I've seen attempts to explain the system, but I've never seen them well-articulated. And I think the complexity is a major part of the problem where many are taken advantage of. Do insurance companies not share at least some of the blame in the system?
And what is driving this large cause in administrative overhead? Something about a doctor having to write letters to justify anti-emetics for a pediatric cancer patient to the insurance company?
I'm pretty sure nobody understands the healthcare system.
But rather than getting bogged down in all of the regulatory-captured details that of course just sum up to the broken system we have, let's put the bare reality quite plainly: "Those who make peaceful revolution impossible will make violent revolution inevitable".
Political campaigns rejecting government-based reform only work if the industry uses the breathing room to clean up their act on their own. When it throws those political campaigns out there in bad faith merely to run interference so it can continue collecting rent while not actually reforming, eventually people will have had enough and cheer on escalations past those neutralized avenues of reform.
I think this comment betrays the reality of Americans interaction with healthcare insurance. It’s not about regulatory awareness, but angst over the system - People die because of the decisions made by insurance companies.
If you read or hear the things people are saying, they’re expressing frustration over the way they’re treated by insurance providers and their policies. The costs across the industry are insane, and insurance companies sit at the intersection of all the money, leaching away 15-20% (your numbers) as profit. Go to a Reddit thread about this murder, and you’ll hear stories of all sorts of families who faced existential questions of paying exorbitantly for or losing access to necessary healthcare. Because of a UnitedHealth policy.
It’s a boiling point of the increasingly divided society with growing wealth inequality. It doesn’t matter what the regulations say, people are suffering and they’re lashing out. The narrative isn’t actually about UnitedHealthcare and their profits.
Remember how death panels were evil, but a bottomless layer cake of corporate bureaucracies making those same decisions, with added profit margins at each layer, was somehow perfectly fine?
I am not trying to get political, or be flippant, I just truly marvel at how easily we are programmed. I mean all of us, myself included.
>People die because of the decisions made by insurance companies.
And if we had single pay, wouldn't people still die but now there is someone else to blame? Meaning there is still a budget for care, it is not infinite. There will still be a group to decide what to accept and what not.
Well sure, theoretically budgets are limited. But (1) the entire "profit" of insurance companies, and other middle-men, today becomes extra cash in the budget. Which if OP is to be believed, would be upwards of a 25% increase - just from insurance companies. (2) A single-payer would have more negotiation power to actually drive down costs, because if the single-payer doesn't buy your goods, there is no market for you to sell to. (3) There is no expectation of out-of-pocket expenses, so no one was to worry about a massive bill after losing a family member.
Also, a key difference with single-payer healthcare is (generally) the distribution and accountability of program. We'd dispense with "preexisting conditions" and "in/out of network" and provide this service to everyone. Every single person would be eligible, it'd truly be for the citizenry. Because of this, coverage becomes a legislative practice, and if coverage or care is not meeting expectations, it can be changed.
(also, UnitedHealth profit margin was consistently > 20% pre-2024)
> On the 2021 phone call, which was recorded by the company, nurse Victoria Kavanaugh told her colleague that a doctor contracted by United to review the case had concluded that McNaughton’s treatment was “not medically necessary.” Her colleague, Dave Opperman, reacted to the news with a long laugh.
>“I knew that was coming,” said Opperman, who heads up a United subsidiary that brokered the health insurance contract between United and Penn State. “I did too,” Kavanaugh replied.
> Opperman then complained about McNaughton’s mother, whom he referred to as “this woman,” for “screaming and yelling” and “throwing tantrums” during calls with United.
I don't have a lot of sympathy for these people.
One of my early crap jobs was the mailroom at a Wausau Insurance branch. A claims adjuster gave me a case to make copies of, not warning me I’d be seeing graphic pics of a kid smashed between a dumpster and a wall. I guess she was so immune to that stuff by that point that it didn’t occur to her.
When I gave it back to her I remarked on how tragic the incident was. Her reply was that the mom had two other kids and was going to make a lot of money off this. Naturally the claims adjuster was white and the kid was black. There was testimony in the case about how much their brother’s death traumatized the two surviving boys, who saw it happen. How they tended to just cling to each other in meetings with a therapist.
On top of that the incident occurred because the insurance company had told the Rent-A-Center that their employees weren’t allowed to help delivery trucks back in, specifically because of liability if something like this happened (kid ran behind the dumpster to get a ball right as a delivery truck hit the dumpster).
The job warps these people into losing their humanity.
I spent quite a bit of time trying to figure out what drives such high costs in US healthcare, some years back.
My conclusion is everything does. This conveniently makes it easy to dismiss criticism of any one part (all of which are responsible) because “well they’re just increasing it a little—go look at these other things, they’re bad too, and if you add up all of that, they’re worse!”
Right, but if you keep not addressing the one in front of you because of that kind of misdirection, you never fix any of it, because all of it is taking too much money.
I will say that our private insurance system in particular seems to be responsible for most of the insanely-high indirect costs of our system.
Dozens of hours for patients and their families lost per major incident, playing middleman between insurance and provider billing departments, trying to make insurance do what they’re supposed to. Stupid billing systems where the prices are all kinda fake, which wastes time in a few ways. Tons of time shopping for and managing healthcare plans by folks in HR. Government social safety net people having to dick around with private insurance nonsense to sort out who’s getting what from where. Employees losing time poring over plans to figure out which one they should get (is it just me, or if you’re offered three is there always one that doesn’t make any sense compared to the other two, no matter what kind of usage pattern or expectations you can think up?) Tons and tons of overhead staff at providers.
That third plan might be there just to make the other two look reasonable. Restaurants do this all the time with menus.
You conclusion reminds me of yesterday's thread about Rogue where one the best players was that way not due to some amazing trick or skill but because he was just a bit better than average on most aspects of the game. He didn't have to be the best at anything, all the little parts above the median added up.
The list of things at the end of your comment are all basically drivers for GDP. Our economic policies seem to incentivize the construction of Kafkaesque dystopias. I just can't see how such a leviathan could ever be dismantled.
Yeah, this really makes me think that America's soaring GDP is really just BS numbers, because a lot of the "productivity" that it reflects is just BS jobs that add negative value to society. I'm wondering if, at some point, there's going to be a big correction as the rest of the world realizes that it makes no sense to value the USD as highly as it is, since much of that "value" is in stuff like Americans selling each other overpriced houses (due to artificially constricted supply) and overpriced healthcare.
It was reported in The Nation (and nowhere else that I ever found when I went looking—so, grain of salt) that Obama said that all the totally unnecessary jobs that’d be eliminated are exactly why he wouldn’t push full single payer.
It’s a regressive-tax-funded white collar makework jobs program. JFC.
Yes, I agree that is at least one reason that happened, and possibly the main one.
I think the Nation’s quote of him on the topic points out something that may be true, which is that he might have balked at doing it given how many people would be laid off (hundreds of thousands, surely) and what the optics of that would be, though I kinda doubt the quote itself.
But yeah, even if he’d been gung-ho behind it, it wasn’t happening.
The thing that drives high costs is the bottom line: profit is more important than human lives.
If you stick a gun in someone's face and demand they hand over their cash, you're a criminal.
If you do the same thing with contracts, paperwork, and quarterly reports for Wall St, you're a CEO.
There is no difference between these. One is camouflaged by the abstractions of profit and bureaucracy. But both are murderously violent, and there should be no legal or moral distinction between them.
Likewise climate change and ecocide; online disinformation, media lies, and other kinds of semantic pollution; workplace violence, and other "externalities."
Invention and daring can be good things. But when all you're contributing are death, stress, illness, mass bankruptcy, declining opportunities for most of the population, and other symptoms of corporate sociopathy, you are over the line.
>I will say that our private insurance system in particular seems to be responsible for most of the insanely-high indirect costs of our system.
Lots of developed nations have private insurance systems, somewhat similar to the US. Both Japan and Germany have such systems, yet healthcare costs here in Japan are pretty cheap usually. (Here, it's a public/private system, kinda like Obamacare: if you don't have a job or are between jobs or a part-time worker, you'll get government-provided insurance, which you have to pay depending on your prior income I think; when you have a regular full-time job, you get private insurance that your company contracts for. But the insurance works basically all the same way: you pay 30% of the actual cost, and the insurance company pays 70%.)
There's something uniquely bad about the American system, but honestly I don't know what it is. I suspect it has to do with very bad regulation, or a lack of it. Here, it seems the costs for many things (like necessary medical procedures) are strictly regulated by the government. Also, no one pays bills to insurance companies AFAICT: you just pay the healthcare provider, and they go to the insurance company for the remainder.
Sure, the actual universal element of other OECD healthcare systems is price controls, de facto or direct, not necessarily whether private insurance still exists. I don’t think even a majority outlaw private insurance, and it’s a major part of quite a few.
We heavily regulate the supply and heavily subsidize payments.
Like a major premise of US healthcare policy is that preventing investment reduces costs. Good luck when that's the starting condition.
For example, reducing costs is the justification for limiting how many doctors are trained. Fortunately, our planning has been perfect rather than disastrous.
Realistically, the big cost differential in absolute terms in healthcare are borne in the elder group (65+). See this:https://pmc.ncbi.nlm.nih.gov/articles/PMC7411536/. This is exactly where the "government social safety net" takes effect (medicare and medicaid) and, in my opinion, the real spending bazooka of US subsidies take effect.
I say this as someone who wound up owning one business in this area (health insurance agency/producer) and was looking at expanding directly to the insurance providing aspect. I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.
Yes, we pay more per-capita for our public healthcare system than some countries do for universal coverage, but we don’t cover everyone. Just for the public parts.
Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.
What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.
> Yes, we pay more per-capita for our public healthcare system than some countries do for universal coverage, but we don’t cover everyone. Just for the public parts.
> Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.
Government funded but it's not a social safety net or mandate in a conventionally sense: it's an insurance subsidy. It effectively incentivizes depressing your own personal income to achieve high-subsidy plans (namely, the silver plan in most if not all states) resulting in abnormally high subsidies. It's just a form of tax planning today. See people taking "early retirement" with substantial assets (>1mm, which isn't much for HN but substantial in much of the country) at 40, reducing disbursements, and effectively costing the taxpayer ~36k/year in subsidies.
In an idea world, your assets would be subject to seizure under means testing on assets, not just income, before subsidies are provided. Seriously, go check out reddit /r/fire. They talk about it (and how a reduction in ACA subsidies in 2025 will force them out of retirement at the advanced age of 45).
> What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.
I'm going to be real: this is just wrong. Price controls only works in two circumstances:
* You are willing to tolerate reduced availability of goods and services
* You are actively willing to prohibit others from purchasing goods and services with their own money
1 is complete anathema to the US consumer market. If price controls were to be implemented, the elderly would likely get care first, which is unlikely to yield practically the needed result relative to current costs curves -- keeping the working population working with preventative and minimizing the cost on the elder bracket. In my opinion, this mispricing is in part due to the ACA, but that's neither here nor there.
2 would require Norway style controls of Ozembic and similar. I don't think Americans would ever tolerate "your money, you aren't allowed to buy it". Prices are high because Americans can pay in dollars more than other nations and are willing to do so.
There is a very real perception that medicine can fix poor health choices and we should spend arbitrarily large amounts of money to fix it. It's a fantastic business to be in -- people insist "healthcare is a human right" and are willing to tax others to pay it.
You can't genuinely believe that the reason that the 65+yo group costs more is the social safety net?
As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.
> I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.
Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.
In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?
At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.
> As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.
Sort of: as you get older, time catches up to you. In the USA for, heart disease kills 1015/100k for both genders (see: https://usafacts.org/articles/what-are-the-top-causes-of-dea... in Germany, it is just 673/100k for just men alone. We have an obesity problem, not a healthcare problem, when it comes to life expectancy.
> Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.
The question here is QALYS. We quite literally avoid this discussion in the US at all (see this: https://pubmed.ncbi.nlm.nih.gov/19738253/). The issue isn't that we disagree about the issues: it's that the issues are not addressed and Americans pretty much always say "spend more".
> In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?
Healthier populations. Americans make awful health choices.
> At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.
Not really. Margin shifts along value chains; it's rarely destroyed. All that would happen is the profits would shift to another location. Then the game becomes how to get there.
Healthcare costs in the US are broadly in line with the level of consumption. Americans have a uniquely insatiable demand for tests, drugs and elective surgery. Most countries with significantly lower costs have very different cultural attitudes and/or some form of rationing, because the only way to meaningfully reduce the cost of health are is to reduce how much of it you consume.
In the US system, insurers are the only actor with any real incentive or ability to constrain costs by limiting consumption; a very large part of the bureaucracy involved in the insurance system is about trying to manage consumption. We're seeing exactly how well that's working out for them, spilled all over the sidewalk.
Talk to people in the UK or Canada or Germany or Australia. See how their media covers healthcare. They're furious about their healthcare systems too, they're talking about a mounting crisis, just for different reasons. These systems accept long waits and the flat refusal to fund less cost-effective interventions as a necessary evil.
I'm wondering if HIPPA might be overly costly and counter productive. While I agree with the critical infrastructure designation for healthcare and associated cyber security initiatives, I don't think that there's any real value to my health information being private. Getting basic health care requires you to allow multitudes of third parties access to your health care information anyways, so is HIPPA's purpose actually being achieved? It's not like a hacker is going to get access to my bank account if they know I have high blood pressure. Just about everybody has some kind of condition. I think there are misplaced concerns about health insurance misusing the info to discriminate against people based on certain conditions, but I'm pretty sure there's already ways for them to do this now, and if we really want that to not happen, then just make a law to address that concern instead of HIPPA.
I think your understanding of HIPAA is reversed. It's not about privacy. It's about setting rules by which health information can be shared between organizations of different types.
I think the average American understands everything they need to understand when they pay their premiums and are refused the care they require to survive.
It’s laughable that anyone can have this reaction of “gee, maybe if people only understood _why_ a CEO makes billions and has the highest rate of denied claims, they wouldn’t accept violence”
I'm currently arguing with my health insurance about their refusal to cover a treatment because they allegedly haven't received the required documentation. This is after faxing these documents to a number that turned out to be a black hole, attaching a PDF to a message in their messaging portal, and eventually sending it by certified letter, complete with a returned delivery confirmation. Today I got a letter in the mail saying that my grievance was denied because they've yet to receive the necessary documents to process my claim.
Here I am paying out of pocket for a medically necessary and covered service simply because the insurance company is playing games. I would prefer they not try to cut their costs by playing stupid games like this about valid claims in the hope that I just give up so they don't have to pay. It's feeling like I'm going to have to sue them to get this resolved. At least it's harder for corporations to play games with process service.
> health insurance companies to spend 80-85% of their premiums on claims and healthcare
I don’t really know what narratives you’re objecting to. But I want to point out the existence of that regulation doesn’t make healthcare companies passive bystanders in the cost of healthcare in America. e.g., notice it collectively incentivizes them to drive the overall cost of healthcare up as much as possible, to maximize the size of their slice of the pie.
The fundamental problem is running healthcare as a profit-driven system. The incentives operating the system cannot possibly be aligned with the people the system is ostensibly meant to serve. (Not that it’s not going to be unraveled, short of literal revolution.)
> require health insurance companies to spend 80-85% of their premiums on claims and healthcare
> enormous increase in administrative overhead
Do you see the problem here?
As an outsider it's hard to say, but clearly there is some ginormous loopholing going on here.
I haven't found much in the way of details, but apparently one of the reasons why insurance companies are buying up medical practices is because it enables accounting dipsy-doodle to avoid the healthcare spending requirements.
Definitely was already there. I'd guess that people hate insurance companies more than they hate politicians - in fact, I'd go so far as to say that at least some of the hate for politicians is sublimated hate for insurance companies and our Kafkaesque healthcare system. It's almost a bit surprising that this is the first time this has happened. And now that someone has done it, it seems likely that there will be copycat attempts.
Was it? If that's the case, why do the majority of M4A voters say their support is conditioned on them retaining access their existing private insurance?
You get frustrated when your doctor is 30 minutes late. Being denied coverage by your insurance for something serious and expensive is a matter that causes hate.
At first glance, this looks pretty similar to the Bob Lee murder last year. I find it interesting and a little surprising how different the reaction and coverage has been
This reminds me more of Chris Dorner. The manifesto is shorter, but this sense of injustice felt by the perpetrator is similar.
Back in the days, mainstream media had enough control over the narrative to water down the "manifesto" part and avoid copycats. This time, "rogue" social medias are much more prevalent, so there's not much of a barrier to prevent the perpetrator from becoming a hero. We can think that copycats will emerge.
I guess that billionaires around the world are dusting off their "apocalypse bunker" protocol...
And, in case we all need a reminder: Chris Dorner was an actual monster, and his brief casting as a cause celebre a pretty big embarrassment in retrospect.
His two first victims, chosen deliberately, were completely innocent people. He selected them because one was the daughter of a police officer he'd had dealings with before. I don't think there's a rhetorical way out for you here.
> But that did not stop social media commenters from leaping to conclusions and from showing a blatantlack of sympathy over the death of a man who was a husband and father of two children.
The journalists' tone and choice of words here, which I've italicized, isn't helping the overall feeling many Americans have of "the people running the show have active and unceasing contempt for us", which of course is what's driving the "torrent of hate for health insurance industry" that this article sets out to document.
I'm sorry, but where do these writers get off wagging their fingers and tut-tutting people who'd prefer not to spend their neurons on sympathy for someone at the helm of an inhuman system? The point's already been made, but plenty of monsters are husbands and fathers.
I dont find the "lack of sympathy" to be an issue.
What I do find disappointing is the lack of concern over people being gunned down in the street, and the not so subtle glee some people are expressing.
Murder should not be normalized or endorsed. It isn't healthy for a society and doesn't lead to progress.
>What I do find disappointing is the lack of concern
This is (was) the CEO of the largest health insurer in the country which has shown a lack of concern for paying out insurance or securing data both private and medical. Their data leak this year is second only to National Public Data's leak (also this year) of practically every single SSN on the planet and arguably worse because their leak also contains medical data.
Murder is never okay, but this guy is also about the most unsympathizable man in the country.
> this guy is also about the most unsympathizable man in the country.
There's no way that is true. It's only remotely possibly true if you're only talking about people who at least nominally obey the rules and laws of society. You don't actually think that he was worse than a murderer, or a rapist, or a child abuser, of which we have many, many thousands in this country.
I recognize a distinction between a premeditated direct intent to kill someone, and whatever it was this guy did. If you have different values then you might not.
I do recognize a distinction as well - what this guy did was worse.
Don't get my wrong, shooting someone in broad daylight is a bad thing and I will agree that we shouldn't encourage it. In this case I don't have any sympathy for the victim. There's a difference there - I recognize that the assassin is wrong but that's orthogonal to my sympathy (or in this case, lack of) for the victim.
What the CEO did was worse. While someone who premeditates a murder clearly has knowledge of and familiarity with the person being murdered the CEO does not have that for the deaths that are a result of denying care. They feel almost clinical to him, numbers on a balance sheet to be weighed against the bottom line. It's textbook banality of evil - the deaths he was responsible for were just the cost of doing business, and what a business it is.
The "banality of evil" was originally used to describe the bureaucrats who enabled the mass-murder of Holocaust victims (Godwin's law strikes again!). Their actual goal, the primary outcome they were trying to maximize, was murdering Jewish people and other "undesirables". I don't think this guy was trying to do anything on that level. I don't think he sat down every day and said "how do we kill more people?" Rather, he was working within a really bad system that has bad incentives and no one knows how to fix it.
Was this guy uniquely evil, as far as health care executives go? Like...if more of them get murdered, will you just shrug and say "yeah they kinda had it coming"?
> Was this guy uniquely evil, as far as health care executives go?
I think if you poll the people taking this as a good thing, you will get an overwhelming answer of “probably not”, and the implications are exactly what you suppose.
There’s an awful lot of wiggle room in the “more of them” phrase, so I suppose the only realistic answer is “it depends.”
But speaking more generally - I think a lot of people would, indeed, shrug. The US healthcare system is one of the most miserable parts of living in this country and virtually everyone has had to deal with it at some point. And whether or not they deserve the direct blame, insurance execs (and pharma execs, etc) directly profit from that misery.
I think a lot of people are not going to shed a single tear over events like this.
The sheer breadth of misery this person inflicted through his actions is hard to quantify, and trying to say who is worse/better will always be a judgement call. But the broad dislike for this person doesn't come from nowhere..
Our healthcare system literally shaves ~5 years of lifespan off of the country as a whole. Illegal denial of claims by his company almost certainly kill hundreds of thousands a year.
When deciding who deserves my scorn, I genuinely do put those who are in power and commit atrocities at scale (like healthcare CEOs) above one-off violent criminals.
Even if you’re a few levels removed from the deaths you’ve caused, you still have blood on your hands imo.
I'd rather have the Sackler family show up for a dinner than the Manson family, but if we're being honest, the former is responsible for several orders of magnitude more deaths than the latter.
Who knows too... maybe if we have better access to affordable quality (mental) healthcare, which does not deny millions of claims in any given year, then we might perhaps have less murders, rapist, and abusers running around.
> You don't actually think that he was worse than a murderer, or a rapist, or a child abuser, of which we have many, many thousands in this country.
I think there is not much point in defining a single metric of "worse" because that is confusing. A rapist is worse if they are following your spouse. This guy is worse if he is about to make a decision that will prevent your loved one from getting medical treatment at the exact time that they need it.
The acts of Murders, rapist, and child abusers are far more heinous than health insurance CEOs. However, I would argue the magnitude of damage is larger from the decisions of health care CEOs.
Like I said, I dont think it is about sympathy, but not wanting to live in a country where people are murdered in the street. That is the part that is disgusting and dangerous.
No way. Humanity since the dawn of time has always had the potential to mob when things became dire. We still have it today, only it is more controlled via technology and rationality. This killing will not start anarchy. But it does have the capability to start a resistance against existing power structures, and that is what everyone is actually (consciously or unconsciously) worried about. We are only conditioned to believe that anarchy might ensue as that is the easiest way to instill fear of rebellion against the power structure.
Yes, and mobbing often leads to mass deaths and people worse off than the state before. I dont think this is the straw that breaks the camel's back or anything. It just seems like one more incremental step in the wrong direction.
Maybe I'm sensitive because I have been reading about the french revolution, and how mob rule lead to mass murder which left everyone worse off.
I think the french revolution left everyone worse off than if it didnt happen, The first republic didnt address any one the underlying economic issues. The failure of populist mob governance lead to first empire, and the Napoleonic wars which killed several percent of Europe's population (~6million) in France's attempt to loot its way back to economic prosperity.
No clue. However if I were to speculate on a comparison, I think the us would skip the first Republic entirely and go straight to a repressive authoritarian police state fighting domestic terrorists.
I don't think any of the revolutionary elements can get enough support for governmental change, and the majority wold rather give up their freedoms than give in to terrorists.
Jumped the shark there, dude! But some of these posts are hilarious over-the-top horseshit. Seriously...
Get a grip. For all we know the shooter was pissed b/c his girlfriend was banging the health insurance executive while babysitting for him!
[I would loooove for HN to have optionally-visible meta-threads, so onlookers like me could sit in the gallery, drink a beer, joke and remark about what is posted w/o affecting the stream of thought. Now back to y'all...]
> We have a system of laws and courts to decide what is criminal.
We do, but unfortunately it heavily favors the party with the most money. If you want to take a health insurance company to court it's gonna cost you a lot of money in lawyer fees and you'll face a phalanx of corporate lawyers who have a lot of experience in crushing cases brought by their customers. That's not to say that people should go out and take matters into their own hands, but there is a lot of pent-up frustration out there and we really need to start addressing some of these issues before more of this happens.
The problem with this argument is that it assumes that one killing implies anarchy and and discarding of the system. It does not. Chances are, most reasonable people believe there should be a chain of justice with courts, laws, and investigations.
Someone has turned to vigilante justice here not because they believe that the courts are useless, but because they believe that this is such an extreme case that courts would not have worked in this case.
What I believe people fear is not the rise of anarchy due to one killing, but a fundamental shift in attitudes of the ordinary people in response to the unreasonable rise of the power structure. This threatens not order but the very power structure itself, which implies that a lot of people who benefit from injustice will suddenly be at risk of losing those benefits (money).
I pay around $20k/year for health insurance for myself, my wife and my daughter. I need insurance coverage to save my life and it is denied and I die. Under what US Statute (any state or federal) can a prosecutor charge the people
responsible for my death? surely on the system of laws and courts you say we have there is something… I’ll wait…
also people should most definitely NOT kill law abiding citizens! we do have laws for that
I guess this is the crux of it. The law does not hold anyone responsible for your death, and nobody is responsible for providing you life saving services.
These are the laws that your fellow citizens have chosen and established.
you know, our history says that at times, injustices may need to be fought with a touch of violence…
killing CEOs is not the kind of violence any reasonable human being can condone, but people tragically affected by someone’s actions may not be all that reasonable
If we throw up our hands and accept that each individual can be the judge of injustice, and execute whatever retribution they see fit, these individuals also meet that criteria.
By abandoning democratic law, you also abandon 3rd party discretion and control over which injustices are legitimate.
It's exactly the same logic. You can't just take your own set of issues, say you're obviously right about everything, and then factor out everybody else's big issues. If you make a consequentialist argument for murdering insurance executives, other people do in fact get to use the same moral logic to stop things you disagree with them about, like gender-affirming care and abortion.
being directly responsible for someone’s death is just not the same as having a difference of an opinion (like we are having). I will definitely not try and hunt you down… however, if you are responsible for a death of my loved one - that might be another story…
jokes aside, I am not saying this tragedy was justified in any way but we are not talking here about “opinions” and “religion” for sure
Sure. Again: if you just hate the guy and have no compunctions about saying why after he's murdered, then whatever, that's not interesting enough to argue about. But if you're literally saying "this was good and more like this would be better" --- and some people are --- that is a notably warped proposition.
By that logic, every health system in the entire world is murdering people constantly. Meanwhile: I'm talking about a guy walking up to an executive and shooting him in the chest.
You can say that you are murdering people by posting on HN instead of working more and donating the money to charity.
>At what point is defending their murdering of people an acceptable approach? :)
We have laws that define where your responsibility starts and ends. For a random citizen, you have 0 obligation to help someone pay their healthcare bills.
For a health insurance company, they have a legal obligation to spend 85% of revenue on member healthcare, with all expenses and profit coming from the remaining 15%. This is codified by the ACA 85/15% law passed under Obama. United meets this obligation.
Another person has tried to rationally explain to you why your position is unhinged and you weren’t taking it, so I’ll put this more plainly. Take up arms today to defend your ideology. Rally everyone you can and go to war. It won’t be a long war.
> People should not kill law abiding citizens they disagree with because everyone has a different opinion.
That's not what happened.
Brian Thompson isn't a "law abiding citizen I disagree with" he's a law abiding citizen who killed people. If you or your loved one died because of his actions, would you "have a disagreement with him"? Is that what you'd call that?
There is a massive difference between not helping and killing someone. If you attribute the deaths from healthcare denials to him, did he also save every life that wasnt denied?
> There is a massive difference between not helping and killing someone.
Tell that to the people whose family members died due to his actions.
I'm not arguing this with you again for you to ignore what I say again.
> If you attribute the deaths from healthcare denials to him, did he also save every life that wasnt denied?
> How many millions of people did he save?
None that wouldn't have been saved by anyone doing his job. Literally, it was just his job, and he was close to as bad at is as he could get away with. All the evidence I've seen is that this guy was an obstacle to saving lives at every opportunity he got.
Even if we somehow pretend he made any effort to saving lives, how many lives do you have to save to get a free pass for a murder in your mind? Is that how you think this works?
Honestly, I think there's something wrong with your conscience. Grow some compassion for other humans.
I actually think the murderer would have been found and either arrested or killed for resisting arrest by now, were that the case.
That the murderer, who killed someone in literal broad daylight on the sidewalk of one of the biggest cities in the world, is still on the loose speaks volumes to me about all sorts of things.
It speaks volumes as to how incompetent the NYPD is. NYC is one of the most policed cities with the most cameras constantly watching people, and the fact that a crime like this can happen in broad daylight and the perpetrator can remain a ghost is an indictment of that whole dystopian atmosphere and system
In a society where democratic tools no longer function effectively—due to capture by concentrated powers—people often feel powerless to address systemic harms. I can understand how the only power an individual can have in that situation is something like murder.. but it’s making many assumptions.. like this person really was working as an individual from moral grounds in the interests of majority of society.. and that we can trust this moral judgement to and individual, as in today it might be an arguably utilitarian good but tomorrow it might be a cultural or religious thing.. will this action really would have any positive affect on healthcare results for many people, or change any behaviors of people in power apart from getting more security guards..
I think most people are confusing captured democracy for the fact that the actual voting population is split on issues once people step outside their bubble.
> Murder should not be normalized or endorsed. It isn't healthy for a society and doesn't lead to progress.
I guess the American revolution didn't lead to progress then. Or any of the other revolutions, many of which had assassinations. And murder is not being endorsed. Putting an end to it is.
This is one of those things we state as a normative absolute in general society and you usually only see the nuance (or how it’s basically just a polite lie, in some cases) in relevant college classes or spaces dominated by certain kinds of professionals and nerds (the kind who took those college classes, usually).
There's a distinction to be drawn between challenging norms of discourse like not speaking ill of the dead, and actively cheerleading murders, like "we should boycott Starbucks for providing evidence about the murderer to police", or Taylor Lorenz calling for the assassination of Anthem's CEO by name.
The incoming President told his supporters that if he lost they’d still have to the option of shooting his opponent, when he ran in 2016. Instead of being ejected from politics forever by an outraged public, he went on to win that election. Then another one more recently.
I don't think you understand me. I'm not saying people are taking to fainting couches over norms violations. They're reacting to people like Taylor Lorenz literally calling for the assassination of people by name. In my case, past that, for Lorenz doing so based on a comically flawed understanding of what her target was doing.
I'm terribly sorry, but all of your italicized fragments, taken in isolation, do paint a stark picture of the murder of a person.
You might have beef (or whatever you call it these days) with his job and industry but in the end a man was murdered. You may not like and "hate" seems appropriate to describe how you feel about a legitimate industry in the USA. Your issue is with a deeply embedded part of the US experience - health insurance, and not with this man.
Please attack the industry that you hate and not the individual ... who was murdered. That is what the journos are doing.
> I'm sorry, but where do these writers get off wagging their fingers and tut-tutting people who'd prefer not to spend their neurons on sympathy for someone at the helm of an inhuman system?
And what exactly is your solution?
Healthcare should be a charity from the rich?
It should be nationalized, and somehow magically all the problems go away?
You’ve got the answer right there. It should be nationalized. And a major reason it will never be nationalized is because of lobbying by health insurance corporations.
Do you have an argument that would be persuasive to someone who doesn't believe the voters in every state where this was proposed were successfully hoodwinked by "money"?
Interesting, tried Vermont but couldn’t find it (a 2015 single-payer effort, but not that), will look more later, I’d love to see what a state-level law at governments taking over hospitals and such even looks like, gotta be some weird reading and I have no idea how you’d write that such that it’d have a prayer of surviving court challenge—seize poor people’s houses to give to companies (or, on behalf of a company that then backs out, and all you got was wrecking some of your own citizens’ houses, lol) you’re all good according to the courts, but do basically the reverse? No way that’d fly. Those proposals have to be crazy reads.
I’d maybe vote against state level single payer, let alone taking over healthcare entirely, because I think it’d be a ton less efficient than doing it at the federal level—enormous amounts of money already go to various federal healthcare programs and it’d be better to pool that, and also lack of state level control over their markets is likely to cause problems. I dunno, it might depend on the law, but my gut reaction is a “no” vote on that, too.
Anyway, as for the other question, I believe that the rise of the postwar think-tank industry (a mash up of k-street and Madison Avenue, but for white papers, as it quickly became) and deliberate party and industry efforts to shift public sentiment in pro-market directions, tied up with lots of government spending on anti-Soviet messaging (were they bad? Oh, yeah. Were all the things the government tried to lump in with them and decry as un-American bad? Ehhhh… I mean atheism is among those, see the change to the pledge and to our money at the time, among other things, and I think atheism’s fine) is probably why healthcare can be this incredibly messed-up and nationalization remains not just not-popular-enough-to-pass, but entirely outside the Overton window, yes.
Vermont actually passed a single-payer resolution, which would have been the signature achievement of Peter Shumlin, the governor at the time. But actually executing on the resolution required a budget and tax plan to fund it, and the whole thing fell apart.
Medicare for all is actually a very popular policy, with majority approval (across people who identify with both parties).
M4A is nationalized health insurance if not quite nationalized healthcare, but the point remains that the only reason we don’t have major steps in this direction is because of people in power who will not let it happen.
Yes. My point is exactly that. People want nationalized healthcare, but once there’s layer upon layer of media propaganda and power plays by the donor class of both parties, the people don’t end up voting for (or don’t have the option to vote for) their own interests.
Unfortunately, it is the same system where journalists have bills to pay and mouths to feed, and their wages comes from advertising of these Fortune 500 companies.
"The point's already been made, but plenty of monsters are husbands and fathers."
For example, the ones establishing and profiting from so-called "social media" at the expense of organisations that employ journalists.
Advertisers choose between supporting organizations that employ journalists versus supporting ones that do not, the ones profiting instead from the "torrent of hate". NYT has plenty of paying subscribers; it is not 100% dependant on ads, unlike "social media", generally.
Indeed "the people running social media have active and unceasing contempt for us". They prefer computers over people. Surveillance over sympathy.
It's mostly not rational. For instance, much of the conversation over the last day has been about Anthem pushing back on anesthesiology pay on the East Coast. That's people angry about their insurers working to make surgeries cost less by employing the literal guideline Medicare uses, and yet people online were overtly suggesting Anthem's CEO be murdered over it. Incoherent.
This won't win me any points in this particular forum, where this opinion (that I strongly hold) is unpopular, but I'm reminded of what someone else said about Net Neutrality: it's a bunch of people suiting up and taking sides on behalf of one group of giant corporations against another group of giant corporations. That's the "health care debate" in the US, where medical staff are paid 2-3x more than they are in other countries, and expensive procedures are prescribed and delivered at drastically higher rates. It's my problem with "Medicare For All", which more or less absolves providers from their role in choking people out with health care costs, despite the leading role they have in this situation.
At any rate: there's no serious theory of change that begins with murdering health care industry people.
> At any rate: there's no serious theory of change that begins with murdering health care industry people.
I dunno. This is the most publicly-united I’ve seen people against the industry maybe ever. Usually they’re separately-angry at the industry in their partisan silos (everyone hates it, more or less—hence the amazingly consistent and widespread reaction) but this has been the closest thing to a bipartisan healing moment since, like, the week after 9/11. Not particularly close to that, sure, but I can’t think of anything closer.
If this were part of a theory of change, it strikes me as no less serious than any other I’ve seen. At least.
Yes, there is a lot of frustrations. Voters disagree on what they want. That does not justify people to start shooting people when they dont get their way.
Want what? I dont think the majority of Americans endorse vigilante murder of law abiding citizens. That is just a vocal and bloodthirsty segment of the online population.
Literally everyone I know IRL was like, “nice. More please.” I was actually surprised and heartened to see the initial HN thread, even, was overwhelmingly supportive.
This is top of my list for conversation topics to steer things toward when I’m around Republican relatives, so we’ll have something we can agree on.
Law-abiding doesn’t mean much when you can kill lots of people for money and remain within the bounds of the law. Killing one such person is definitely far less bad than killing a bunch of people arbitrarily. Yet only one of these cases is illegal, and it’s the better of the two.
This is logic that makes sense inside of filter bubbles on the Internet that I think most people --- most people are not in any one particular filter bubble and certainly not this one --- would find absolutely repellant. To put it in perspective: it is literally the logic used by people who shoot up abortion clinics.
How do you feel about murdering doctors who demand pay for treatment, citizens that vote against single payer, or people that fail to donate to your gofundme?
I can’t begin to relate to seeing someone with a median income failing to donate to some particular go-fund-me as the same as choosing to head an organization that makes more money when people don’t get the health care they need, and overseeing operations that did that even more recklessly than the industry standard. One has taken on a business relationship already and is taking people’s money then screwing them, at a mass scale. The other just didn’t donate to a gofundme that may not even be legit and for someone they have no connection to.
Similar reaction for the other examples. I’m baffled that they look similar to anybody at all.
[edit] hold on, ok, another angle that may clear up why I’m confused: if my health insurer denies my legit claim, should I be more, less, or equally angry with the leadership of that company, or with every single person in the country who fails to donate to my resulting gofundme? I’m immediately inclined to wish horrible things on one of these groups, and to find the idea of wishing horrible things on the other confusing and repulsive.
There are laws enacted by our elected government (Democrats under Obama) that say exactly how much overhead is acceptable for a health insurance company, and all business expenses and CEO pay comes out of that portion. If they collect too much in premiums to and their profits exceed that percent, they have to refund the insurance members.
Health insurance has a fixed profit margin on claims paid. Denying claims costs them money. Pay 10 billion in claims and they make 2 billion. Deny half the claims and they make half as much.
What "problem"? You're not being clear about what you're trying to say. That a particular insurer has done bad things? Nobody was going to take the other side of that argument.
Denied claims mean less profit for the insurer. They only get to keep a percent of what they pay to hospitals. Do you have a response to that?
One of the primary jobs of insurance companies is to vet claims. If we didnt want that, you could just make a shared bank account and let doctors and hospitals bill anything they want to it. You might save 10% on overhead, but it would collapse instantly.
If that were true then United Healthcare wouldn't have rolled out an automated system that (reportedly) denies ~90% of people regardless of their actual need.
I'm not going to stick up for UHC, which is an obnoxious company, but do you honestly believe UHC is denying 90% of claims? Have you thought the implications of that claim through?
The ACA’s loss ratio rules don’t apply to self-funded plans (many large employers use these) even if they’re administered (and possibly re-insured) by a health insurance company, which is usually the case. Just doesn’t apply at all.
Certain plans also allow much lower loss ratios, like 60/40 for expat plans.
A provider that manages to have a lot of new plans in a given state in a given year is immune from loss ratios rules in that state, for that year. I don’t know how gameable this is but my WAG would be it’s only state insurance commissions preventing this from being the case in every state, every year, for every provider, and keeping it to only some states in some years for some providers (I bet the biggies manage to rotate their state[s] and have at least one most years)
So a company the only business of which is health insurance can easily spend far less than 80 or 85% of income on payouts, and only need maintain that ratio on some subset—possibly small—of the premiums it’s collecting.
I don’t know how the game of this affects decisions for insurers that also own providers, but I bet there’s something beneficial there and that’s why they’ve been snapping up provider offices for the last several years.
Most of that makes sense to me. there is a self funded plan, my understanding is that the employer is collecting (and usually subsidizing) the premiums.
At the end of the day, my experience is that my UHC healthcare is about 10% more than healthcare from non-profit Kaiser, and Kaiser is far more stingy with services.
I think there is a hell of a lot wrong with healthcare in the US, but I don't think that constitutes murder just because the stakes are life an death.
Ethics depend not just on the outcome, but the processes that leads to that outcome.
The incentives in healthcare are terrible, but it is the government which has structured the system and those incentives.
I dont think it counts for something good. I think it is giving in to one of the worst possible aspects of humanity. Like people cheering at a lynching.
if they are that successful to make it to a point where they can be hired to be CEO of UHC or Monsanto or other axis of pure evil, perhaps they would choose to take their talents elsewhere
The notion that the providers are the ones sucking up all the money in the healthcare industry is certainly... novel.
The majority of people in this particular industry have nothing to do with actually providing health care, just as the majority of employees at a major university have never stood in front of a blackboard.
The problem with our health insurance system is that it's insidious. Our doctors spend ~25% of their time filling out information that only gets filled out to try to get insurance to not deny the claims, and hospitals have entire billing departments whose only job is dealing with the billing of our stupid ass system. The problem isn't just the ~15% that the insurance companies take directly, it's that since their percentage of profit is capped, they work to raise prices of the entire health care system so that their 15% cut is bigger. Insurance companies literally negotiate pharma companies to charge a larger amount to uninsured people so they get to take a bigger cut.
That's not all of the reason (some of it is higher cost of living, compare G20 vs G7 and the gap narrows a bunch). Some of the reason is because of US education costs, and immigration policies that make it harder for people to come and work in healthcare.
Does it? Average physician cash comp in Germany is 75kEU, and average cash comp in the US is something like $350kUSD. Note here I'm using one of the largest and soundest economies as a comparison, and one with substantial uptake of private health insurance.
If what I was backing with "pie charts" was "everyone else is being unreasonable", sure, but that's not what I said. Go look it up. Zero out all insurer costs. What percentage of health care costs do we save?
There's a lot more than just "Insurer costs" and "Doctors' BMW payments" in the pie chart. Again, relatively little of it has to do with actually treating injuries and illnesses. And that's not even getting into the massive market distortions associated with forcing the concept of "insurance" into a market where virtually every single customer will eventually need to file multiple claims.
You usually come up with better arguments than this. We all have off days, I guess.
I've lost track of what you're saying. I'm saying that if you zero out the insurance companies, you don't significantly impact total health costs, because the insurers aren't where those costs are; that's the claim I made upthread you found "... novel", but it's not novel, and it's easy to go verify.
How much care costs can be attributed to providers needing and paying for departments to deal with insurance companies? How much care costs can be attributed to providers needing to spend x% of time merely documenting to ensure insurance will not deny claims/services? We can deal with going after provider fraud separately.
In the United States, physician salaries were 6.5 times GDP per capita for specialists and 4.1 times GDP per capita for generalists.
(Shrug) I'm OK with the notion that doctors contribute somewhere between 4 and 7 times more value than your average schlub driving a bus, and I'm OK with paying them accordingly.
Now, how much do the administrators, insurance-company execs, and other noncontributors make?
I'm honestly not sure if I should attribute this comment to disingenuity, ignorance or just bad faith.
> pushing back on anesthesiology pay on the East Coast.
Not even close. BCBS was just pushing extra charges onto patients.
> insurers working to make surgeries cost less
This is laughably ill-informed, I don't know where to begin. The only thing insurers are doing is increasing the gap between what they collect and what they have to pay out. They do this by denying claims. Making the service cheaper has nothing to do with it.
> where medical staff are paid 2-3x more than they are in other countries
Because medical school is so expensive. Also, doctors spend 3-8 years working for minimum wage (ie medical residency) and the cost of billing and administration is enormous. One study showed a primary care doctor spent $99,000 a year on billing and roughly 25% of ER income spent on the same [1].
The US spends the most per capita on healthcare than any other OECD country, by about 50% (Switzerland is #2) [2] for less coverage, worse outcomes and lower life expectancy.
Medicare spends almost all (~98.5%) of its funds on patient care and ~1.5% on admin, compared to 15-25% on admin for private insurers (including Medicare Advantage).
It amazes me how concifently wrong and ignorant about a subject can be while having such strong opinions.
Anthem proposed to apply the precise guidelines Medicare uses to pay for anesthesiology, including references to those CMS guidelines. Billing for anesthesiology has been a hot button issue: the search you want is [anesthesia surprise billing]. Anesthesiology is one of the highest-paid specialties in American medicine.
You cannot reasonably support Medicare and claim that Anthem was doing something unconscionable, because Anthem was adopting Medicare's own policies.
Medicare's admin cost ratio is a function of who it covers. Somewhere in the comment history on HN, there's a short writeup I did of how the math works out if you extend Medicare to the whole population; the admin overhead, for obvious reasons, shoots up --- people pay the same amount of money but require far fewer services, reversing the "advantage" Medicare has in the metric currently.
Insurers use the Medicare schedule as a weapon to simply reduce how much providers get paid and/or increase how much patients have to pay out-of-pocket.
The Medicare schedule is generally low because of the negotiating power of the Federal government so when Anthem (or whoever) says something like "we'll pay Medicare rates" or "we'll pay 120% of the Medicare rate" they're really just cutting payments and increasing patient costs. Nothing more.
In the recent BCBS case, all they were doing was saying "it may take 8 hours for the surgery but we're only going to pay you for 3". They haven't made the surgery cheaper to provide. They just wanted to pay out less.
Also, if we're going to simply do everything based on Medicare, why exactly do we even need private insurers? Just expand Medicare to everyone if the schedules are good, right?
You're saying "the Medicare schedule" as if it's an abstraction, but it is literally the payment process used by the largest buyer of medical services in the country. What Medicare pays matters more than what anybody else pays, because most medical services are performed for Medicare patients. So I'll ask directly: how is it unconscionable for Anthem to use those policies, but not for Medicare to use them?
You are exactly right that Anthem is demanding providers charge less for surgeries, not for surgeries to take less time. Providing "less anesthesia" is not a thing. This is entirely about preventing health providers from charging more money to Anthem and, in turn, their customers. That's why Medicare does the same thing.
The fundamental difference between Anthem and Medicare is that when Medicare cuts reimbursement, that cost isn't passed on to patients, but when Anthem does, it is. Medicare's rates are arguably too low, but low Medicare rates are getting a good deal for the country. Low Anthem rates are passing costs onto consumers and profits onto shareholders.
That is not how any of this works. Insurers and health chains are in a continuous process of rate-sheet negotiation, and the result of that negotiation is reflected in your premium costs. Most people's out-of-pocket costs are capped, and even the most routine surgeries (like a tonsillectomy) exceed the out-of-pocket cap (I checked! This is a number people report.)
This is about the trade association for anesthesiologists deputizing angry people on Twitter to go to bat for them overcharging for their services.
Okay. So other than getting mad on HN, what do you propose we do to fix the feelings people have about this situation and prevent this happening again?
I don't think we're going to fix this problem on HN, so I'm content just to point out that a lot of what people are saying about this situation is unfounded.
I don't either, but people feel this way about millionaires and healthcare execs for a reason, they're not just being cruel for the sake of it. Think about the reasons for it, and try to come up with a solution. That's a way more interesting discussion than getting mad about people being dumb on BlueSky or whatever.
People have built a frustrating system for themselves with a century of complicated and messy political decisions (and resulting regulations). They don't have the will or attention span required to solve the various problems via the slow moving & gridlocked political system. So, they take out their frustration on the highest profile participants in the system.
Solutions? I'm worried that there aren't solutions. There are only bandaids.
There is really basic stuff that we're going to have to do no matter what that doesn't involve restructuring the system, like drastically increasing the number of practicing physicians, which is capped by (you guessed) Medicare, which sponsors residencies. But all we can talk about is payer structure because of a complete fixation on insurance companies as singular villains.
This could be an opportunity for me to learn something new...
I thought the American Medical Association were the ones who artificially constrain the supply of physicians. Is that not true, or is the AMA constraint transitively related to the Medicare caps in some manner?
Which I think itself is a bit of a red herring. Medicare subsidized residency slots are not the only way training doctors could be funded, and largely an artifact of our billing procedures and criteria.
It is just one aspect of how incredibly constrained the supply of healthcare is in the US. Medications that are over the counter in many countries requires someone with 12 years of training.
Sure, and my point is that the entire bottleneck is based on a a completely arbitrary artifact of how we handle billing in the US. It is a policy choice.
Residents provide healthcare to patients with real value. This healthcare either gets attributed to the attending physician or goes unbilled. The market value of care provided exceeds what it actually costs to employ and train a resident.
Yes, largely the fact that Medicare forbids billing for resident services. Im sure there is also an objection on the insurance reimbursement side as well, but I see no reason why a successful procedure of adequate quality performed by a resident should not be billable at the same rate.
Heyyy, we're starting to talk solutions after all. Good stuff. What do you think is UHG's and its executives' role in supporting or opposing the policies and politicians who could enact these fixes? I didn't verify this, but I'm going to go out on a tiny limb and guess that UHG and its execs pay for legislative seats to be filled by Republicans. Republicans famously want to reduce Medicare funding. Do you think lowered Medicare funding would result in more or fewer Medicare-funded residency positions? Certainly there's more at play in elections than UHG itself, but I'm wondering which side of the solution they're on.
> there's no serious theory of change that begins with murdering health care industry people.
You sure about that? Show me one theory of change where the oppressed somehow rise above without violence? Even the groundwork for Ghandi's peaceful protest were laid by a strong anti-colonial military force that led assassinations of British military officers. You think Britain left because Ghandi said some profound things and changed their minds? The official position was that continued occupation of India would be met by violent resistance and they retreated.
There have been many many examples throughout history of oppressed people rising up with violence against their oppressors. The majority of the substantial changes in culture happen this way - things reach a boiling point and it spills out on the streets.
I'm not saying mob justice is an ethical or principled way to instill change. But historically it has been extremely successful.
Bullshit. Show me the proof. Given that nearly all successful revolutions against oppressive powers have been backed by violence, I'm curious what you come up with.
There is one group, the insurance companies, which have unequivocally stated that they will physically harm other people if it yields marginally higher profits. That's not up for debate, that's the stated business model. It is extra-judicial killing for profit, backed by the state. And when the state abuses their monopoly on power, history shows that people will claw it back as violently as they feel necessary.
The proof is that you'd be going to war over a 5% discount in prices, and it's based on an accounting of where the money in our health system goes. Sorry, the numbers here are easy to find and they are unforgiving.
Political operative here. If you're wondering why healthcare reform has been so hard to get and so piecemeal, even though most Americans want it, the big reasons are:
1) any reform has to get past the Senate, and the Senate gives a lot of extra weight to states with conservative electorates. In 2009, this meant the pivotal Senators were right-wing Blue Dogs, an independent (Lieberman), and a former Republican (Specter). In 2024, this means the pivotal Senator will be a conservative Republican, since Dems run fewer Blue Dogs, and liberals can't win states like North Dakota and Louisiana.
2) people don't only vote on healthcare; Democrats also support much less popular stances on other issues, especially immigration.
Lobbying etc. matters some, but is much less important than those two big ones.
Polls consistently show the public supports Democrats more than Republicans on healthcare policy, even as they trust Republicans more on other issues like inflation and immigration
Right, I'm a pretty engaged Democrat, but I'm asking: what reforms do you think are within the boundaries of acceptable to the median voter? Clearly single-payer is not. It couldn't even survive in Vermont.
as someone from VT, VT was way too small to do single-payer on it's own The whole point of single payer is to have a monopsony that can effectively negotiate with everyone else. For it to have a chance, they would have had to join with MA.
I think the reform that would be acceptable to the median voter is a public option for Obamacare. Just let people select Medicare as an option instead of one of the private companies (and even better, let companies provide it as an option for their employees as well).
thats the option that I have always preferred, provided the opt in Medicare/medicaid option is provided at cost to the general public.
If set up this way, I dont see why anyone would reject it. At worst, it would be another option amongst many.
The poison pill would be if opt-in medicare was funded from taxes on the general public who were paying concurrently for their private insurance. Medicaid funding would continue to support the poor.
However, this would only be a start. The real problem with US healthcare is a lack of spending controls. European socialized healthcare refuses to purchase treatment if the cost/Quality of life improvement is too low.
There are two broad concerns with public-option M4A:
* The resulting customer shifts will result in private insurance becoming more expensive or, worse, exiting some markets, which violates the requirement people have that, in the worst case, their current insurance remain accessible to them.
* The resulting customer shifts will drastically increase the cost of Medicare, threatening the existing program with benefit cuts.
I agree that those are the public concerns. regarding the second bullet, this is why I suggest a separate pool offered at cost.
Regarding the first, I dont think that this is a forgone conclusion, at least immediately, but admit I haven't thought through how the transition would work. With any public option gaining members, there are bound to be insures that lose them.
The majority of Americans believe the Federal government should provide health care [1][2].
The current Democratic Party is essentially "Republican Lite", Republican with a happy face on it. Democrats as a whole are more interested in defeating progressives and leftists than they are in defeating Republicans.
This is issue polling. There are lots of problems with issue polling, but even when delivered well, the fundamental problem is it's not concrete. Poll people to see if they'd like the option to stop paying for health insurance: you'll get Assad numbers. Now write a ballot initiative for single payer, where customers see the tax price tag, and have to worry about losing their current private health insurance: the numbers fall through the floor. This isn't supposition: it's happened over and over for the past several election cycles. People do not like this idea as a concrete thing.
I remember polling either done at the same time or the same pollster that found different approval ratings for Obamacare and the ACA. Its like dihydrogen monoxide vs water.
Right, but the point is (I'm belaboring) we don't have to rely on issue polling at all here, because has repeatedly made it to actual ballots, which are the votes that actually count.
I'm a Coloradan who voted for the 2016 universal healthcare (aka ColoradoCare) proposal, but I understand why the majority (79%) voted against it: there was sticker shock at the additional 10% income tax (with caveats, but people saw the 10%) and an inability of proponents to answer basic questions such as "Will I be able to keep my current doctor?", "Will I be able to get an abortion?", and "Will there be additional tax increases?".
Health "insurance" companies in the US are not actually, primarily insurers. For the most part, they are not in the business of insuring rare events. Maybe they were primarily in the insurance business at some point in the past, but today they are mainly in the business of entrenching themselves in the middle of all interactions between patients, doctors, and hospitals, and extracting rents from all of them. Health "insurance" companies have become extractive businesses that produce nothing of evident value except unpleasant paperwork, and extract an economic rent for it, to the detriment of everyone else. I call them "paperwork-shuffling processors."
Accurate. They are literally middle men taking a cut without offering anything to the process. Switch to single payer, dump the middlemen, and have our taxes pay for essential services (keeping us alive and healthy). Seems simple enough but…
I like the ACA. I think the Swiss system makes a lot of sense. Community rating, guaranteed issue, mandate, subsidy, then universal single payer at retirement, where costs are concentrated. It's a sane system. The problem isn't the system structure.
all of insurance and all of healthcare is "other people's money" :) it just depends where other people's money is going.
this is amazing thing to me as European living in the United States, people want Gov to spend money for education or healthcare or ... COMMUNISM!! but corporate subsidies and 984 trillion dollars to the department of offense - oh RIGHT ON - let me get another gig job to pay more to that :)
Not force, just the veiled threat that if you don't pay you won't have healthcare.
Everyone will require healthcare at some point, and at the points where you need the most you can't go do some window shopping and price comparison. Why make it more difficult, cumbersome, expensive, and bureaucratic? Ideologues can be rather illogical.
Most Americans support a public option, which is the transition step toward a healthcare system that more closely aligns with other first world nations.
The voters are for the most part uninformed, bordering on flat out ignorant. I feel safe in saying the experts who solve problems like this do know better than voters.
I suppose, careful what you wish for. The NHS (UK's single payer health provider), allegedly the envy of whole wide world, is failing under the burden of insufficient funding, aging society and years of mismanagement by politicians. We're talking, properly dysfunctional, like ambulances taking hours to be dispatched to life-threatening emergencies or people dying on emergency wards due to neglect.
Literally the same thing is true of health care providers, which is why we have artificially constrained supply of physicians, sky-high delivery of procedures other countries don't routinely do, and integer multiple compensation across the board for practitioners.
Yes. I almost added a comment about that too. In my experience, all doctors, nurses, and other caregivers with whom I have interacted at hospitals have told me they feel treated like "factory workers" who must meet stringent "quality of care" KPIs, set by hospital executives far removed from actual patient care.
So why are we putting jerseys on and taking the field against the insurers when virtually all of the actual money is going to providers? We could zero out all insurance costs, putting insurers into literal de jure indentured servitude, and get nothing more than a grocery store circular coupon discount on health costs, because insurers are not in fact where the costs are.
I'm certainly not going to valorize insurers, but I find it deeply frustrating the providers are getting a pass here. You can see it on this thread, where there are commenters expressing surprise that I'd even suggest providers are the primary beneficiaries of the current system.
The entire health care system is broken but insurance companies tend to be the pain people experience so that's what people lash out at.
But you don't expect someone dying from losing health care to shut up until they come up with rational cost management system? The point isn't that the average person needs to how to portion blame but that the health care system needs to stop treating people in the fashion it does.
That's a problem though when the blame is so screwy, because it leads people to solutions that are not solutions. Medicare itself drastically overpays for medical services compared to the G20. The biggest problem is with providers, and it's exactly stuff like anesthesiologists overbilling for surgeries.
Yes, the blame apportioned by the average person is screwy. But that should be clue to the experts with a more sophisticated view. What it should tell them is that health care reform schemes that rest on the average person exerting or responding to incentives are not going to work.
A lot of private "health insurance" at large companies is just:
- the company pays out-of-pocket for all employee health expenses
- they don't want to directly deal with bills from doctors and hospitals, so they contract that out to a third-party administrator (TPA), which purely handles paperwork and has no financial role at all
but this doesn't remove the tension between the employer wanting to pay less, and the patient wanting more to be paid for
(and for single-payer systems, you still have the tension between taxpayers wanting to pay less and patients wanting more care, although those groups at least overlap a lot more)
Yes, but unless it's literally Lasik, which has a robust private market, your provider will probably literally make a price up on the spot. That happened to me several years ago, when we needed urgently to get a CT scan for our daughter; it was late in the afternoon, the provider couldn't get the insurer on the horn, they proposed to do it the next day, I was jumpy and said "fuck it I'll pay out of pocket", they looked confused and then just made up a price: $1000.
So, private insurance companies ripping off patients is such an injustice that we are arguing that a literal murder could be (somewhat) justified - in HN of all places, where "it's the evil billionaires" was never a popular position - as if we are in total desperation and everything is on the table.
...when it is simply a consequence of America's system and the solution (public health insurance) is implemented in every other places.
Have we all got drunk on libertarianism until we would rather see CEOs murdered on the street than admitting maybe, sometimes, government managing its own citizens' welfare is an acceptable solution?
The libertarian argument is that he should have employed better security to protect himself from weirdos. This is why the rich need more tax cuts -they need to be able to afford security.
Genuine question: What is so difficult about healthcare in the USA?
European countries solutions range from free to government subsidised (for those who can't afford it). The free ones vary in quality, but systems where you pay unless you can't work pretty well, and the quality is very high.
Why is this such an issue in the USA? Is it purely a "powerful people with vested interests" thing?
The US spends over 17% of GDP on healthcare while comparable countries are around 8%. There are some ways we could reduce that but at the end of the day americans consume a lot of healthcare and americans get paid a lot to provide health care so any solution is going to have cost related problems. Because theres so much money involved there are tons of special interests which makes it politically extremely difficult to change anything. Two of the most obvious things we should do are pay less for pharmaceuticals and increase the number of doctors but the pharma lobby and AMA make that impossible.
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[ 2.8 ms ] story [ 361 ms ] threadAmericans React to UnitedHealthcare CEO's Murder: 'My Empathy Is Out of Network' (141 points, 12 hours ago, 329 comments) https://news.ycombinator.com/item?id=42327272
Moderators Delete Reddit Thread as Doctors Torch Dead UnitedHealthcare CEO (45 points, 3 hours ago, 22 comments) https://news.ycombinator.com/item?id=42332347
This is a good start comparing america's healthcare expenditure to other countries' expenditures: https://randomcriticalanalysis.com/why-conventional-wisdom-o...
The short of it, on a national level:
Health spending is determined by income
Income predicts changes in health expenditure
The rising health share explained by rising quantities per capita (not prices!)
America spends much more because it consumes much more
The claim that US health care prices are inexplicably high was never well-evidenced!
Real health inputs (labor) increase rapidly with income levels
High overall wage rates and profit margins cannot explain much.
Physician take-home pay explains even less
The composition of the American health workforce is consistent with trends observed elsewhere.
and finally...
Diminishing returns to spending and worse lifestyle factors explain America’s mediocre health outcomes
These headline claims map to large sections of the linked content. I highly recommend chewing through it all.
But rather than getting bogged down in all of the regulatory-captured details that of course just sum up to the broken system we have, let's put the bare reality quite plainly: "Those who make peaceful revolution impossible will make violent revolution inevitable".
Political campaigns rejecting government-based reform only work if the industry uses the breathing room to clean up their act on their own. When it throws those political campaigns out there in bad faith merely to run interference so it can continue collecting rent while not actually reforming, eventually people will have had enough and cheer on escalations past those neutralized avenues of reform.
If you read or hear the things people are saying, they’re expressing frustration over the way they’re treated by insurance providers and their policies. The costs across the industry are insane, and insurance companies sit at the intersection of all the money, leaching away 15-20% (your numbers) as profit. Go to a Reddit thread about this murder, and you’ll hear stories of all sorts of families who faced existential questions of paying exorbitantly for or losing access to necessary healthcare. Because of a UnitedHealth policy.
It’s a boiling point of the increasingly divided society with growing wealth inequality. It doesn’t matter what the regulations say, people are suffering and they’re lashing out. The narrative isn’t actually about UnitedHealthcare and their profits.
I am not trying to get political, or be flippant, I just truly marvel at how easily we are programmed. I mean all of us, myself included.
Private Health Insurers: Free Market!
It came down to this simple realization:
In a somewhat socialized healthcare system, every dollar not spent to benefit the patient is called waste, and we work to reduce it. [0]
In a for-profit healthcare system, every dollar not spent on the patient is considered shareholder value, and we work to increase it.
My hardcore libertarianism ideals died right there, at that realization.
[0] Let's keep it local and say that's medicare/medicade.
[0.1] Sorry, I did get political.
And if we had single pay, wouldn't people still die but now there is someone else to blame? Meaning there is still a budget for care, it is not infinite. There will still be a group to decide what to accept and what not.
Also, a key difference with single-payer healthcare is (generally) the distribution and accountability of program. We'd dispense with "preexisting conditions" and "in/out of network" and provide this service to everyone. Every single person would be eligible, it'd truly be for the citizenry. Because of this, coverage becomes a legislative practice, and if coverage or care is not meeting expectations, it can be changed.
(also, UnitedHealth profit margin was consistently > 20% pre-2024)
> On the 2021 phone call, which was recorded by the company, nurse Victoria Kavanaugh told her colleague that a doctor contracted by United to review the case had concluded that McNaughton’s treatment was “not medically necessary.” Her colleague, Dave Opperman, reacted to the news with a long laugh.
>“I knew that was coming,” said Opperman, who heads up a United subsidiary that brokered the health insurance contract between United and Penn State. “I did too,” Kavanaugh replied.
> Opperman then complained about McNaughton’s mother, whom he referred to as “this woman,” for “screaming and yelling” and “throwing tantrums” during calls with United.
I don't have a lot of sympathy for these people.
One of my early crap jobs was the mailroom at a Wausau Insurance branch. A claims adjuster gave me a case to make copies of, not warning me I’d be seeing graphic pics of a kid smashed between a dumpster and a wall. I guess she was so immune to that stuff by that point that it didn’t occur to her.
When I gave it back to her I remarked on how tragic the incident was. Her reply was that the mom had two other kids and was going to make a lot of money off this. Naturally the claims adjuster was white and the kid was black. There was testimony in the case about how much their brother’s death traumatized the two surviving boys, who saw it happen. How they tended to just cling to each other in meetings with a therapist.
On top of that the incident occurred because the insurance company had told the Rent-A-Center that their employees weren’t allowed to help delivery trucks back in, specifically because of liability if something like this happened (kid ran behind the dumpster to get a ball right as a delivery truck hit the dumpster).
The job warps these people into losing their humanity.
My conclusion is everything does. This conveniently makes it easy to dismiss criticism of any one part (all of which are responsible) because “well they’re just increasing it a little—go look at these other things, they’re bad too, and if you add up all of that, they’re worse!”
Right, but if you keep not addressing the one in front of you because of that kind of misdirection, you never fix any of it, because all of it is taking too much money.
I will say that our private insurance system in particular seems to be responsible for most of the insanely-high indirect costs of our system.
Dozens of hours for patients and their families lost per major incident, playing middleman between insurance and provider billing departments, trying to make insurance do what they’re supposed to. Stupid billing systems where the prices are all kinda fake, which wastes time in a few ways. Tons of time shopping for and managing healthcare plans by folks in HR. Government social safety net people having to dick around with private insurance nonsense to sort out who’s getting what from where. Employees losing time poring over plans to figure out which one they should get (is it just me, or if you’re offered three is there always one that doesn’t make any sense compared to the other two, no matter what kind of usage pattern or expectations you can think up?) Tons and tons of overhead staff at providers.
You conclusion reminds me of yesterday's thread about Rogue where one the best players was that way not due to some amazing trick or skill but because he was just a bit better than average on most aspects of the game. He didn't have to be the best at anything, all the little parts above the median added up.
It’s a regressive-tax-funded white collar makework jobs program. JFC.
I think the Nation’s quote of him on the topic points out something that may be true, which is that he might have balked at doing it given how many people would be laid off (hundreds of thousands, surely) and what the optics of that would be, though I kinda doubt the quote itself.
But yeah, even if he’d been gung-ho behind it, it wasn’t happening.
If you stick a gun in someone's face and demand they hand over their cash, you're a criminal.
If you do the same thing with contracts, paperwork, and quarterly reports for Wall St, you're a CEO.
There is no difference between these. One is camouflaged by the abstractions of profit and bureaucracy. But both are murderously violent, and there should be no legal or moral distinction between them.
Likewise climate change and ecocide; online disinformation, media lies, and other kinds of semantic pollution; workplace violence, and other "externalities."
Invention and daring can be good things. But when all you're contributing are death, stress, illness, mass bankruptcy, declining opportunities for most of the population, and other symptoms of corporate sociopathy, you are over the line.
Lots of developed nations have private insurance systems, somewhat similar to the US. Both Japan and Germany have such systems, yet healthcare costs here in Japan are pretty cheap usually. (Here, it's a public/private system, kinda like Obamacare: if you don't have a job or are between jobs or a part-time worker, you'll get government-provided insurance, which you have to pay depending on your prior income I think; when you have a regular full-time job, you get private insurance that your company contracts for. But the insurance works basically all the same way: you pay 30% of the actual cost, and the insurance company pays 70%.)
There's something uniquely bad about the American system, but honestly I don't know what it is. I suspect it has to do with very bad regulation, or a lack of it. Here, it seems the costs for many things (like necessary medical procedures) are strictly regulated by the government. Also, no one pays bills to insurance companies AFAICT: you just pay the healthcare provider, and they go to the insurance company for the remainder.
Like a major premise of US healthcare policy is that preventing investment reduces costs. Good luck when that's the starting condition.
For example, reducing costs is the justification for limiting how many doctors are trained. Fortunately, our planning has been perfect rather than disastrous.
I say this as someone who wound up owning one business in this area (health insurance agency/producer) and was looking at expanding directly to the insurance providing aspect. I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.
Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.
What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.
Yes, because the US is currently experiencing an adverse selection bias where healthy avoid enrolling until an issue occurs. See this: https://www.aeaweb.org/articles?id=10.1257/app.20170117
> Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.
Government funded but it's not a social safety net or mandate in a conventionally sense: it's an insurance subsidy. It effectively incentivizes depressing your own personal income to achieve high-subsidy plans (namely, the silver plan in most if not all states) resulting in abnormally high subsidies. It's just a form of tax planning today. See people taking "early retirement" with substantial assets (>1mm, which isn't much for HN but substantial in much of the country) at 40, reducing disbursements, and effectively costing the taxpayer ~36k/year in subsidies.
In an idea world, your assets would be subject to seizure under means testing on assets, not just income, before subsidies are provided. Seriously, go check out reddit /r/fire. They talk about it (and how a reduction in ACA subsidies in 2025 will force them out of retirement at the advanced age of 45).
> What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.
I'm going to be real: this is just wrong. Price controls only works in two circumstances:
* You are willing to tolerate reduced availability of goods and services * You are actively willing to prohibit others from purchasing goods and services with their own money
1 is complete anathema to the US consumer market. If price controls were to be implemented, the elderly would likely get care first, which is unlikely to yield practically the needed result relative to current costs curves -- keeping the working population working with preventative and minimizing the cost on the elder bracket. In my opinion, this mispricing is in part due to the ACA, but that's neither here nor there.
2 would require Norway style controls of Ozembic and similar. I don't think Americans would ever tolerate "your money, you aren't allowed to buy it". Prices are high because Americans can pay in dollars more than other nations and are willing to do so.
There is a very real perception that medicine can fix poor health choices and we should spend arbitrarily large amounts of money to fix it. It's a fantastic business to be in -- people insist "healthcare is a human right" and are willing to tax others to pay it.
As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.
> I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.
Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.
In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?
At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.
Sort of: as you get older, time catches up to you. In the USA for, heart disease kills 1015/100k for both genders (see: https://usafacts.org/articles/what-are-the-top-causes-of-dea... in Germany, it is just 673/100k for just men alone. We have an obesity problem, not a healthcare problem, when it comes to life expectancy.
> Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.
The question here is QALYS. We quite literally avoid this discussion in the US at all (see this: https://pubmed.ncbi.nlm.nih.gov/19738253/). The issue isn't that we disagree about the issues: it's that the issues are not addressed and Americans pretty much always say "spend more".
Europe has already begun rationing, by the way (see this: https://pmc.ncbi.nlm.nih.gov/articles/PMC1831659/#:~:text=Be....) It's not as though it doesn't already occur; we simply choose to blame insurance companies instead of a national system.
> In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?
Healthier populations. Americans make awful health choices.
> At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.
Not really. Margin shifts along value chains; it's rarely destroyed. All that would happen is the profits would shift to another location. Then the game becomes how to get there.
In the US system, insurers are the only actor with any real incentive or ability to constrain costs by limiting consumption; a very large part of the bureaucracy involved in the insurance system is about trying to manage consumption. We're seeing exactly how well that's working out for them, spilled all over the sidewalk.
Talk to people in the UK or Canada or Germany or Australia. See how their media covers healthcare. They're furious about their healthcare systems too, they're talking about a mounting crisis, just for different reasons. These systems accept long waits and the flat refusal to fund less cost-effective interventions as a necessary evil.
It’s laughable that anyone can have this reaction of “gee, maybe if people only understood _why_ a CEO makes billions and has the highest rate of denied claims, they wouldn’t accept violence”
Here I am paying out of pocket for a medically necessary and covered service simply because the insurance company is playing games. I would prefer they not try to cut their costs by playing stupid games like this about valid claims in the hope that I just give up so they don't have to pay. It's feeling like I'm going to have to sue them to get this resolved. At least it's harder for corporations to play games with process service.
I don’t really know what narratives you’re objecting to. But I want to point out the existence of that regulation doesn’t make healthcare companies passive bystanders in the cost of healthcare in America. e.g., notice it collectively incentivizes them to drive the overall cost of healthcare up as much as possible, to maximize the size of their slice of the pie.
The fundamental problem is running healthcare as a profit-driven system. The incentives operating the system cannot possibly be aligned with the people the system is ostensibly meant to serve. (Not that it’s not going to be unraveled, short of literal revolution.)
> enormous increase in administrative overhead
Do you see the problem here?
As an outsider it's hard to say, but clearly there is some ginormous loopholing going on here.
I haven't found much in the way of details, but apparently one of the reasons why insurance companies are buying up medical practices is because it enables accounting dipsy-doodle to avoid the healthcare spending requirements.
Back in the days, mainstream media had enough control over the narrative to water down the "manifesto" part and avoid copycats. This time, "rogue" social medias are much more prevalent, so there's not much of a barrier to prevent the perpetrator from becoming a hero. We can think that copycats will emerge.
I guess that billionaires around the world are dusting off their "apocalypse bunker" protocol...
The journalists' tone and choice of words here, which I've italicized, isn't helping the overall feeling many Americans have of "the people running the show have active and unceasing contempt for us", which of course is what's driving the "torrent of hate for health insurance industry" that this article sets out to document.
I'm sorry, but where do these writers get off wagging their fingers and tut-tutting people who'd prefer not to spend their neurons on sympathy for someone at the helm of an inhuman system? The point's already been made, but plenty of monsters are husbands and fathers.
What I do find disappointing is the lack of concern over people being gunned down in the street, and the not so subtle glee some people are expressing.
Murder should not be normalized or endorsed. It isn't healthy for a society and doesn't lead to progress.
This is (was) the CEO of the largest health insurer in the country which has shown a lack of concern for paying out insurance or securing data both private and medical. Their data leak this year is second only to National Public Data's leak (also this year) of practically every single SSN on the planet and arguably worse because their leak also contains medical data.
Murder is never okay, but this guy is also about the most unsympathizable man in the country.
There's no way that is true. It's only remotely possibly true if you're only talking about people who at least nominally obey the rules and laws of society. You don't actually think that he was worse than a murderer, or a rapist, or a child abuser, of which we have many, many thousands in this country.
The difference in opinion might be many people considering the guy himself to be a murderer, and not just of one or two people?
-Joseph Stalin
https://www.oxfordreference.com/display/10.1093/acref/978019...
Don't get my wrong, shooting someone in broad daylight is a bad thing and I will agree that we shouldn't encourage it. In this case I don't have any sympathy for the victim. There's a difference there - I recognize that the assassin is wrong but that's orthogonal to my sympathy (or in this case, lack of) for the victim.
What the CEO did was worse. While someone who premeditates a murder clearly has knowledge of and familiarity with the person being murdered the CEO does not have that for the deaths that are a result of denying care. They feel almost clinical to him, numbers on a balance sheet to be weighed against the bottom line. It's textbook banality of evil - the deaths he was responsible for were just the cost of doing business, and what a business it is.
I think if you poll the people taking this as a good thing, you will get an overwhelming answer of “probably not”, and the implications are exactly what you suppose.
But speaking more generally - I think a lot of people would, indeed, shrug. The US healthcare system is one of the most miserable parts of living in this country and virtually everyone has had to deal with it at some point. And whether or not they deserve the direct blame, insurance execs (and pharma execs, etc) directly profit from that misery.
I think a lot of people are not going to shed a single tear over events like this.
Even if you’re a few levels removed from the deaths you’ve caused, you still have blood on your hands imo.
I'd rather have the Sackler family show up for a dinner than the Manson family, but if we're being honest, the former is responsible for several orders of magnitude more deaths than the latter.
An ounce of prevention is worth a pound of cure.
I think there is not much point in defining a single metric of "worse" because that is confusing. A rapist is worse if they are following your spouse. This guy is worse if he is about to make a decision that will prevent your loved one from getting medical treatment at the exact time that they need it.
The acts of Murders, rapist, and child abusers are far more heinous than health insurance CEOs. However, I would argue the magnitude of damage is larger from the decisions of health care CEOs.
Sure. That includes the US health care system too.
The company that person was the key decision maker for has apparently been murdering people for years legally.
So, karma?
People should not kill law abiding citizens they disagree with because everyone has a different opinion.
Good when it works, but what happens when it fails?
Maybe I'm sensitive because I have been reading about the french revolution, and how mob rule lead to mass murder which left everyone worse off.
From your point of view was the "everyone left worse off" a short term thing, or did it eventually come good for most, or something else?
How far along the path do you reckon the US is to the same kind of thing?
I don't think any of the revolutionary elements can get enough support for governmental change, and the majority wold rather give up their freedoms than give in to terrorists.
Get a grip. For all we know the shooter was pissed b/c his girlfriend was banging the health insurance executive while babysitting for him!
[I would loooove for HN to have optionally-visible meta-threads, so onlookers like me could sit in the gallery, drink a beer, joke and remark about what is posted w/o affecting the stream of thought. Now back to y'all...]
We do, but unfortunately it heavily favors the party with the most money. If you want to take a health insurance company to court it's gonna cost you a lot of money in lawyer fees and you'll face a phalanx of corporate lawyers who have a lot of experience in crushing cases brought by their customers. That's not to say that people should go out and take matters into their own hands, but there is a lot of pent-up frustration out there and we really need to start addressing some of these issues before more of this happens.
Someone has turned to vigilante justice here not because they believe that the courts are useless, but because they believe that this is such an extreme case that courts would not have worked in this case.
What I believe people fear is not the rise of anarchy due to one killing, but a fundamental shift in attitudes of the ordinary people in response to the unreasonable rise of the power structure. This threatens not order but the very power structure itself, which implies that a lot of people who benefit from injustice will suddenly be at risk of losing those benefits (money).
also people should most definitely NOT kill law abiding citizens! we do have laws for that
These are the laws that your fellow citizens have chosen and established.
killing CEOs is not the kind of violence any reasonable human being can condone, but people tragically affected by someone’s actions may not be all that reasonable
By abandoning democratic law, you also abandon 3rd party discretion and control over which injustices are legitimate.
jokes aside, I am not saying this tragedy was justified in any way but we are not talking here about “opinions” and “religion” for sure
At what point is defending their murdering of people an acceptable approach? :)
Not at all. The US "health care" system has the extremely bad reputation it has for a reason.
This guy seems to (for all we know) have only killed a single person (so far).
The person he shot has likely killed far more. I'm not sure why you're ok with that, or am I misunderstanding?
https://www.theregister.com/2023/11/15/unitedhealthcare_ai_m...
>At what point is defending their murdering of people an acceptable approach? :)
We have laws that define where your responsibility starts and ends. For a random citizen, you have 0 obligation to help someone pay their healthcare bills.
For a health insurance company, they have a legal obligation to spend 85% of revenue on member healthcare, with all expenses and profit coming from the remaining 15%. This is codified by the ACA 85/15% law passed under Obama. United meets this obligation.
That's not what happened.
Brian Thompson isn't a "law abiding citizen I disagree with" he's a law abiding citizen who killed people. If you or your loved one died because of his actions, would you "have a disagreement with him"? Is that what you'd call that?
How many millions of people did he save?
Tell that to the people whose family members died due to his actions.
I'm not arguing this with you again for you to ignore what I say again.
> If you attribute the deaths from healthcare denials to him, did he also save every life that wasnt denied?
> How many millions of people did he save?
None that wouldn't have been saved by anyone doing his job. Literally, it was just his job, and he was close to as bad at is as he could get away with. All the evidence I've seen is that this guy was an obstacle to saving lives at every opportunity he got.
Even if we somehow pretend he made any effort to saving lives, how many lives do you have to save to get a free pass for a murder in your mind? Is that how you think this works?
Honestly, I think there's something wrong with your conscience. Grow some compassion for other humans.
If this were you or I it would be a segment on the 6 o'clock news and a cold case
That the murderer, who killed someone in literal broad daylight on the sidewalk of one of the biggest cities in the world, is still on the loose speaks volumes to me about all sorts of things.
I guess the American revolution didn't lead to progress then. Or any of the other revolutions, many of which had assassinations. And murder is not being endorsed. Putting an end to it is.
What’s this norm you mention?
What norm?
You might have beef (or whatever you call it these days) with his job and industry but in the end a man was murdered. You may not like and "hate" seems appropriate to describe how you feel about a legitimate industry in the USA. Your issue is with a deeply embedded part of the US experience - health insurance, and not with this man.
Please attack the industry that you hate and not the individual ... who was murdered. That is what the journos are doing.
Depending on the shooters motivation, I think they're of the opinion that the time for dialogue has passed.
Given your spelling of dialogue, I think it's unlikely we'll ever really understand the shooter's motivation.
And what exactly is your solution?
Healthcare should be a charity from the rich?
It should be nationalized, and somehow magically all the problems go away?
I’d maybe vote against state level single payer, let alone taking over healthcare entirely, because I think it’d be a ton less efficient than doing it at the federal level—enormous amounts of money already go to various federal healthcare programs and it’d be better to pool that, and also lack of state level control over their markets is likely to cause problems. I dunno, it might depend on the law, but my gut reaction is a “no” vote on that, too.
Anyway, as for the other question, I believe that the rise of the postwar think-tank industry (a mash up of k-street and Madison Avenue, but for white papers, as it quickly became) and deliberate party and industry efforts to shift public sentiment in pro-market directions, tied up with lots of government spending on anti-Soviet messaging (were they bad? Oh, yeah. Were all the things the government tried to lump in with them and decry as un-American bad? Ehhhh… I mean atheism is among those, see the change to the pledge and to our money at the time, among other things, and I think atheism’s fine) is probably why healthcare can be this incredibly messed-up and nationalization remains not just not-popular-enough-to-pass, but entirely outside the Overton window, yes.
M4A is nationalized health insurance if not quite nationalized healthcare, but the point remains that the only reason we don’t have major steps in this direction is because of people in power who will not let it happen.
For example, the ones establishing and profiting from so-called "social media" at the expense of organisations that employ journalists.
Advertisers choose between supporting organizations that employ journalists versus supporting ones that do not, the ones profiting instead from the "torrent of hate". NYT has plenty of paying subscribers; it is not 100% dependant on ads, unlike "social media", generally.
Indeed "the people running social media have active and unceasing contempt for us". They prefer computers over people. Surveillance over sympathy.
This won't win me any points in this particular forum, where this opinion (that I strongly hold) is unpopular, but I'm reminded of what someone else said about Net Neutrality: it's a bunch of people suiting up and taking sides on behalf of one group of giant corporations against another group of giant corporations. That's the "health care debate" in the US, where medical staff are paid 2-3x more than they are in other countries, and expensive procedures are prescribed and delivered at drastically higher rates. It's my problem with "Medicare For All", which more or less absolves providers from their role in choking people out with health care costs, despite the leading role they have in this situation.
At any rate: there's no serious theory of change that begins with murdering health care industry people.
I dunno. This is the most publicly-united I’ve seen people against the industry maybe ever. Usually they’re separately-angry at the industry in their partisan silos (everyone hates it, more or less—hence the amazingly consistent and widespread reaction) but this has been the closest thing to a bipartisan healing moment since, like, the week after 9/11. Not particularly close to that, sure, but I can’t think of anything closer.
If this were part of a theory of change, it strikes me as no less serious than any other I’ve seen. At least.
This is top of my list for conversation topics to steer things toward when I’m around Republican relatives, so we’ll have something we can agree on.
Law-abiding doesn’t mean much when you can kill lots of people for money and remain within the bounds of the law. Killing one such person is definitely far less bad than killing a bunch of people arbitrarily. Yet only one of these cases is illegal, and it’s the better of the two.
Similar reaction for the other examples. I’m baffled that they look similar to anybody at all.
[edit] hold on, ok, another angle that may clear up why I’m confused: if my health insurer denies my legit claim, should I be more, less, or equally angry with the leadership of that company, or with every single person in the country who fails to donate to my resulting gofundme? I’m immediately inclined to wish horrible things on one of these groups, and to find the idea of wishing horrible things on the other confusing and repulsive.
Health insurance has a fixed profit margin on claims paid. Denying claims costs them money. Pay 10 billion in claims and they make 2 billion. Deny half the claims and they make half as much.
look up that ACA 85/15 law
Because there is a clear legal understanding of how much profit is acceptable.
Ahhh. I guess you're not aware of stuff like this?
https://www.newsweek.com/hospitals-are-reporting-more-insura...
https://www.theregister.com/2023/11/15/unitedhealthcare_ai_m...
One of the primary jobs of insurance companies is to vet claims. If we didnt want that, you could just make a shared bank account and let doctors and hospitals bill anything they want to it. You might save 10% on overhead, but it would collapse instantly.
If that were true then United Healthcare wouldn't have rolled out an automated system that (reportedly) denies ~90% of people regardless of their actual need.
The CEO getting shot seems to indicate it's probably more true than less true.
The ACA’s loss ratio rules don’t apply to self-funded plans (many large employers use these) even if they’re administered (and possibly re-insured) by a health insurance company, which is usually the case. Just doesn’t apply at all.
Certain plans also allow much lower loss ratios, like 60/40 for expat plans.
A provider that manages to have a lot of new plans in a given state in a given year is immune from loss ratios rules in that state, for that year. I don’t know how gameable this is but my WAG would be it’s only state insurance commissions preventing this from being the case in every state, every year, for every provider, and keeping it to only some states in some years for some providers (I bet the biggies manage to rotate their state[s] and have at least one most years)
So a company the only business of which is health insurance can easily spend far less than 80 or 85% of income on payouts, and only need maintain that ratio on some subset—possibly small—of the premiums it’s collecting.
I don’t know how the game of this affects decisions for insurers that also own providers, but I bet there’s something beneficial there and that’s why they’ve been snapping up provider offices for the last several years.
At the end of the day, my experience is that my UHC healthcare is about 10% more than healthcare from non-profit Kaiser, and Kaiser is far more stingy with services.
I think there is a hell of a lot wrong with healthcare in the US, but I don't think that constitutes murder just because the stakes are life an death.
Ethics depend not just on the outcome, but the processes that leads to that outcome.
The incentives in healthcare are terrible, but it is the government which has structured the system and those incentives.
The majority of people in this particular industry have nothing to do with actually providing health care, just as the majority of employees at a major university have never stood in front of a blackboard.
So, yeah, you'll have to do a little better than that.
You usually come up with better arguments than this. We all have off days, I guess.
https://web.archive.org/web/20210421025041/http://theinciden...
(Shrug) I'm OK with the notion that doctors contribute somewhere between 4 and 7 times more value than your average schlub driving a bus, and I'm OK with paying them accordingly.
Now, how much do the administrators, insurance-company execs, and other noncontributors make?
> pushing back on anesthesiology pay on the East Coast.
Not even close. BCBS was just pushing extra charges onto patients.
> insurers working to make surgeries cost less
This is laughably ill-informed, I don't know where to begin. The only thing insurers are doing is increasing the gap between what they collect and what they have to pay out. They do this by denying claims. Making the service cheaper has nothing to do with it.
> where medical staff are paid 2-3x more than they are in other countries
Because medical school is so expensive. Also, doctors spend 3-8 years working for minimum wage (ie medical residency) and the cost of billing and administration is enormous. One study showed a primary care doctor spent $99,000 a year on billing and roughly 25% of ER income spent on the same [1].
The US spends the most per capita on healthcare than any other OECD country, by about 50% (Switzerland is #2) [2] for less coverage, worse outcomes and lower life expectancy.
Medicare spends almost all (~98.5%) of its funds on patient care and ~1.5% on admin, compared to 15-25% on admin for private insurers (including Medicare Advantage).
It amazes me how concifently wrong and ignorant about a subject can be while having such strong opinions.
[1]: https://www.fiercehealthcare.com/finance/study-billing-for-m...
[2]: https://www.oecd-ilibrary.org/sites/7a7afb35-en/1/3/7/2/inde...
You cannot reasonably support Medicare and claim that Anthem was doing something unconscionable, because Anthem was adopting Medicare's own policies.
Medicare's admin cost ratio is a function of who it covers. Somewhere in the comment history on HN, there's a short writeup I did of how the math works out if you extend Medicare to the whole population; the admin overhead, for obvious reasons, shoots up --- people pay the same amount of money but require far fewer services, reversing the "advantage" Medicare has in the metric currently.
The Medicare schedule is generally low because of the negotiating power of the Federal government so when Anthem (or whoever) says something like "we'll pay Medicare rates" or "we'll pay 120% of the Medicare rate" they're really just cutting payments and increasing patient costs. Nothing more.
In the recent BCBS case, all they were doing was saying "it may take 8 hours for the surgery but we're only going to pay you for 3". They haven't made the surgery cheaper to provide. They just wanted to pay out less.
Also, if we're going to simply do everything based on Medicare, why exactly do we even need private insurers? Just expand Medicare to everyone if the schedules are good, right?
You are exactly right that Anthem is demanding providers charge less for surgeries, not for surgeries to take less time. Providing "less anesthesia" is not a thing. This is entirely about preventing health providers from charging more money to Anthem and, in turn, their customers. That's why Medicare does the same thing.
This is about the trade association for anesthesiologists deputizing angry people on Twitter to go to bat for them overcharging for their services.
we like to think we are just da best at everything
after all, I sometimes read about people coming to the US for care so it must be better?
Solutions? I'm worried that there aren't solutions. There are only bandaids.
I thought the American Medical Association were the ones who artificially constrain the supply of physicians. Is that not true, or is the AMA constraint transitively related to the Medicare caps in some manner?
It is just one aspect of how incredibly constrained the supply of healthcare is in the US. Medications that are over the counter in many countries requires someone with 12 years of training.
Residents provide healthcare to patients with real value. This healthcare either gets attributed to the attending physician or goes unbilled. The market value of care provided exceeds what it actually costs to employ and train a resident.
https://pubmed.ncbi.nlm.nih.gov/21217491/
You sure about that? Show me one theory of change where the oppressed somehow rise above without violence? Even the groundwork for Ghandi's peaceful protest were laid by a strong anti-colonial military force that led assassinations of British military officers. You think Britain left because Ghandi said some profound things and changed their minds? The official position was that continued occupation of India would be met by violent resistance and they retreated.
There have been many many examples throughout history of oppressed people rising up with violence against their oppressors. The majority of the substantial changes in culture happen this way - things reach a boiling point and it spills out on the streets.
I'm not saying mob justice is an ethical or principled way to instill change. But historically it has been extremely successful.
There is one group, the insurance companies, which have unequivocally stated that they will physically harm other people if it yields marginally higher profits. That's not up for debate, that's the stated business model. It is extra-judicial killing for profit, backed by the state. And when the state abuses their monopoly on power, history shows that people will claw it back as violently as they feel necessary.
To be fair, we’ve never tried it.
1) any reform has to get past the Senate, and the Senate gives a lot of extra weight to states with conservative electorates. In 2009, this meant the pivotal Senators were right-wing Blue Dogs, an independent (Lieberman), and a former Republican (Specter). In 2024, this means the pivotal Senator will be a conservative Republican, since Dems run fewer Blue Dogs, and liberals can't win states like North Dakota and Louisiana.
2) people don't only vote on healthcare; Democrats also support much less popular stances on other issues, especially immigration.
Lobbying etc. matters some, but is much less important than those two big ones.
https://www.the-independent.com/news/world/americas/us-polit...
I think the reform that would be acceptable to the median voter is a public option for Obamacare. Just let people select Medicare as an option instead of one of the private companies (and even better, let companies provide it as an option for their employees as well).
If set up this way, I dont see why anyone would reject it. At worst, it would be another option amongst many.
The poison pill would be if opt-in medicare was funded from taxes on the general public who were paying concurrently for their private insurance. Medicaid funding would continue to support the poor.
However, this would only be a start. The real problem with US healthcare is a lack of spending controls. European socialized healthcare refuses to purchase treatment if the cost/Quality of life improvement is too low.
* The resulting customer shifts will result in private insurance becoming more expensive or, worse, exiting some markets, which violates the requirement people have that, in the worst case, their current insurance remain accessible to them.
* The resulting customer shifts will drastically increase the cost of Medicare, threatening the existing program with benefit cuts.
Regarding the first, I dont think that this is a forgone conclusion, at least immediately, but admit I haven't thought through how the transition would work. With any public option gaining members, there are bound to be insures that lose them.
The current Democratic Party is essentially "Republican Lite", Republican with a happy face on it. Democrats as a whole are more interested in defeating progressives and leftists than they are in defeating Republicans.
[1]: https://news.gallup.com/poll/468401/majority-say-gov-ensure-...
[2]: https://thehill.com/policy/healthcare/351928-poll-majority-s...
Approval is high for "Something Else" but low for the alternatives.
this is amazing thing to me as European living in the United States, people want Gov to spend money for education or healthcare or ... COMMUNISM!! but corporate subsidies and 984 trillion dollars to the department of offense - oh RIGHT ON - let me get another gig job to pay more to that :)
Everyone will require healthcare at some point, and at the points where you need the most you can't go do some window shopping and price comparison. Why make it more difficult, cumbersome, expensive, and bureaucratic? Ideologues can be rather illogical.
Less sick people is better in general for a society, not only socially but also economically speaking, do you agree with this statement?
I agree with the statement as you present it, all other things being equal.
And they still get nothing done when it comes to entrenched interests. Let's not glorify the average voter either.
... But you still have group A (patients) paying group B (doctors) with group C's (taxpayers', or currently insurers'/policyholders') money.
What point are you making here?
- https://tribunemag.co.uk/2023/07/defunding-the-nhs
Otherwise, I agree with you.
You’re even replying this to a comment that literally contains “I agree with you”.
It’s like stepping between your friends complaining about jet lag to talk about how your corner bodega raised the price of bubble gum.
If you just want to talk about providers then write a screed on it. People will comment their opinions on the subject you want to discuss.
Then share an opinion on that.
> in the hopes of getting a maybe 5% savings break on their health insurance costs?
You were so close.
All you had to do was condescendingly presuppose a motive, and fabricate a statistic to make it about your desired topic again.
Regarding providers overcharging, the following article by Atul Gawande (from 15 years ago!) had a big impact on me -- it agrees with you:
https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... / https://archive.ph/g8zXl
But you don't expect someone dying from losing health care to shut up until they come up with rational cost management system? The point isn't that the average person needs to how to portion blame but that the health care system needs to stop treating people in the fashion it does.
- the company pays out-of-pocket for all employee health expenses
- they don't want to directly deal with bills from doctors and hospitals, so they contract that out to a third-party administrator (TPA), which purely handles paperwork and has no financial role at all
but this doesn't remove the tension between the employer wanting to pay less, and the patient wanting more to be paid for
(and for single-payer systems, you still have the tension between taxpayers wanting to pay less and patients wanting more care, although those groups at least overlap a lot more)
...when it is simply a consequence of America's system and the solution (public health insurance) is implemented in every other places.
Have we all got drunk on libertarianism until we would rather see CEOs murdered on the street than admitting maybe, sometimes, government managing its own citizens' welfare is an acceptable solution?
European countries solutions range from free to government subsidised (for those who can't afford it). The free ones vary in quality, but systems where you pay unless you can't work pretty well, and the quality is very high.
Why is this such an issue in the USA? Is it purely a "powerful people with vested interests" thing?