after receiving ~$250/mo. in tax credit).
2019, my employer starts offering insurance, so I'm no longer eligible for the ACA tax credit. The only plan they offer costs me $125/mo., has a $4500 deductible, and extremely skimpy coverage. According to the literature they gave us, my employer's pitching-in another $400-something/mo.
So this group plan costs significantly more, has a much higher deductible, and covers significantly less (in my case, it's the difference between medication being covered and not).
Huh I didn’t know about the tax credit. That sounds like another layer of backwards thinking and another reason to get rid of the whole practice. I’m sorry for your situation.
The "Premium Tax Credit"[0] was a centerpiece of the Affordable Care Act (aka Obamacare), and widely publicized by the media and Obama. ACA exchange premiums are not affordable for most of the people it was trying to help without the tax credit.
I don't think I understand this. Take two scenarios. In both cases, I'm 22 years old, just exiting college, and starting my first job.
In scenario 1, I start working at a 1000 person company that offers insurance benefits. I sign up for their plan, and my employer pays for nearly all of it.
In scenario 2, I start working at a tiny company that doesn't offer insurance benefits. I find an individual plan (coincidentally from the same insurance company used in scenario 1) that suits me, and sign up for it, paying out of pocket.
The total amount paid to the insurance company in scenario 1 is, as is typical, lower than in scenario 2.
In both of these scenarios, the insurance company doesn't know anything about me. For scenario 1, sure, they might know the mean and variance of expected health costs of the 1000 people already at the company, but that does not extend to me. They cannot assume I will conform to the rest of the group. I am new, and an unknown, and they do not know how I will affect those statistics. For scenario 2, I'm just another independent signup. I might have health care costs in line with the average of all of their beneficiaries, or I might be an outlier (on either end), or something in between. But that's the same as scenario 1.
This feels like it has nothing to do with risk assessment; this is just a reflection of the company in scenario 1 having greater negotiation power because they're representing 1000 people, versus you just representing yourself.
It’s kind of created by the immoral environment of private insurance, but I would argue someone who doesn’t have health insurance to save a few backs, who can otherwise afford it, and waits until they suddenly have $100k expenses incoming to get insurance is a moral hazard even if they’re going to die.
Imagine there were no private companies but a perfect decentralized blockchain shamwow insurance system that magically worked and distributed all profits back to its participants.
I would think the dying man is committing moral hazard here. But it’s up for debate.
If you do this against a big private insurance company and they lose a penny, it doesn’t sound so bad, but I’m not convinced
I think the implication of the GP's comment is that we still provide it, we just don't tie it to employment. There are a lot of nasty side effects of this coupling, including decreased employee mobility.
1 - If my company buys health insurance for me, its tax deductible(pre-tax), if I buy it myself it is after-tax. Now companies are can just gross-up pay, and don't have to compete on healthcare...
2) Pooling remains an issue, but as it stands now, consumers have little to no choice, one would imagine that once a 125m households start shopping for insurance there is going to be competition on price...
I believe the pre-tax post-tax thing is actually wrong. The difference is that you pay for the plan with post-tax money until tax season rolls around, when if I remember correctly (from having an individual plan for several years) you get to deduct those costs.
So really, it's just the typical American thing of people being terrible at understanding tax codes and adjusting their withholdings correctly.
>You may deduct only the amount of your total medical expenses that exceed 7.5% of your adjusted gross income. You figure the amount you're allowed to deduct on Form 1040, Schedule A.
It’s another subsidy for big business in the US. If you work for a small employer that doesn’t offer health insurance, you’re paying with after tax money.
My reading of this [1] seems to match up with what I said:
"""
- If you buy health insurance through the state- or federally run health insurance marketplaces, you can deduct only the portion of the premium you pay out of your own pocket. You cannot deduct the amount of any subsidy.
- If you buy an individual or family health insurance plan, either on the open market or through a marketplace, and you pay all of the cost out of pocket, then the whole amount is deductible.
Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America. Those uninsured people still need healthcare. If enough people start calling up small clinics asking for pricing, a cottage industry of small health providers will pop up to service these people with transparent pricing.
The insurance industry has perverted our healthcare system. The major reason doctors moved from private practice to being associated with hospitals is to simplify billing because health insurance companies look for any reason to refuse payment. To reverse this trend, we need more people willing to bypass insurance and buy healthcare directly.
Health insurance is a failed experiment. People should pay for their healthcare directly, and the government should provide for those who require serious, expensive treatments (after a payment that is some percentage of their income).
> People should pay for their healthcare directly, and the government should provide for those who require serious, expensive treatments (after a payment that is some percentage of their income).
It's cheaper for the government to pay for everything. If you incentivize skipping check-ups and minor treatments they turn into large expensive care.
The rest of the western world has had universal health care for ~50 years now and it works better in every other western country than it does in the US. The US should just choose a country and copy it.
>Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America.
Thats actually exactly what I think the thought is for most people who advocate this...remove employer provided insurance and there will be so many uninsured that someone will have to do something. I think the hope is that something would be "Universal single payer healthcare coverage."
That may be right, but we already had 50 million uninsured american's and Obamacare barely passed and was pretty insurance friendly. I just don't see the political will to get it done, then we are just stuck with 40% of the currently insured uninsured.
Specialists that operate outside of most insurance networks, such as plastic surgeons do pretty well. As do specialties like dentists, orthodontics, and optometrists where insurance coverage is limited and a significant number of people pay out-of-pocket.
And I'd argue that the US is moving towards a similar system for healthcare. Lots of small clinics are popping up around the nation to provide limited care to individuals for price-conscious individuals.
What we need is something to cut the tether that insurance companies have. Insurance is nearly as important for determine the rates you pay for care as it is for covering costs.
> and the government should provide for those who require serious, expensive treatments (after a payment that is some percentage of their income).
I'm for it as long as it doesn't involve the government micromanaging how the health care providers perform their services. This is a problem with all health insurance, public or private, but the micromanagement is done on a more direct level with government-provided insurance, with doctor report cards and so on. They do this now for at least some Medicaid and Medicare implementations, and some of the provisions of Obamacare even accelerated this process.
> Its not like Corporate America is going to make up the difference and start paying cash to compensate for the lost benefit, at least thats what happened as pensions got stripped away from the workplace.
They may not have compensated in cash (although surely some did), but they compensated elsewhere in the total compensation package. Benefits got better or salaries grew or vacation improved or 401K matches were introduced or etc etc.
As for insurance pools, what is stopping people from forming groups that can negotiate their own rates? If there is a law, why can it not be changed?
There's two proven paths to do this on different ends of the spectrum.
The first is single payer which has proven implementation and is able to lower costs by directly controlling prices.
The second is what Switzerland does which is where much of the inspiration for the ACA came from, except every single person would be required to buy from the exchanges rather than using some employer program. The ACA failed to properly acknowledge the negotiation power of certain large employers who often have large numbers of healthy young employees and have a deep understanding of their own risk pool, leaving the ~3% of people who use the exchanges paying more simply because they are a higher health risk population. Additionally, the ban/tax on "cadillac" plans absolutely needs to go into effect as it's an important mechanism for controlling costs in a market health insurance solution, as in demand doctors could just require patients have said cadillac plans that pay out more.
There are handfuls of solutions in the middle of this, but they generally involve the government controlling prices to a certain degree, but only single payer would be effective at both bringing costs down and insuring more people, as you absolutely have to create short term shortages in order to solve both problems at once.
It's not mutually exclusive with a Universal Healthcare plan, for one thing. But I think it's still a worthwhile goal with or without a separate initiative for universal healthcare.
It brings costs down, because many more people are now on a level playing field. If we stick with the current market-based system, this would make a big difference in actually having it start to function like a market. The average, middle class American will actually have to evaluate the costs of their plan and shop around for the best value, and they will also be very aware of how much they're spending and push for measures to bring down costs. If we do also build up a universal healthcare system, then working, middle class people will end up actually using the universal healthcare system, and again will be incentivized to push to make it work well.
As things stand today, people on the "open market" plans are clearly being treated as second class citizens, they're paying more and getting worse coverage than people who have a special connection (whether that's a company plan, union, etc). The taxing is also wonky and unfair, at least if I understand this correctly if I pay for a marketplace plan I'm paying with after-tax money, but if my company pays for my plan it's untaxed.
In my opinion there are also additional reasons this would be a net good thing, even if it were merely neutral on the two criteria that you call out. It will give people more freedom to do what they want to do -- right now if you want to quit a job or work only part-time, even if you have a source of income or savings to make it feasible, healthcare is a major hurdle. If you want to start a small business and need to offer healthcare for your employees, it's an even bigger hurdle. I would rather live in a world where it's as easy as possible to make your own path, and people are not beholden to a full-time job to have access to healthcare.
I think the concept of separating healthcare coverage from employment is an important first baby step to bringing costs down in that it makes healthcare consumers more aware of how much they are spending instead of hiding it as off-paycheck compensation.
This awareness can be raised in other ways. For example, some employers have added a chart in HR websites that outline how much is spent on each employee (it is personalized for each employee) in categories of wages, taxes, retirement, healthcare and the like. It is a way of communicating how much money is expended on an employee.
If one were to know how much was spent on one's healthcare coverage, would the average person think "ok, need to be efficient to get that number down" or "gosh, I better get what I'm paying for?" In the sense that healthcare plans are transfers from the healthier to the sicker, one would hope the former. In the sense that healthcare plans are almost-all-you-can-eat buffets of medicine, I think the latter is more likely.
You should have both public and private options at the same time. In Spain you have a good public system but you also have a parallel private system. It keeps a check on the price rise of private insurance as people have the option. For a family of four I pay 300 EUR a month for the best plan. Most people pay about 180 EUR for four people.
Do you think that companies would give you a raise equivalent to what they were paying on your behalf for healthcare? I suspect not.
I mean, it's one thing if we moved to a single payer system, which would be great, but just moving out of the employer's hands and into the general public seems like a disaster. (Also, I am not a fan of the employer healthcare model.)
that's a fair point, but which is easier for an employee to compare, wages between two companies or job offers when they buy their own insurance and know the cost, or to compare wages AND benefits of two different jobs/offers
> Do you think that companies would give you a raise equivalent to what they were paying on your behalf for healthcare? I suspect not.
Its anecdotal, but my company and the company my mom works for, both already do this if you choose to opt out of the employer plan. Total compensation is not a foreign concept to most businesses.
Sure. But how many people know how much their employer is paying on their behalf, and could use that to effectively have the same earning power? I know I had no idea until the Affordable Care Act put it on my tax documents.
That depends on the details. I'm sure to have missed a many important details below (I doubt anyone even knows them all).
For an instant raise to happen: companies must not only lose their tax deductions on what they contribute to insurance, they also need to count that contribution to employee's wages even if the employee doesn't take it. As soon as young childless employees realize that they are paying taxes on what amounts to the insurance payments to their co-worker who has a lot of kids they will demand they get the cash.
Well, for one thing, the employers get to use pre tax money (up to a limit) for their spending while individuals have to use post tax money, so it would be at least 30% less.
Yep, and what people don't always realize is that because employer health plans get more expensive every year for employers, it negatively impacts wage growth. You are paying for it even if you don't necessarily feel it.
But the individual policies on the exchange have increased year over year as well, and a lot of those insurers on the exchange went out of business/disappeared after 2-3 years anyway.
(from 2017-2018 for example insurance on the exchange increased 32% for silver plans and 20% for Gold plans)
I don't understand what that has to do my comment. I never mentioned anything about the exchanges. Health insurance policies generally get more expensive year over year for everyone, whether an employer is paying for it or you as an individual.
You seem to be highlighting employer provided insurance costs increase (which they do), but historically they increase at a lower rate than individual plans (i.e. the alternative).
This is really important. Pulled from the underlying study[1], employers cover 82%/70% (individual/family) of the cost of healthcare. Those numbers are down just slightly from 86%/73% in 2019.
Or, put another way, employers have borne 69%/80% of the cost of healthcare increases. You complain because your individual plan has gone up by $986 in 20 years? Your employer's cost has gone up $4,005. Oh, and that's with cutting the underlying coverage ("skimpier").
It negatively impacts wage growth because that extra $4k is a bottom-line benefit (or cost of employment, if you want to think about it that way).
Finally, note the disparity between individual and family plans. Employers are offering 2.5x more benefit—nearly $9,000 more—to workers with families.
Fig. 1.10 shows premiums increasing from $2,196/$5,791 in 2019 to $7,188/$20,576. (Note also that 72% of that is attributed to premium increases vs. inflation and worker earnings, per Fig. 1.14.) Fig 6.1 shows % of premium paid by workers going from 14%/27% to 18%/30%.
The benefit for employers is there are a lot of workers who are there now solely for their family health insurance coverage. I have a feeling this has prevented earlier action by employers, but now it’s past the tipping point.
> Finally, note the disparity between individual and family plans. Employers are offering 2.5x more benefit—nearly $9,000 more—to workers with families.
Interestingly, my employer discloses the full premium that they pay to the health insurer every year. As an employee without a partner/dependents (I just graduated college/started my career), my employer spends ~$17k/year less on my health/dental/vision benefits than employees with a partner/dependents.
That effective pay difference makes me mildly salty.
It's an interesting topic, particularly as it relates to employers being women/family-friendly. How do you feel about parental leave, for instance?
Of course, this is a benefit that's within your control: just get a partner/dependent! And the flip side is that even individual employees might value knowing that the company "has your back" as your family situation changes.
Or, more bluntly, your company has to offer disparate benefits, because other employers do, and no employee with a family would work for your company otherwise.
Of course, all this masks the REAL problem that employers and healthcare are so intertwined. Even this article puts some of the blame on employers, when really it's the healthcare companies and the overall rising cost of care.
It's worth pointing out that for the vast majority of people doctors != insurance. The payer is not the provider.
The refrain of "people like their health insurance" deliberately conflates the two. People like their doctors, not their insurance. Doctors accept multiple insurance companies.
And to top it off, old people (actual old people) are already using socialized medicine. They aren't using private insurance (or, if they are, it's used to cover coinsurance/deductibles).
I like my health insurance in the sense that I am fairly confident that I will like my current health insurance better than the insurance I will have in five years. The same way that I liked the insurance I had five years ago better than the insurance I have today.
Basically I think no one expects it to get better, so they are just all hoping it doesn't continue to get worse (while expecting that it will).
That statement was a stumbling block in one of the recent Democratic debates. I have no idea why none of the candidates drive the point that insurance != doctor home(in most cases) .
Warren did, with a pretty decent line something like "I've talked to a lot of people about this and I'm not sure I've ever heard someone say they like their insurance. Their doctor? Their hospital? Sure, but not their insurance. People care about having access to the providers they like—they don't care about their insurance".
I had to tune out after that part of the debate. Watching a bunch of candidates, and especially the frontrunner, claim not that MFA was OK but their plan was better, but that MFA is some kind of impossible dream that can't work, just pissed me off too much. Screw them. Seriously.
The real issue generally speaking is people with union negotiated healthcare tend to really like their health insurance because in at least certain cases, they're getting Cadillac plans that give them a one up on seeing the best doctors around, in addition to in certain cases paying less in premiums than they would be taxed for M4A.
The second piece is that M4A is a huge unknown, and so they'd want to keep their health insurance because they're afraid that what the government will offer will ultimately be worse.
The first point is certainly easy to address as that money would then likely be renegotiated to result in salary increases, but with regards to the second, what would stop a republican administration from doing things like, effectively banning abortion by refusing to pay doctors who perform them through executive order.
I felt this is something that politicians say to two groups: the insurance companies and the "anti-socialism" libertarian crowd (who have injected themselves into the republican party).
The healthcare system has become a symbiotic relationship where providers and insurance companies work together to funnel money from just about every business in the US into their pockets.
Hospitals increase staff to justify billing more, then insurance companies use increased costs to justify raising rates. Internally, hospitals and insurance companies are also in a tug of war over their slice of the pie. These conflicts introduce even more people-hours into the treatment of patients, in the form of revenue cycle managers, lawyers, medical coders, etc.
Each new layer added to the cost onion of healthcare results in the pie growing, since most insurance providers can only take in some percentage of what is spent. So they need to spend more to make more.
Incentives. There is no incentive for a doctor that sees a patient to provide a favorable outcome for the patient. Whether the patient stays sick or not, the doctor still gets paid. But here's the kicker: The doctor gets paid even more if the patient has to come back. The payments come from the insurance company.
Take this concept to the level of a very large health care network (but non-HMO). Patient has early signs of serious but uncommon condition, goes to doctor. Doctor checks for common, obvious things. Finds non-specific symptoms, refers patient to a specialist or three, and the patient is diagnosed with "Not-My-Problemitis".
Disease progresses and the patient is now able to tell the majority of the symptoms are vascular in nature, not muscle or bone as previously thought. More referrals are given. The specialist orders a battery of tests, but they yield false negatives as the symptoms are not occurring at the time of the test, and the patient was not advised that the symptoms needed to be occurring during the test for it to be valid. Patient is again diagnosed with "Not-My-Problemitis" and possibly referred to a research institute, where they'll have quite a long wait time.
By this point, the patient may have lost their employment due to the frequent sick time and time off for appointments, and generally being frustrated in general. They can qualify for Medicaid but will have to start the process over again, but much slower as providers have to tread carefully with care received under Medicaid supervision, as if they were treading on thin ice. But oops, the patient has now gone into critical condition and is sent to the ICU, which is statistically likely to be owned by the same health organization that had their hands involved in the patient's earlier care.
Due to the patient's hospital visit, regardless of whether the patient survives, a payout of Six or even Seven figures is rewarded. Ka-Ching! Insurance companies are hesitant to deny those kinds of claims now, if they involve life or death. Too much bad PR. Thanks, Michael Moore! Of course, it doesn't work out as well for the hospital if the patient had lost their job and is back on Medicare, as there isn't much profit to be made there, if any. That's just the collateral cost of doing business.
I would like some evidence of this. I've read and heard many people confidently pin the high cost of health care on: too much administration, greedy doctors, undocumented immigrants, over use of tests, over prescription of drugs, too much paperwork causing inefficiency, and probably others I'm forgetting. They can't all be the primary cause.
[ and before someone replies, it is a mix of those, of course ]
In competitive markets, competition will keep costs and profits from ballooning.
What kind of market conditions are required for spending to increase in all sorts of directions? I can immediately point to education as an example where both lenders and colleges both have a vested interest in growing eachother's businesses, paid for by the customer.
Maybe things would be better if people paid for their own health care? Having workers pay for their own healthcare along with the healthcare of those who are unwilling/unable to work just means that things are going to be expensive for workers.
The entire health insurance industry makes ~$25B in profits a year, correct? That doesn't seem overly large considering it is the entire insurance industry.
It’s not only profit. They also cause a lot of administrative overhead. For example if doctors had to deal only with one insurer or at least one coding system they wouldn’t need four billing assistants as I have seen. In essence insurance companies do a lot of unnecessary stuff. Their profit is only a small part of that cost.
There are two coding systems (ICD - for diseases, and CPT for procedures) that are mandated to use by medicare/medicaid and all the insurance companies use them as well. Most of them even accept the same forms. They need those billing assistants for other reasons.
”They need those billing assistants for other reasons.”
Whatever it is they do exactly it deals with insurance companies. Germany also has private doctors but they have much smaller staff and dealings with insurance are very straightforward. American insurance companies cause a lot of friction. I don’t know exactly why but they do.
Insurance companies are mainly trying to combat fraud. They kick back claims if they are formatted wrong (why did you code an operation on the left knee when the right knee was the problem), or they deem that the work done was improper, unnecessary or does not fit the standard of care. Billing staff also handle accounts receivable and collections.
The biggest problem IMO is how we structure payment for health services in the USA. The fee for service model is highly inefficient and disincentivizes preventative care. All of the current proposals for universal healthcare do not address this fundamental problem, and so long as this remains in place we will continue to have the highest costs in the world. (disclosure, I am working to try and solve this problem)
If you were to pick countries to emulate, I would pick Singapore, Japan, the Netherlands, and Switzerland instead of Canada and the U.K.
Much of the administrative stuff insurers do to prevent healthcare providers from doing unnecessary stuff. In a taxpayer funded system, there would still have to be an entity to double check healthcare providers’ billing.
> According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
Yes, I agree. I don’t see why Medicare should only apply to those 65+. But until it applies to everyone, insurance companies have to serve that purpose. I worded it confusingly, but I meant to imply that insurance companies’ work is not all waste, since they’re doing a task that someone has to do, even if all healthcare was taxpayer funded.
We don't need to argue what hypothetical shareholders would do, we have hard facts that health insurance CEOs are getting paid billions, and receiving yearly pay increases that outpace most Americans[1].
And another 9% of their revenues is for useless administration (relative to a single payer system). They estimate that if administration and premiums get cut (and thus no profits) as a result of a single payer system, then we would save $615B per year.
I think you missed a zero. About $80 per citizen. Still a negligible part of premiums though.
The problem with health insurers isn't their profits (though that's a popular political talking point), but rather it is the part they've played in creating/enabling all the inefficiency in the current bureaucracy.
The money isn't being pissed away into insurance industry profits.
It's being pissed away when the hospital, and the insurer spend 2 hours arguing over how to bill a $500 procedure. Net cost? $640. $500 for the procedure, $35/hr * 4 hours for the paper-pushers.
Net benefit to the patient? Minus $100, out of their premiums. Would you like to pay cash, or discuss with us a financing plan?
It's being pissed away when the hospital buys bus ads, and the insurer buys superbowl ads. I've not seen a single hospital ad in Canada... Because the hospitals weren't competing for my business.
It's being pissed away when a hospital tries to sneak in a $100 bill for two aspirins, and justifies it by citing how much they spend on charitable care. (Hint: That charitable care is the hospital writing off some other poor bastard's $100 bill for two aspirins.)
In no other country is your healthcare tied to your employment but the US. Germany has had a national healthcare system since around 1880 (after the country was unified, based on what Krupp did for their employees). Why is the US the outlier (also in cost per capita)?
I think another thing about employer-based healthcare that few think about is that if you work for a large company then it is almost certainly self-insured, meaning that you or your employer is paying premiums into a fund that it is managing itself.
How crazy is it to think that not only does Apple or Ford or Trader Joe's need to manage it's own business but that it is also hiring actuaries/insurance specialists/consultants etc to manage a complex insurance program for all of its workers? I'm not sure many people that work at large companies realize that their employer knows every diagnosis, procedure, and prescription you've ever picked up, and actively trying to incentivize you to use as little healthcare as possible.
> I'm not sure many people that work at large companies realize that their employer knows every diagnosis, procedure, and prescription you've ever picked up, and actively trying to incentivize you to use as little healthcare as possible.
I work for such a company, and it's great. I pay about $30 per month for a plan with a tiny deductible ($2,500), and they offer great wellness perks like weekly classes (yoga, kick-boxing) in-office, partner with a local CSA that does a bi-weekly produce truck out in the parking lot. They do encourage folks to get yearly wellness screenings, and basic dental cleanings by increasing your plan by about $2 per week if you don't.
This is a single, no dependents rate. I believe the comprehensive plan, with families runs about $70 per month.
As it were, the plan is employer funded but we have some type of partnership with a major provider for administration so the employer itself isn't hiring actuaries / specialists / consultants. Perhaps your personal experiences differ here?
I don’t understand your comment. If the company is large it is likely self-funded, so it is taking on the risk, whether they are doing it in house or hiring a benefits consultant to do it for them.
I didn’t say anything about the quality of a self-funded plan, simply just pointing out that a self-funded plans means your relationship with your company is not merely just a worker but you morph into this insurance risk that they now have to actively manage. I am pointing out how strange it is to ask a company to have to do that, which is unlike any other country in the world.
> I don’t understand your comment. If the company is large it is likely self-funded, so it is taking on the risk, whether they are doing it in house or hiring a benefits consultant to do it for them.
Because they partner with a larger provider for the doctor / hospital / pharmacy networks and specialist support. This is a very common pattern insofar as I'm aware.
The network of providers available to you is a separate issue from whether your company manages the risk or an insurance company does. Didn’t mention anything about provider networks.
> The network of providers available to you is a separate issue from whether your company manages the risk or an insurance company does
What I'm saying is, my company manages the risk. We partner with a larger insurer company that provides A) network B) specialists for the roles you've claimed a company would normally hire. Because of this we don't have inside actuaries and specialists and such. As a result, there is no inside man looking at my claims.
I will ask for for a third time, have you experience that differs here?
What you’ve described is the self-insurance model for large companies. That doesn’t conflict with any of my earlier comments. Companies can decide whether they want to administer it internally or use a consultant.
You seem to believe that just because a company uses a consultant that no one in HR or Finance or management would be privy to viewing your claims history via the consultant? Not sure what would lead you to believe that. Just because your company is outsourcing the task doesn’t mean it is shielded from the data.
Wow. I work in a 30-40 person office. My plan, which is the nicest available to us, is ~$300/month. Deductible is $1.5k single and $3k family, and I don't have any nice wellness perks like you described. Overall, I hate this plan. It will be handy if I ever get hit by a car and need lots of pricey surgery, but otherwise not so much. The price will be going up about 15% next year.
Deductibles are weird. If you have kids, or are on medications, you don't think much about it, because you are in and out paying co-pays $25 here, $50 there, $100 somewhere else, and that boils the frog quickly.
If you are healthy and single, and have to get anything beyond a physical done, you get slammed paying the whole shebang out of pocket because you haven't put any money towards your deductible all year.
The greatest thing in health care over the past decade has been the explosion in Convenient MD urgent care centers and the like. It makes getting checked up when something needs to get checked up about as easy as going to Jiffy Lube, which is miles better than going to an ER or trying to thread the needle through the schedule for an appointment at your PCP.
> also hiring actuaries/insurance specialists/consultants
What usually happens is that they pay a health insurer to "administer" the plan, or a "Third Party Administrator", which gains them access to all the actuarial stuff, as well as the provider discounts and negotiations, for a service fee, meaning the only effective difference is that your employer doesn't have its funds in a "pool" but can instead choose how much, or little to pay, from its own funding.
My understanding is that the issue is payment is so divorced at this point from services rendered that there is no pressure to lower costs anywhere.
Hospitals pass their costs along to the insurance companies and insurance companies pass those costs along to individuals, and everything that happens in the middle is so convoluted that the average person can't make heads or tails of it to push back.
Our healthcare system is so wildly (and increasingly) inefficient, I don't doubt there will be a breaking point when politicians will finally be forced to nationalize it. Let it keep getting worse. Let them see the bed they're making.
Even at famously generous employers they will try very hard to push you towards high deductible plans by giving you 1-2 thousand extra dollars per year in your HSA. Of course the high deductible plans discourage you from seeking care so it saves your employer peanuts it can add to its war chest in Ireland
Some of this probably has its roots in the ACA adding extra taxes onto “Cadillac insurance plans” though which I didn’t even learn about until recently. Yes, apparently you may need to pay extra taxes for extra good insurance
There are a ton of hidden taxes tacked onto ACA but everyone I know with a marketplace plan hates theirs. I'm really not sure where that money is going.
I manage a health plan for our smallish business of 19 employees. We offer "pretty good" health insurance, meaning, we pay around $600 per employee per month for health and dental. It gets worse every year. I am considering moving toward a HSA based plan, because upon analysis, it's actually probably better for everyone involved. The max out of pocket per year is the same, but instead of a $1000 deductible you have a $5k deductible. This works for our business (and I am assuming a bunch of other tech businesses) because our employees are generally young and in good health. It's a cheaper plan, the worst case scenario for an employee is the same, and I can give raises for the difference in price, and once every few years someone will need more than a $1k deductible, but the raise from the last couple years greatly exceeds the one time cost.
Anyway, just trying to frame my logic here, because I don't consider myself an evil employer trying to skimp on health insurance for my employees (which many I consider friends), but an employer that has to approve health plan changes annually which each increase cost by a considerable amount. If this trend continues, each employee will cost $900 a month within 5 years, and the coverage will be half as good. That's $5k a year per employee that I could put into their salaries, while not screwing anyone over on the worst case scenario.
From my perspective, I am unlikely to hit the out of pocket maximum but quite likely to spend more than $1k/year. All the high deductible does is discourage you from seeking care for things before they become serious. Not sure how it worked from the employer’s end, but $5k/year will get taxed at roughly 50% before I see it so it’s not clear whether that will be greater than my out of pocket costs
The missing link here is premium savings. HDHP plans exchange higher deductibles for a nontrivial premium discount. Insurance companies like to assure employers that employees will bank this discount into a tax-advantaged HSA. So the theory goes, a reasonably healthy subscriber will have sufficient savings to meet their deductible.
This falls apart in practice when employees, who are already spread thin financially, elect an HDHP but can't or won't set aside cash to cover expenses.
Late to reply, sorry. Yes there are ups and downs, but you can setup automatic deductions from paychecks straight into an HSA. I haven't done the full analysis and asked everyone at work, but if the trend continues for the next few years it's going to be really hard for a high deductible HSA plan to not come out ahead. Whether or not we eat the extra cost to keep the convenience will be a decision to be made then.
My comment was only to serve as counterpoint that companies aren't all looking at an HSA because they want to screw people over. Many are looking at an HSA based health plan because they are increasingly becoming more attractive as benefits shrink while becoming more expensive. Again, I am friends with my coworkers, my family is on the same health plan, and I have everyone's best interest in mind, and I wouldn't approach the decision lightly. Obviously there are shitty people out there managing employer plans, I don't speak for them!
The Cadillac insurance plan tax has never gone into effect and has been pushed back a few times now, and truthfully is unlikely to ever be implemented.
This said, the tax on these sorts of plans are absolutely necessary with regard to controlling costs within the system, as cadillac plans which pay providers more for care, give them increasing amounts of leverage to demand payout increases from every other cheaper insurance plan.
The American health insurance system is not insurance--it's a long-term payment plan. Why does insurance need to get billed when I go for a yearly checkup with my doc, or when I pick up some prescription-strength ibuprofen? My auto insurance company doesn't get billed when I get the oil changed in my truck. My homeowners insurance company doesn't get billed when I have to recharge the refrigerant in my heat pump. The insurance companies have taken all the monetary interactions between clinics and patients away, except for the (oftentimes criminal) balance billing that occurs when your claim was denied for some ass-hat reason like "You didn't tell your insurance company whether or not you had other insurance."
> whats the alternative to an employer provided health plan?
There are a number of alternatives:
1. Government health plan at the state level (i.e. the Canada model)
2. Compulsory private insurance (i.e. the Switzerland model). But employers don't provide it and insurers have to insure everyone who pays. Single, larger, and more diverse risk pool instead of 3 separate pools - one with working age people and children, one with old people, one with everyone else
3. Government-owned and -operated hospitals and clinics, free at the point of use (i.e. the UK model)
4. Government health plan at the federal level (i.e. the France model)
All four have been found to cost less per patient for similar or better outcomes.
Yes, it would be great if US employees had those options, but they don't hence they aren't alternatives. The main alternative in the US to an employer based group insurance policy is an individual plan.
One day the US may catch up to the rest of the world, but unfortunately, the US seems content with millions of uninsured, healthcare related bankruptcies, and milking those who can afford coverage more every year in exchange for less.
Doesn’t the fact that vastly different systems perform better than the US possibly suggest that our problem is something other than the payor model? What is the theoretical reason why US costs would be higher than Switzerland? Premiums for private insurance should be much lower in the US, given that Medicare takes high cost people out of the private pool.
The US hasn't had compulsory private insurance up until about 10 years ago. Before that costs were going up even faster[1]. Even then if your employer is providing your health plan the amount of "shopping around" you can do is limited - most companies have 2 or 3 options (a PPO, an HMO and something with an HSA). This leaves only the uninsured (i.e. the poor) or previously uninsurable (pre-existing conditions) in the actual open private insurance marketplace. It's not surprising that premiums there will be crazy high and it's not really that close to being the Swiss model.
> our problem is something other than the payor model
I partially agree with that - the payer model is one facet among many. There are other problems with healthcare in the US. Hospitals can veto opening of competing hospitals in the area, complex billing, not enough residency spots leading to a shortage of doctors, whatever the F is happening with prescription drugs etc. GP was only asking for alternatives to employer healthcare though.
The difference between Switzerland and the US is that in Switzerland pricing is regulated. The free market does not work when your life is at stake. You can shop around as much as you like for a butt enlargement and skip it if it's too expensive, but if you find a bat in the bedroom you need a physician straightaway, and then he will overcharge you.
There are some procedures where shopping around is conceivably an option.
Once you're in desperate need (say, when it's bad enough that you're calling an ambulance), or unconscious, it's not realistic to suggest price-shopping.
Markets of the mostly-free sort work well enough for commodity products, like the kind of peanut butter you're buying a jar of every few weeks (though even that's regulated, from things to food safety to nutrition labeling); for everything else, government's a fabulous tool to make sure people aren't taken advantage of, whether it's through heavy regulation (e.g. Switzerland, as someone mentioned) or offering the service itself (e.g. UK).
The vast majority of health care is a commodity product. Unless you have some super rare condition, whatever your problem happens to be it's extremely likely to receive more or less the same treatment from a large number of potential providers.
My last reading of their work was years ago, but at the time the study found that folks will use fewer health resources when on a high deductible plan. However--the study allowed folks to revert to their old insurance (i.e., lower cost insurance) if they got sick. Meaning the study would show those in high-deductible plan would use fewer resources only because the people in that plan who used more resources quit the study.
Have you looked at a newspaper since, say, 2007 or so? You will find that many have politics sections which have spent an awful lot of time covering the matter. Other news sources frequently cover it as well.
I just want to tack on: People being forced to skip simple preventative medicine, potentially building up a ticking time bomb when those conditions become more expensive to treat.
> An entire generation is draining their savings to keep up with premium costs.
Knock on wood but, myself and pretty much everybody I know has insurance covered ~75% through our full time employers. I think my portion of my insurance is about... $100/mo? I've never had to use it way/shape/form in the past... 5-10 years.
Isn't the truth that the most unhealthy people are what drives health care costs?
It'd be interesting to see a visual of who uses their insurance and how much of it they use. Let's not forget that lack of exercise, obesity, and heart disease are rampant in America.
It seems to be more the exception, rather than the rule, that you will continue to be fine without medical coverage for eternity. One day, something is going to happen. Consumption of health care tends to be back-loaded in life.
Yeah, I really wonder where that $10,000/person figure comes from when you remove obesity and smoking related illnesses, so, the two highest and most preventable causes of death in this country.
I always believed you should be able to qualify for lower costs (or be charged higher) depending on how you take care of yourself. Annual physical fitness test. I'm a little sick and tired of paying high premiums for people to have healthcare that don't take care of themselves.
The brotherhood of "we can all band together to pay for each other" falls apart when the line to McDonald's is wrapped around the corner in my eyes.
If you take in over 3,500 calories a day of pizza, soda, cheeseburgers, or candy then follow it up with little to no exercise/movement, you are contributing to the "health insurance crisis".
> I always believed you should be able to qualify for lower costs (or be charged higher) depending on how you take care of yourself. Annual physical fitness test. I'm a little sick and tired of paying high premiums for people to have healthcare that don't take care of themselves.
Better hope you never get in a car accident or similar accident or get diagnosed with cancer or a chronic condition.
Congratulations for being in perfect health and not needing any sort of medical care. There are plenty of people who don't smoke and aren't obese and can still be bankrupt by standard medical treatments.
I would bet money (let's say the value of my annual insurance premiums) that if the two of us took a physical fitness test or compared overall "health" in areas that are more controllable (weigh, cholesterol, body fat percentage, amount of exercise, and other indicators like smoking/drug/alcohol use), I would be considered healthier than you.
But I have an endocrine condition that requires very expensive medication and annual tests that cost a lot of money.
You're selfish, and that's fine. But the second you ever actually need health care, I hope you remember how quickly you dismiss "people who don't take care of themselves."
This isn't universal and it's also not inclusive of those people who have spouses/partners or children/other dependents. Your employer may cover your premium (or most of it), but it won't always cover those of your dependents at the same percentage.
And I say this as a person who is, with few exceptions, healthy. But medications for common conditions and emergencies , can radically change the cost of all of this.
> Knock on wood but, myself and pretty much everybody I know has insurance covered ~75% through our full time employers.
That is money that would otherwise be given to you in the form of salary, so, yeah, you're paying for it even if it doesn't seem like it.
Historically, the main reason for employer-provided health insurance in the U.S. is that it provided a loophole to increase effective employee compensation in a tax-free manner.
My employer dropped dental insurance a few years ago. They never gave me a pay bump to compensate. Now I spend $1,600/year on cleanings for a family of 4. At least it is out of my HSA, so pre-tax.
They likely dropped it due to budget issues, so of course they weren't going to give you a pay bump. If they had dropped it simply because there was no need to give it to you, you'd probably see a pay bump, or at least faster salary growth in future years.
No. I have a set of skills that the market finds valuable. Part of that value is providing health insurance. Any employer I choose will pay me a salary, and have healthcare benefits.
Somebody has to pay for it... and it currently isn't the billionaires like Democratic candidates wish it was.
Do you not see how much this limits your mobility and freedom to do as you please?
If health care (and insurance) were de-coupled from your employment, you would have much more freedom to move around jobs, or even go without a job for a time if you so chose, etc.
Would you be OK with your employer paying for your housing? education? food?
Your employer being in control of your health (and those other things) is sickening. They are just taking power and choices away from you.
I realize the avg YC visitor will not want to hear this, but when you are taking care of
1) literally tens of millions of foreign nationals that have washed up on America's shored with all manner of maladies and even diseases that never existed in the USA before, and others that have been eradicated for decades, and all those people bring in multiples of their family members with all manner of other maladies and are of elderly age, who then immediately go on medicare and social security. And illegals the emergency rooms for any and all maladies since all of them are of course criminals (regardless of whether you want to split legal hairs, they are still violators or both the rule of law and committing major offenses against the society and people they are parasitizing).
2) The population is full of clusters of immensely unhealthy populations like blacks that are wildly disproportionately affected by specific diseases like sickle cell and kidney diseases and also lead wildly disproportionately unhealthy lifestyles with obesity rates off the chart all around the south in particular.
3) Our corporation captured government is utterly corrupt and politicians and the health sector is too busy lining each others's pockets to actually provide any real leadership of the country neither have any loyalty to anymore and are just trying to get rich off faster than the next guy before the music stops.
Just look at the stocks of health industry companies before and after "Obamacare" passed that was a massive last minute bait and switch pork barrel profit maker for the health industry, while essentially plundering hard working Americans to pay for the healthcare of millions of foreigners that have been imported into the USA against the enslaved American population's will … because having the product of your work taken from you to support the life and lifestyle of others against your will and under threat of violence and ruin is nothing but slavery.
So here wer are, paying twice as much for half the health care we got just 10 years ago when it was said it was bad, but at least millions of foreign nationals are taken care of at the American tax slave's cost.
> Not to mention the millions of people locked into careers they would otherwise get out of, if not for the health coverage.
Replying with a throwaway for obvious reasons. I work at one of the big tech companies -- I'm paid well, but the benefits are very good. I just got an offer from a startup that I really like. It's a job I would like to take.
I'm going to have to turn down the offer. Part of the reason I'm going to have to turn it down is that even though it offers insurance, its coverage isn't as good as what I have and the subsidy offered will add $15k a year minimum to my health care expenses. My partner needs surgery (an expensive surgery), and I'm the primary bread-winner (for now) -- I have to make pragmatic decisions because of stuff like healthcare, even at the expense of my own aspirations.
And to be clear, my scenario is significantly better than so many others who are stuck in truly terrible places (where I work is not terrible by a longshot) or in careers they would like to change, because the truth is, health care in the US is a joke.
Even if the current employer is big enough to negotiate lower prices or deals for its coverage and that's a barrier to entry for the startup, both companies could be set one a level field in a universal healthcare system removing this cost center from both companies. Even if the cost is (partially) rolled into something like payroll or income taxes, it would still impact the big company and the startup much more equitably.
Barriers to entry are one item this site and many of its users and are fighting to better disrupt industries and create value. If you can't get talent because you can't provide healthcare and a solution for that exists in most developed nations (universal care), why are we not engaging that?
Large employers are self insured. The insurance companies just manage the benefits. In that sense there is no negotiation, beyond a manager fee. Price is determined by health of employees and benefit level.
I'm assuming the unspoken point here is that, after negotiation, the startup couldn't make up for enough of the difference for the parent to be able to seriously consider them.
Insurance on healthcare.gov is really not bad - just get $20k more from startup and buy your own insurance. Assuming idiot republicans don’t fuck it up in the next few months.
It’s also an absolute moral disgrace that we’ve decide the profits of insurance industry and other for profit entities are more important than many people’s lives and the suffering of many others. Anyone who wants to argue in favor of the continued existence of this system should have all of this hung around their necks.
They really should offer the employee the option to take the benefit in cash instead of getting the health insurance then you could barter with the healthcare centers. The health insurance and healthcare centers(hospitals/clinics) are a cartel and the only way to bring down prices is through competition and that doesn't happen when you give an arbitrary amount of your paycheck to a clandestine insurance agency that has dubious relationships with the hospitals.
Sharing this idea in order to gather critique.
The cost of healthcare in the USA is insane.
Could we look for insight into the US Military?
Example: This morning, a coworker told me she's going to have an operation on her back. The "cost of the tray" (I have no idea what this is) is $14,000. She has to pay $8,000 up-front two days before the operation, and the remainder will be financed over two years.
To me, it's insane to think the US Military pays $14,000 for this same operation in US Veterans' hospitals.
Why don't we look into the military to see how they're doing it?
The insurance companies are for profit corporations who pay politicians so they can keep taking your money when you're healthy and cutting you when you're not. The army is not, as far as I know, a for profit enterprise.
Oh I'm sure the military doesn't pay that much. They get to leverage staff doctors, and negotiated rates. You know like other countries with single payer systems, etc. get.
People in the U.S. get screwed, because hospitals are businesses, and they know how much they can charge to make a profit. When a hospital has an entire legal arm just for suing people in court, because they aren't making their payments, you know something is wrong.
isn't the problem actually that there is no limit on what they can charge? if i have an accident they won't ask me if i agree on the price, they just charge me while i'm unconscious. i don't get to negotiate prices and the ambulance will take me to the closest hospital, not the cheapest for me.
not only that... your healthcare provider has contracts with the insurance company and the insurance company can actually block you from simply paying cash for services.
>When a hospital has an entire legal arm just for suing people in court, because they aren't making their payments, you know something is wrong.
A good example of this is the Ford Pinto and it’s exploding gas tanks after impact due to them being exposed. This resulted in multiple accidents and deaths. Ford later learned they could retrofit every Pinto sold for a total cost of $11 (in that years value) per Pinto. They decided not too because court costs per death would be less than the profit loss.
Without boring you with unnecessary details, it can be summed up as this: Does B < PL?
B = Burden of adequate precautions
P = probability that the defendants actions will result in an accident
L = Loss/Cost of accident if it occurred
When looking at hospitals, they understand the costs of hospitalizing someone for 3 days, 3 hours, or 3 years. They also know the costs of providing care to all of their patients without the thought of insurance companies reemburssing them. For them, the idea of shrinking profits in order to maximize care is not ideal. So, in this case, they will often charge insurance companies the maximum allowed, charged uninsuranced patients the maximum, etc. Why do they do this? Because for them, B<PL. The total cost of employing 10 lawyers to fight 100+ cases of defaulted medical bills or lobby for a new policy, that will still be less than the amount of profit they would lose if the hospital paid for all that care to begin with.
Active duty military members do not get healthcare at the VA. The VA is reserved for veterans.
That said, as a recipient of VA healthcare I don’t pay a dime. Some vets do but I have a service-connected disability rating above the threshold for free healthcare for life. Prescriptions, ER visits, physical therapy, etc are all covered.
I have a friend who was a nurse at the VA who told me they loved working there because there’s never a hesitation to order a test due to insurance coverage. If my doctor feels that something is important, they order it.
Whether it’s migraine medication, PT due to some jaw issues or a vasectomy, they’re all covered for me.
There have been some complaints about VA service in the past but in the 10+ years I’ve been using them it’s been a breeze.
Replying to both (am the original questioner, and thanks for the answers) I'm a brit and to be precise, the NHS is free at point of use, not free. Just to be clear.
It's also now underfunded, but it's still a system I'll literally fight for.
You can get permanent residency in Canada within 6 months via Express Entry, unless there's something you're particularly looking for in Switzerland you won't find in Vancouver ;) [1] You can then apply for citizenship after having lived there for 3 years out of the most recent 5.
Yes, it is possible. Our health insurance is only slightly less expensive, though (and can only be paid with post-tax money). We hold the proud second place in healthcare costs.
You’ll also have some issues with opening a bank account here — Swiss banks are not particularly fond of US customers, because of reasons.
No, Americans have a long and deeply embedded tap root so they die if they are pulled up.
Nope, sorry, I'm thinking of turnips. Easy mistake.
Yes you can move I guess.
Alternatively perhaps you can give some aggro to your representative and make a public noise so this horrible system you appear to have gets fixed. Bonus: you get to stay in your own country and make things better for everyone else there as well.
535 comments
[ 5.1 ms ] story [ 344 ms ] threadMeanwhile, I've had people brag to me about paying $10/ for damn to near full coverage. I'm starting to wonder if BCBS employer plans are just garbage
The statistical value of single insurance (Basic ACA) for 1 year is north of $10,000, so $1200 has the employer picking up most of the tab still.
This is why the linkage to employers for coverage is so insidious - it hides the true cost of the system in lowered salaries. People look at an unsubsidized exchange plan like mine, with its $2,144/month premiums, and go "holy shit, I only pay $10/month for mine at work, that's horrible!"
If she opted into it, her contribution would be ~$300/month, her employer's contribution would be $900/month.
If she wanted to cover me with it, her contribution would be $1,500/month, and her employer's would be $900/month.
Unsurprisingly, we did not take advantage of this, and she remains on my insurance (Since my employer handles 90% of the premium for both of us.)
When we were still dating, I had a good look at what the $300/month health plans provided. Absolutely flippin nothing. Deductibles of $8,000/year, and co-pays of 25%. If all you can afford is a $300/month plan, there's no way in hell you can afford an $8,000/year + 25% medical bill.
Meanwhile, Canada provides universal healthcare for $5,200 USD/year/person, with similar health outcomes.
Edit: fixed a typo in the employer's contribution.
I have a plan on the state exchange for around $300/month and an out of pocket max around $8k (I'm 34 years old).
I just budget $12k/year for healthcare and move on. This seems reasonable for people who can afford to take the risk of potentially having to pay anywhere from $4-12k/year.
If employers didn't provide health insurance to employees wouldn't we just wind up with 40% of the insured uninsured? Its not like Corporate America is going to make up the difference and start paying cash to compensate for the lost benefit, at least thats what happened as pensions got stripped away from the workplace. Even if the employer's did make up the cash difference, its not like that will bring pricing down, individuals can't negotiate individual insurance rates, pools of employees can negotiate group rates, so if anything costs would probably go up.
How will this help: 1) insured more people; or 2) bring costs down?
This is why the exchanges exist. They're huge pools of people on a group rate. New York state negotiates with insurers on my behalf, and is additionally able to regulate their premium increases each year.
Another advantage for big businesses over small businesses.
At least with the employer provided insurance the employer is negotiating, and you know who that is and you know they have a self-interest in keeping costs down.
Last year saw a drop (down 1.5% in the 39 states using Healthcare.gov), and 2020 looks small thus far as well. https://www.politico.com/story/2019/06/03/obamacare-rate-hik...
I, quite frankly, trust my state more than my employer in a fight against my insurer. I obtain coverage via the NY exchange.
It was doing that for decades prior, too. Obamacare didn’t change it much in either direction.
Put that "Medicare for All" into play first.
I think in the US we have different issues than face Germany/Switzerland/France, and for the US to contain costs my opinion is we would have to rip private insurance out completely.
Our main Government provided system (Medicare for the elderly) is a combination of government and private, and to put that system in perspective, Germany spent 375B (not sure if $ or Euro) in healthcare total in 2017, and US Medicare spent $609B in 2017. Germany covered an entire country (82M people) Medicare covered 15% of the US (44M people).
The Bismarck model like Germany with multiple payers, but they are non-profit and pricing is regulated. Doctors and hospitals are private, and there is still supplemental private insurance. Financing is a combination of employer and taxes, where the government takes over the employer portion if the person is unemployed. This is sorta what the U.S. has for those with employer subsidized health care except for the insurers being for-profit and unregulated pricing.
The Beveridge model like in the U.K. financed through taxes and where the government provides care. This is so-called socialized medicine. In the U.S. we have this system for veterans in the form of the V.A.
The national health insurance model, with private doctors and hospitals but the government is a single-payer. Canada. Medicare.
And lastly, out-of-pocket.
We use all of these in the U.S. and it's insane.
We could in theory adopt a Bismarck system. Force the insurers to be non-profit. Make everyone work off Medicare pricing. Supposedly existing Medicare pricing is too low. Fine, let the doctors and hospitals negotiate that with Medicare. Allow supplemental insurance for those who want it.
MFA polls badly when you ask Americans what if they had to give up their current insurance. But I think this is misleading. Of course it's going to poll poorly if you ask someone to give something up. That's basic loss aversion. Turn the question on its head and ask a bunch of 65+ year olds how they'd feel about giving up Medicare in return for their Medicare withholdings back to buy their own private insurance. Guessing that wouldn't poll too well.
I don't think MFA is necessarily the best option. Americans value choice. But it seems to be the universal care option with the most political momentum right now. I'll take it. But I'd be happy with a Bismarck-type system too.
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/
As long as people are covered it would be a good start (I won't bother engaging further on the single payer/private insurance/hybrid systems, not enough room and not the right forum)...it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured. I know that is not attributable to you, and you seem optimistic we get there anyway, I hope you are right.
One last thing I will note, is there are all kinds of hidden costs through other insurance that hopefully would come down under a single payer (maybe even under a public/private hybrid like Medicare Part D) , take car insurance one reason premiums and deductibles are so high is because a lot of that goes towards personal injury claims (medical costs). The same can be said for odd things like homeowners insurance for example. A lot of these insurance policies people already pay for in some ways supplement health care coverage.
>We use all of these in the U.S. and it's insane.
Well said.
And who are you attributing this to? This seems like either a strawman or a misunderstaning to me.
>>Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America.
FYI, USA currently spends about $10,800 per person on healthcare, roughly $3.5 trillion.
IMO, the discussion should revolve purely around pricing and efficiency. Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system.
I would like to see basic pricing reforms demonstrate that year-over-year price can be held constant. That would be a nice start.
Of course it could. It works in Germany! And France! And Switzerland! Why not here?
Look, I don't know how this can possibly work with our current system. It cannot be solved by the market alone. There's no transparency in the current system. Insurers can just keep passing price increases along. And many Americans want "the best" and "right now" and that ends up increasing costs for all of us.
People will argue that the American system is so expensive because: reasons. e.g. we subsidize the rest of the world. Or we are overweight. Or we don't get enough exercise. Or we want the best of everything. Or health insurance profits and CEO salaries. Or fraud.
We also keep saying: America is exceptional. None of what other countries do will work here.
So what do you propose? At the end of the day, doctors, hospitals, and the payer or payers need to negotiate reasonable pricing for decent care. And that cost needs to be spread equally across all Americans. I'd favor doing it with cost-sharing from paychecks like we do now for Medicare, with the government picking up the bill for the unemployed, and with tax credits to offset income differences. I like the system than France has, where you have a co-pay, but it gets reimbursed. This makes the consumer at least aware that there is cost to using the system. Then allow supplemental insurance for people who want better.
And Americans will somehow need to realize that not every medical problem has to be solved right away. And that you don't need the most expensive treatment option for every issue.
We cannot continue to ration health care by ability to pay. It's immoral.
1) We cannot provide the same services with the same mechanisms, processes, and infrastructure at 50% of the current price. The margin simply isn’t that high. Everything from the design of the hospital, to the regulations around the equipment provisioned in each room, to the processes followed by staff throughout a given patient visit need to change, along with the specific tools and techniques used to perform procedures, before we even get into how and what procedures are chosen to treat or manage a given symptom or disease, whether acute or chronic.
2) Even with all of the above, a system that optimizes for price will absolutely have to make trade-offs in other areas to achieve that. Understanding where, when, and how those trade-offs are made and if they are being made fairly and uniformly based on malady, procedure, patient population, etc. is not a minor detail.
These are massive structural, policy, and economic changes which will impact a double-digit percentage of GDP. Why should anyone have any faith that this will be done in any semblance of a sane, reasonable, compassionate, let alone fair, efficient, or effective manner?
If the government has shown it’s entirely incapable of passing effective legislation to manage the cost of healthcare, why should government be granted an order of magnitude greater role in the provisioning of care?
In any case, the current system is both unfair and unsustainable. Something has to give.
US defense spending is by far the highest of any other country in the world, and renowned for its wastefulness.
Social Security is going bust whenever we talk about it, and is merely a program which confiscated money today, in order to hand it out tomorrow, and doesn’t even invest it in the meantime.
And which half of government is it that’s capable of passing legislation again?
The numbers speak for themselves and it is ridiculous the US spends 100% more for half the people (e.g. Medicare) than Germany spends to cover 2x as many people and their entire country.
That said keep in mind Medicare patients are the most expensive patients in that they have the highest rate of chronic diseases of any other demographic. Its not apples to apples, but more importantly a Universal coverage could probably be extremely effective in preventing untold millions of chronic conditions through preventative care. What happens now is millions of people reach Medicare eligibility who had no coverage before and as a result have all these untreated chronic conditions, and then boom Medicare has to cover the tab when they become eligible. Its such a stupid system, there are even cases of heart surgery's and cancer treatments that are delayed until a patient hits medicare age, making the issue worse and more expensive to treat.
It may sound like I am taking a devils advocate position, but I 100% agree with you on governmental waste.
I didn't say "free healthcare". I said "government pays 100% of costs". Yes, that means ultimately we all pay them through taxes.
> The concept of "private health insurance" outside of supplemental insurance would not exist under that system.
Under Medicare, "government pays 100% of costs" also means "government is the only provider of health insurance". But my whole point is that you don't need to do that in order for the government to use its negotiating leverage to negotiate better rates; the government can do that even if the rates it's negotiating are with private insurance providers. That's basically what the government does now for Federal employees and elected officials; they aren't on Medicare, they have a selection of private insurance plans that have negotiated rates with the government. My suggestion is to simply extend this to all citizens, so the government can negotiate even better rates since they now have a much larger pool of people to negotiate for.
If employers stopped providing it, I think it is presumed that the mentality towards individual plans would change
True meaning it averages out to a reasonably healthy person
It is unfortunately true in the US (probably everywhere) there is worse health/higher incidences of chronic conditions in the poor (mostly because all chronic conditions are diet related). However, in the US the biggest weight would be the elderly who have chronic conditions at a higher rate than any other demographic (generally due to a lifetime of poor diet combined with irregular care over their life to treat the conditions until they are Medicare), but thats the irony these are the people already covered by Government healthcare (and they seem fairly happy with it. Its time to extend it to everyone.
I see people say this constantly. Insurance by definition is literally always a "group plan"—everyone who buys insurance is in the same group. That's literally the point of insurance. It's why it exists. That's what it is. That is fundamentally how insurance works. All insurance, in every category, of every type. There are no exceptions.
Insurance always pools risk across all payers (everyone is in the "group"), and then you expect only a fraction (but we don't know which fraction, of course) to require a payout in any given payment period.
If you're selling something that doesn't work like that, then it's not insurance—by definition.
The difference is that if I know the mean and variance of expected health costs for the group, I can offer a lower premium to every individual member because the variance of total actual cost goes down by n^(-1/2) and I don’t need to cover my butt as much. Especially since almost all group plans are centered around relatively healthy working age people. The privilege of group plans is you’re in a healthier subset.
Individual plans are for people not on those plans and they suck dickballs. There is a high chance of moral hazard. There’s more retired old people. You offer little value to the insurance company so you don’t get to negotiate like a group plan does.
Medicare is mandatory in the US for retired old people. It's universal, it's mandatory, and it covers everything. They're literally not in the insurance pools, so I don't know what you're talking about.
As for the "group plans", those "groups" are too small for insurance purposes—they do not spread risk effectively. The entire "group plan" thing is a scam, and it would be trivial for gov't to just outlaw them entirely in the US, and force individual pricing on business-purchased health insurance like we do for every other kind of insurance we have. Costs would go down for everyone, and individual plans would no longer "suck dickballs".
That said, that is not how I would "fix" the health insurance issues we have. But it's at least better than what we do now...
How about everyone who retired before 65?
As for your other points, I mean yeah, we shouldn’t have employers provide it. But they do, and you need to recognize it. There are definitely group plans large enough to spread risk.
Personal anecdata:
2018, my employer didn't offer insurance. I signed up for a "silver" tier individual plan ($1250 deductible, good coverage) on the ACA marketplace and paid $170-something/mo. (after receiving ~$250/mo. in tax credit).
2019, my employer starts offering insurance, so I'm no longer eligible for the ACA tax credit. The only plan they offer costs me $125/mo., has a $4500 deductible, and extremely skimpy coverage. According to the literature they gave us, my employer's pitching-in another $400-something/mo.
So this group plan costs significantly more, has a much higher deductible, and covers significantly less (in my case, it's the difference between medication being covered and not).
[0] https://www.irs.gov/affordable-care-act/individuals-and-fami...
In scenario 1, I start working at a 1000 person company that offers insurance benefits. I sign up for their plan, and my employer pays for nearly all of it.
In scenario 2, I start working at a tiny company that doesn't offer insurance benefits. I find an individual plan (coincidentally from the same insurance company used in scenario 1) that suits me, and sign up for it, paying out of pocket.
The total amount paid to the insurance company in scenario 1 is, as is typical, lower than in scenario 2.
In both of these scenarios, the insurance company doesn't know anything about me. For scenario 1, sure, they might know the mean and variance of expected health costs of the 1000 people already at the company, but that does not extend to me. They cannot assume I will conform to the rest of the group. I am new, and an unknown, and they do not know how I will affect those statistics. For scenario 2, I'm just another independent signup. I might have health care costs in line with the average of all of their beneficiaries, or I might be an outlier (on either end), or something in between. But that's the same as scenario 1.
This feels like it has nothing to do with risk assessment; this is just a reflection of the company in scenario 1 having greater negotiation power because they're representing 1000 people, versus you just representing yourself.
Imagine there were no private companies but a perfect decentralized blockchain shamwow insurance system that magically worked and distributed all profits back to its participants.
I would think the dying man is committing moral hazard here. But it’s up for debate.
If you do this against a big private insurance company and they lose a penny, it doesn’t sound so bad, but I’m not convinced
Something like this https://en.wikipedia.org/wiki/Health_care_in_the_United_King...
2) Pooling remains an issue, but as it stands now, consumers have little to no choice, one would imagine that once a 125m households start shopping for insurance there is going to be competition on price...
in most circumstances
So really, it's just the typical American thing of people being terrible at understanding tax codes and adjusting their withholdings correctly.
https://www.irs.gov/taxtopics/tc502
>You may deduct only the amount of your total medical expenses that exceed 7.5% of your adjusted gross income. You figure the amount you're allowed to deduct on Form 1040, Schedule A.
It’s another subsidy for big business in the US. If you work for a small employer that doesn’t offer health insurance, you’re paying with after tax money.
"""
- If you buy health insurance through the state- or federally run health insurance marketplaces, you can deduct only the portion of the premium you pay out of your own pocket. You cannot deduct the amount of any subsidy.
- If you buy an individual or family health insurance plan, either on the open market or through a marketplace, and you pay all of the cost out of pocket, then the whole amount is deductible.
"""
[1] https://www.insurance.com/health-insurance/health-insurance-...
The insurance industry has perverted our healthcare system. The major reason doctors moved from private practice to being associated with hospitals is to simplify billing because health insurance companies look for any reason to refuse payment. To reverse this trend, we need more people willing to bypass insurance and buy healthcare directly.
Health insurance is a failed experiment. People should pay for their healthcare directly, and the government should provide for those who require serious, expensive treatments (after a payment that is some percentage of their income).
It's cheaper for the government to pay for everything. If you incentivize skipping check-ups and minor treatments they turn into large expensive care.
The rest of the western world has had universal health care for ~50 years now and it works better in every other western country than it does in the US. The US should just choose a country and copy it.
Just because X policy works elsewhere doesn't mean it would have the same effect in another country.
Thats actually exactly what I think the thought is for most people who advocate this...remove employer provided insurance and there will be so many uninsured that someone will have to do something. I think the hope is that something would be "Universal single payer healthcare coverage."
That may be right, but we already had 50 million uninsured american's and Obamacare barely passed and was pretty insurance friendly. I just don't see the political will to get it done, then we are just stuck with 40% of the currently insured uninsured.
And I'd argue that the US is moving towards a similar system for healthcare. Lots of small clinics are popping up around the nation to provide limited care to individuals for price-conscious individuals.
What we need is something to cut the tether that insurance companies have. Insurance is nearly as important for determine the rates you pay for care as it is for covering costs.
I'm for it as long as it doesn't involve the government micromanaging how the health care providers perform their services. This is a problem with all health insurance, public or private, but the micromanagement is done on a more direct level with government-provided insurance, with doctor report cards and so on. They do this now for at least some Medicaid and Medicare implementations, and some of the provisions of Obamacare even accelerated this process.
They may not have compensated in cash (although surely some did), but they compensated elsewhere in the total compensation package. Benefits got better or salaries grew or vacation improved or 401K matches were introduced or etc etc.
As for insurance pools, what is stopping people from forming groups that can negotiate their own rates? If there is a law, why can it not be changed?
The first is single payer which has proven implementation and is able to lower costs by directly controlling prices.
The second is what Switzerland does which is where much of the inspiration for the ACA came from, except every single person would be required to buy from the exchanges rather than using some employer program. The ACA failed to properly acknowledge the negotiation power of certain large employers who often have large numbers of healthy young employees and have a deep understanding of their own risk pool, leaving the ~3% of people who use the exchanges paying more simply because they are a higher health risk population. Additionally, the ban/tax on "cadillac" plans absolutely needs to go into effect as it's an important mechanism for controlling costs in a market health insurance solution, as in demand doctors could just require patients have said cadillac plans that pay out more.
There are handfuls of solutions in the middle of this, but they generally involve the government controlling prices to a certain degree, but only single payer would be effective at both bringing costs down and insuring more people, as you absolutely have to create short term shortages in order to solve both problems at once.
It brings costs down, because many more people are now on a level playing field. If we stick with the current market-based system, this would make a big difference in actually having it start to function like a market. The average, middle class American will actually have to evaluate the costs of their plan and shop around for the best value, and they will also be very aware of how much they're spending and push for measures to bring down costs. If we do also build up a universal healthcare system, then working, middle class people will end up actually using the universal healthcare system, and again will be incentivized to push to make it work well.
As things stand today, people on the "open market" plans are clearly being treated as second class citizens, they're paying more and getting worse coverage than people who have a special connection (whether that's a company plan, union, etc). The taxing is also wonky and unfair, at least if I understand this correctly if I pay for a marketplace plan I'm paying with after-tax money, but if my company pays for my plan it's untaxed.
In my opinion there are also additional reasons this would be a net good thing, even if it were merely neutral on the two criteria that you call out. It will give people more freedom to do what they want to do -- right now if you want to quit a job or work only part-time, even if you have a source of income or savings to make it feasible, healthcare is a major hurdle. If you want to start a small business and need to offer healthcare for your employees, it's an even bigger hurdle. I would rather live in a world where it's as easy as possible to make your own path, and people are not beholden to a full-time job to have access to healthcare.
This awareness can be raised in other ways. For example, some employers have added a chart in HR websites that outline how much is spent on each employee (it is personalized for each employee) in categories of wages, taxes, retirement, healthcare and the like. It is a way of communicating how much money is expended on an employee.
If one were to know how much was spent on one's healthcare coverage, would the average person think "ok, need to be efficient to get that number down" or "gosh, I better get what I'm paying for?" In the sense that healthcare plans are transfers from the healthier to the sicker, one would hope the former. In the sense that healthcare plans are almost-all-you-can-eat buffets of medicine, I think the latter is more likely.
I mean, it's one thing if we moved to a single payer system, which would be great, but just moving out of the employer's hands and into the general public seems like a disaster. (Also, I am not a fan of the employer healthcare model.)
The payroll tax could be used either to fund a single payer system or to fund deductions for employees helping them buy insurance.
Its anecdotal, but my company and the company my mom works for, both already do this if you choose to opt out of the employer plan. Total compensation is not a foreign concept to most businesses.
For an instant raise to happen: companies must not only lose their tax deductions on what they contribute to insurance, they also need to count that contribution to employee's wages even if the employee doesn't take it. As soon as young childless employees realize that they are paying taxes on what amounts to the insurance payments to their co-worker who has a lot of kids they will demand they get the cash.
(from 2017-2018 for example insurance on the exchange increased 32% for silver plans and 20% for Gold plans)
Or, put another way, employers have borne 69%/80% of the cost of healthcare increases. You complain because your individual plan has gone up by $986 in 20 years? Your employer's cost has gone up $4,005. Oh, and that's with cutting the underlying coverage ("skimpier").
It negatively impacts wage growth because that extra $4k is a bottom-line benefit (or cost of employment, if you want to think about it that way).
Finally, note the disparity between individual and family plans. Employers are offering 2.5x more benefit—nearly $9,000 more—to workers with families.
-----
[1] http://files.kff.org/attachment/Report-Employer-Health-Benef...
Fig. 1.10 shows premiums increasing from $2,196/$5,791 in 2019 to $7,188/$20,576. (Note also that 72% of that is attributed to premium increases vs. inflation and worker earnings, per Fig. 1.14.) Fig 6.1 shows % of premium paid by workers going from 14%/27% to 18%/30%.
Interestingly, my employer discloses the full premium that they pay to the health insurer every year. As an employee without a partner/dependents (I just graduated college/started my career), my employer spends ~$17k/year less on my health/dental/vision benefits than employees with a partner/dependents.
That effective pay difference makes me mildly salty.
Of course, this is a benefit that's within your control: just get a partner/dependent! And the flip side is that even individual employees might value knowing that the company "has your back" as your family situation changes.
Or, more bluntly, your company has to offer disparate benefits, because other employers do, and no employee with a family would work for your company otherwise.
Of course, all this masks the REAL problem that employers and healthcare are so intertwined. Even this article puts some of the blame on employers, when really it's the healthcare companies and the overall rising cost of care.
The refrain of "people like their health insurance" deliberately conflates the two. People like their doctors, not their insurance. Doctors accept multiple insurance companies.
Some do, but not all. One of my providers takes exactly one insurer, which I do not have, so pay out-of-pocket.
Luckily most insurance companies allow you to submit receipts to receive credit towards your deductible.
Basically I think no one expects it to get better, so they are just all hoping it doesn't continue to get worse (while expecting that it will).
I had to tune out after that part of the debate. Watching a bunch of candidates, and especially the frontrunner, claim not that MFA was OK but their plan was better, but that MFA is some kind of impossible dream that can't work, just pissed me off too much. Screw them. Seriously.
The second piece is that M4A is a huge unknown, and so they'd want to keep their health insurance because they're afraid that what the government will offer will ultimately be worse.
The first point is certainly easy to address as that money would then likely be renegotiated to result in salary increases, but with regards to the second, what would stop a republican administration from doing things like, effectively banning abortion by refusing to pay doctors who perform them through executive order.
Hospitals increase staff to justify billing more, then insurance companies use increased costs to justify raising rates. Internally, hospitals and insurance companies are also in a tug of war over their slice of the pie. These conflicts introduce even more people-hours into the treatment of patients, in the form of revenue cycle managers, lawyers, medical coders, etc.
Each new layer added to the cost onion of healthcare results in the pie growing, since most insurance providers can only take in some percentage of what is spent. So they need to spend more to make more.
Take this concept to the level of a very large health care network (but non-HMO). Patient has early signs of serious but uncommon condition, goes to doctor. Doctor checks for common, obvious things. Finds non-specific symptoms, refers patient to a specialist or three, and the patient is diagnosed with "Not-My-Problemitis".
Disease progresses and the patient is now able to tell the majority of the symptoms are vascular in nature, not muscle or bone as previously thought. More referrals are given. The specialist orders a battery of tests, but they yield false negatives as the symptoms are not occurring at the time of the test, and the patient was not advised that the symptoms needed to be occurring during the test for it to be valid. Patient is again diagnosed with "Not-My-Problemitis" and possibly referred to a research institute, where they'll have quite a long wait time.
By this point, the patient may have lost their employment due to the frequent sick time and time off for appointments, and generally being frustrated in general. They can qualify for Medicaid but will have to start the process over again, but much slower as providers have to tread carefully with care received under Medicaid supervision, as if they were treading on thin ice. But oops, the patient has now gone into critical condition and is sent to the ICU, which is statistically likely to be owned by the same health organization that had their hands involved in the patient's earlier care.
Due to the patient's hospital visit, regardless of whether the patient survives, a payout of Six or even Seven figures is rewarded. Ka-Ching! Insurance companies are hesitant to deny those kinds of claims now, if they involve life or death. Too much bad PR. Thanks, Michael Moore! Of course, it doesn't work out as well for the hospital if the patient had lost their job and is back on Medicare, as there isn't much profit to be made there, if any. That's just the collateral cost of doing business.
[ and before someone replies, it is a mix of those, of course ]
In competitive markets, competition will keep costs and profits from ballooning.
What kind of market conditions are required for spending to increase in all sorts of directions? I can immediately point to education as an example where both lenders and colleges both have a vested interest in growing eachother's businesses, paid for by the customer.
Whatever it is they do exactly it deals with insurance companies. Germany also has private doctors but they have much smaller staff and dealings with insurance are very straightforward. American insurance companies cause a lot of friction. I don’t know exactly why but they do.
The biggest problem IMO is how we structure payment for health services in the USA. The fee for service model is highly inefficient and disincentivizes preventative care. All of the current proposals for universal healthcare do not address this fundamental problem, and so long as this remains in place we will continue to have the highest costs in the world. (disclosure, I am working to try and solve this problem)
If you were to pick countries to emulate, I would pick Singapore, Japan, the Netherlands, and Switzerland instead of Canada and the U.K.
https://www.healthaffairs.org/do/10.1377/hblog20110920.01339...
> According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
[1] https://www.axios.com/the-sky-high-pay-of-health-care-ceos-1...
https://www.peri.umass.edu/publication/item/1127-economic-an...
The problem with health insurers isn't their profits (though that's a popular political talking point), but rather it is the part they've played in creating/enabling all the inefficiency in the current bureaucracy.
It's being pissed away when the hospital, and the insurer spend 2 hours arguing over how to bill a $500 procedure. Net cost? $640. $500 for the procedure, $35/hr * 4 hours for the paper-pushers.
Net benefit to the patient? Minus $100, out of their premiums. Would you like to pay cash, or discuss with us a financing plan?
It's being pissed away when the hospital buys bus ads, and the insurer buys superbowl ads. I've not seen a single hospital ad in Canada... Because the hospitals weren't competing for my business.
It's being pissed away when a hospital tries to sneak in a $100 bill for two aspirins, and justifies it by citing how much they spend on charitable care. (Hint: That charitable care is the hospital writing off some other poor bastard's $100 bill for two aspirins.)
How crazy is it to think that not only does Apple or Ford or Trader Joe's need to manage it's own business but that it is also hiring actuaries/insurance specialists/consultants etc to manage a complex insurance program for all of its workers? I'm not sure many people that work at large companies realize that their employer knows every diagnosis, procedure, and prescription you've ever picked up, and actively trying to incentivize you to use as little healthcare as possible.
I work for such a company, and it's great. I pay about $30 per month for a plan with a tiny deductible ($2,500), and they offer great wellness perks like weekly classes (yoga, kick-boxing) in-office, partner with a local CSA that does a bi-weekly produce truck out in the parking lot. They do encourage folks to get yearly wellness screenings, and basic dental cleanings by increasing your plan by about $2 per week if you don't.
This is a single, no dependents rate. I believe the comprehensive plan, with families runs about $70 per month.
As it were, the plan is employer funded but we have some type of partnership with a major provider for administration so the employer itself isn't hiring actuaries / specialists / consultants. Perhaps your personal experiences differ here?
I didn’t say anything about the quality of a self-funded plan, simply just pointing out that a self-funded plans means your relationship with your company is not merely just a worker but you morph into this insurance risk that they now have to actively manage. I am pointing out how strange it is to ask a company to have to do that, which is unlike any other country in the world.
Because they partner with a larger provider for the doctor / hospital / pharmacy networks and specialist support. This is a very common pattern insofar as I'm aware.
Has your experience differed?
What I'm saying is, my company manages the risk. We partner with a larger insurer company that provides A) network B) specialists for the roles you've claimed a company would normally hire. Because of this we don't have inside actuaries and specialists and such. As a result, there is no inside man looking at my claims.
I will ask for for a third time, have you experience that differs here?
You seem to believe that just because a company uses a consultant that no one in HR or Finance or management would be privy to viewing your claims history via the consultant? Not sure what would lead you to believe that. Just because your company is outsourcing the task doesn’t mean it is shielded from the data.
That's quite a large deductible.
If you are healthy and single, and have to get anything beyond a physical done, you get slammed paying the whole shebang out of pocket because you haven't put any money towards your deductible all year.
The greatest thing in health care over the past decade has been the explosion in Convenient MD urgent care centers and the like. It makes getting checked up when something needs to get checked up about as easy as going to Jiffy Lube, which is miles better than going to an ER or trying to thread the needle through the schedule for an appointment at your PCP.
What usually happens is that they pay a health insurer to "administer" the plan, or a "Third Party Administrator", which gains them access to all the actuarial stuff, as well as the provider discounts and negotiations, for a service fee, meaning the only effective difference is that your employer doesn't have its funds in a "pool" but can instead choose how much, or little to pay, from its own funding.
I thought it was pretty expected that as you get more of the unhealthy parts of the population into healthcare, costs will rise for everyone else.
Hospitals pass their costs along to the insurance companies and insurance companies pass those costs along to individuals, and everything that happens in the middle is so convoluted that the average person can't make heads or tails of it to push back.
Some of this probably has its roots in the ACA adding extra taxes onto “Cadillac insurance plans” though which I didn’t even learn about until recently. Yes, apparently you may need to pay extra taxes for extra good insurance
Anyway, just trying to frame my logic here, because I don't consider myself an evil employer trying to skimp on health insurance for my employees (which many I consider friends), but an employer that has to approve health plan changes annually which each increase cost by a considerable amount. If this trend continues, each employee will cost $900 a month within 5 years, and the coverage will be half as good. That's $5k a year per employee that I could put into their salaries, while not screwing anyone over on the worst case scenario.
This falls apart in practice when employees, who are already spread thin financially, elect an HDHP but can't or won't set aside cash to cover expenses.
My comment was only to serve as counterpoint that companies aren't all looking at an HSA because they want to screw people over. Many are looking at an HSA based health plan because they are increasingly becoming more attractive as benefits shrink while becoming more expensive. Again, I am friends with my coworkers, my family is on the same health plan, and I have everyone's best interest in mind, and I wouldn't approach the decision lightly. Obviously there are shitty people out there managing employer plans, I don't speak for them!
This said, the tax on these sorts of plans are absolutely necessary with regard to controlling costs within the system, as cadillac plans which pay providers more for care, give them increasing amounts of leverage to demand payout increases from every other cheaper insurance plan.
There are a number of alternatives:
1. Government health plan at the state level (i.e. the Canada model)
2. Compulsory private insurance (i.e. the Switzerland model). But employers don't provide it and insurers have to insure everyone who pays. Single, larger, and more diverse risk pool instead of 3 separate pools - one with working age people and children, one with old people, one with everyone else
3. Government-owned and -operated hospitals and clinics, free at the point of use (i.e. the UK model)
4. Government health plan at the federal level (i.e. the France model)
All four have been found to cost less per patient for similar or better outcomes.
One day the US may catch up to the rest of the world, but unfortunately, the US seems content with millions of uninsured, healthcare related bankruptcies, and milking those who can afford coverage more every year in exchange for less.
> our problem is something other than the payor model
I partially agree with that - the payer model is one facet among many. There are other problems with healthcare in the US. Hospitals can veto opening of competing hospitals in the area, complex billing, not enough residency spots leading to a shortage of doctors, whatever the F is happening with prescription drugs etc. GP was only asking for alternatives to employer healthcare though.
1. https://www.thebalance.com/causes-of-rising-healthcare-costs...
Once you're in desperate need (say, when it's bad enough that you're calling an ambulance), or unconscious, it's not realistic to suggest price-shopping.
Markets of the mostly-free sort work well enough for commodity products, like the kind of peanut butter you're buying a jar of every few weeks (though even that's regulated, from things to food safety to nutrition labeling); for everything else, government's a fabulous tool to make sure people aren't taken advantage of, whether it's through heavy regulation (e.g. Switzerland, as someone mentioned) or offering the service itself (e.g. UK).
In Switzerland, people actually shop around regularly and change insurance providers. That probably keeps premium costs down.
My last reading of their work was years ago, but at the time the study found that folks will use fewer health resources when on a high deductible plan. However--the study allowed folks to revert to their old insurance (i.e., lower cost insurance) if they got sick. Meaning the study would show those in high-deductible plan would use fewer resources only because the people in that plan who used more resources quit the study.
An entire generation is draining their savings to keep up with premium costs.
Not to mention the millions of people locked into careers they would otherwise get out of, if not for the health coverage.
This situation is probably going to lead to unbelievable outcomes.
Have you looked at a newspaper since, say, 2007 or so? You will find that many have politics sections which have spent an awful lot of time covering the matter. Other news sources frequently cover it as well.
I guess that I need to acknowledge this is really what most people want in America.
Knock on wood but, myself and pretty much everybody I know has insurance covered ~75% through our full time employers. I think my portion of my insurance is about... $100/mo? I've never had to use it way/shape/form in the past... 5-10 years.
Isn't the truth that the most unhealthy people are what drives health care costs?
It'd be interesting to see a visual of who uses their insurance and how much of it they use. Let's not forget that lack of exercise, obesity, and heart disease are rampant in America.
I always believed you should be able to qualify for lower costs (or be charged higher) depending on how you take care of yourself. Annual physical fitness test. I'm a little sick and tired of paying high premiums for people to have healthcare that don't take care of themselves.
Where do you draw this line ?
If someone cannot afford to eat or live a healthy lifestyle do you kick them while they are down ?
If you take in over 3,500 calories a day of pizza, soda, cheeseburgers, or candy then follow it up with little to no exercise/movement, you are contributing to the "health insurance crisis".
Better hope you never get in a car accident or similar accident or get diagnosed with cancer or a chronic condition.
Congratulations for being in perfect health and not needing any sort of medical care. There are plenty of people who don't smoke and aren't obese and can still be bankrupt by standard medical treatments.
I would bet money (let's say the value of my annual insurance premiums) that if the two of us took a physical fitness test or compared overall "health" in areas that are more controllable (weigh, cholesterol, body fat percentage, amount of exercise, and other indicators like smoking/drug/alcohol use), I would be considered healthier than you.
But I have an endocrine condition that requires very expensive medication and annual tests that cost a lot of money.
You're selfish, and that's fine. But the second you ever actually need health care, I hope you remember how quickly you dismiss "people who don't take care of themselves."
And I say this as a person who is, with few exceptions, healthy. But medications for common conditions and emergencies , can radically change the cost of all of this.
That is money that would otherwise be given to you in the form of salary, so, yeah, you're paying for it even if it doesn't seem like it.
Historically, the main reason for employer-provided health insurance in the U.S. is that it provided a loophole to increase effective employee compensation in a tax-free manner.
That is an outrageous price!
So your continued physical health and financial health is utterly dependant on your current employer.
Do you not see any problem with that?
(I'm not American, I think it's vile, and closer to slavery than I have any interest in touching)
No. I have a set of skills that the market finds valuable. Part of that value is providing health insurance. Any employer I choose will pay me a salary, and have healthcare benefits.
Somebody has to pay for it... and it currently isn't the billionaires like Democratic candidates wish it was.
If health care (and insurance) were de-coupled from your employment, you would have much more freedom to move around jobs, or even go without a job for a time if you so chose, etc.
Would you be OK with your employer paying for your housing? education? food?
Your employer being in control of your health (and those other things) is sickening. They are just taking power and choices away from you.
1) literally tens of millions of foreign nationals that have washed up on America's shored with all manner of maladies and even diseases that never existed in the USA before, and others that have been eradicated for decades, and all those people bring in multiples of their family members with all manner of other maladies and are of elderly age, who then immediately go on medicare and social security. And illegals the emergency rooms for any and all maladies since all of them are of course criminals (regardless of whether you want to split legal hairs, they are still violators or both the rule of law and committing major offenses against the society and people they are parasitizing).
2) The population is full of clusters of immensely unhealthy populations like blacks that are wildly disproportionately affected by specific diseases like sickle cell and kidney diseases and also lead wildly disproportionately unhealthy lifestyles with obesity rates off the chart all around the south in particular.
3) Our corporation captured government is utterly corrupt and politicians and the health sector is too busy lining each others's pockets to actually provide any real leadership of the country neither have any loyalty to anymore and are just trying to get rich off faster than the next guy before the music stops.
Just look at the stocks of health industry companies before and after "Obamacare" passed that was a massive last minute bait and switch pork barrel profit maker for the health industry, while essentially plundering hard working Americans to pay for the healthcare of millions of foreigners that have been imported into the USA against the enslaved American population's will … because having the product of your work taken from you to support the life and lifestyle of others against your will and under threat of violence and ruin is nothing but slavery.
So here wer are, paying twice as much for half the health care we got just 10 years ago when it was said it was bad, but at least millions of foreign nationals are taken care of at the American tax slave's cost.
https://news.ycombinator.com/newsguidelines.html
Replying with a throwaway for obvious reasons. I work at one of the big tech companies -- I'm paid well, but the benefits are very good. I just got an offer from a startup that I really like. It's a job I would like to take.
I'm going to have to turn down the offer. Part of the reason I'm going to have to turn it down is that even though it offers insurance, its coverage isn't as good as what I have and the subsidy offered will add $15k a year minimum to my health care expenses. My partner needs surgery (an expensive surgery), and I'm the primary bread-winner (for now) -- I have to make pragmatic decisions because of stuff like healthcare, even at the expense of my own aspirations.
And to be clear, my scenario is significantly better than so many others who are stuck in truly terrible places (where I work is not terrible by a longshot) or in careers they would like to change, because the truth is, health care in the US is a joke.
Even if the current employer is big enough to negotiate lower prices or deals for its coverage and that's a barrier to entry for the startup, both companies could be set one a level field in a universal healthcare system removing this cost center from both companies. Even if the cost is (partially) rolled into something like payroll or income taxes, it would still impact the big company and the startup much more equitably.
Barriers to entry are one item this site and many of its users and are fighting to better disrupt industries and create value. If you can't get talent because you can't provide healthcare and a solution for that exists in most developed nations (universal care), why are we not engaging that?
To me, it's insane to think the US Military pays $14,000 for this same operation in US Veterans' hospitals. Why don't we look into the military to see how they're doing it?
Or am I completely off-base here? Thoughts?
People in the U.S. get screwed, because hospitals are businesses, and they know how much they can charge to make a profit. When a hospital has an entire legal arm just for suing people in court, because they aren't making their payments, you know something is wrong.
Let that sink in a bit
A good example of this is the Ford Pinto and it’s exploding gas tanks after impact due to them being exposed. This resulted in multiple accidents and deaths. Ford later learned they could retrofit every Pinto sold for a total cost of $11 (in that years value) per Pinto. They decided not too because court costs per death would be less than the profit loss.
Without boring you with unnecessary details, it can be summed up as this: Does B < PL?
B = Burden of adequate precautions
P = probability that the defendants actions will result in an accident
L = Loss/Cost of accident if it occurred
When looking at hospitals, they understand the costs of hospitalizing someone for 3 days, 3 hours, or 3 years. They also know the costs of providing care to all of their patients without the thought of insurance companies reemburssing them. For them, the idea of shrinking profits in order to maximize care is not ideal. So, in this case, they will often charge insurance companies the maximum allowed, charged uninsuranced patients the maximum, etc. Why do they do this? Because for them, B<PL. The total cost of employing 10 lawyers to fight 100+ cases of defaulted medical bills or lobby for a new policy, that will still be less than the amount of profit they would lose if the hospital paid for all that care to begin with.
That said, as a recipient of VA healthcare I don’t pay a dime. Some vets do but I have a service-connected disability rating above the threshold for free healthcare for life. Prescriptions, ER visits, physical therapy, etc are all covered.
I have a friend who was a nurse at the VA who told me they loved working there because there’s never a hesitation to order a test due to insurance coverage. If my doctor feels that something is important, they order it.
Whether it’s migraine medication, PT due to some jaw issues or a vasectomy, they’re all covered for me.
There have been some complaints about VA service in the past but in the 10+ years I’ve been using them it’s been a breeze.
(I'm an American living and paying income taxes in the UK as a software engineer. It is an option.)
It's also now underfunded, but it's still a system I'll literally fight for.
NHS isn’t perfect. But its cost structure is miles more navigable and we’ve found wait times better.
[1] https://www.canada.ca/en/immigration-refugees-citizenship/se...
You’ll also have some issues with opening a bank account here — Swiss banks are not particularly fond of US customers, because of reasons.
Nope, sorry, I'm thinking of turnips. Easy mistake.
Yes you can move I guess.
Alternatively perhaps you can give some aggro to your representative and make a public noise so this horrible system you appear to have gets fixed. Bonus: you get to stay in your own country and make things better for everyone else there as well.