I wonder if they will be setting it up as a health insurance cooperative, an organizational structure in which the primary goal is to serve its members, rather than to generate value for external shareholders: https://en.wikipedia.org/wiki/Health_insurance_cooperative
It's not at all unprecedented for publicly traded companies to create cooperatives for their employees. Employee credit unions are one example.
Co-ops were part of an early proposal while the ACA was still shaping out, but unfortunately, due to pressure from for-profit health insurers, they were later shot down: http://www.nytimes.com/2009/08/17/health/policy/17talkshows....
As a fan of distributism https://en.wikipedia.org/wiki/Distributism, I would love to see an increase in health insurance cooperatives, and cooperatives in general. Under a cooperative structure, the members/policyholders fully own the company, so it's not beholden to outside shareholders seeking to profit at the expense of its members. Any profits that a cooperative generates are returned back to the members/policyholders in the form of lower premiums, or improvements to services.
Thank you for giving a name to something I have been pondering a lot. I have come to this conclusion by thinking about automation and technological unemployment. If people own land, or productive tools, they can be self reliant and exist without jobs from corporations, or help from the state. Naturally people would organise as a cooperative or a market of services, exchanging services for services, because they have little money and no corporate jobs. Yet they can work, so they can create a kindergarten for children of the neighbourhood, or a medical clinic, or a mechanic repair-shop, or a construction company, and so on.
By combining these skills a neighbourhood, or a city could be self reliant. In the future, with the advent of solar energy, agro-bots, 3d-printing and other empowering technologies it will be even easier to be self reliant. I see this as a better solution to UBI which depends on the state, which is corruptible and the corporations, which are greedy. People would retain their agency, unlike in the UBI scenario, where they would be wards of the state.
There is no purpose to automation that does not exist in the service of humanity at large, but only for a few. Automation must be owned by the people directly. We need to have the means of production in our hands in order to survive. There is one single job the advancement of automation can't take from us - the job of taking care of ourselves! And that's hard work.
- People who can not work because they simply can't hold down a job, period.
- Externalities such as neighboring (or even distant) communes dumping wastewater into rivers etc., or polluting the ground, or air... you get the idea. What about natural calamities, such as earthquakes, tsunamis, volcanic eruptions, and such?
- Conflicts over scarce resources. Water, for example. Communes that rely on a common source of water will likely have conflicts. How are they resolved?
- Any commune is exceedingly unlikely to be good at producing all the things it needs. Trade will need to develop. Does 'self-reliance' exclude the possibility of trade?
- How large should a commune be, to enable innovation? Without innovation, there will be stagnation that will harm the commune in the long run.
- How would a commune handle people that are 'different'? How about criminals within and without?
I don't think distributism requires a closed system.
A few of its guiding principles may answer your concerns:
* Subsidiarity teaches that things should be handled at the lowest or least centralized level that is competent to handle them. That doesn't mean that small organizations should be expected to bite off more than they could handle. It may very well be that a giant, multinational corporation is the lowest-sized organization that can handle operating something like an airline, and that is not inconsistent with distributist principles.
* Distributism, as an economic system, is not at all incompatible with things like a strong social safety net. However, it is worth pointing out that if the ownership of productive property were to become more widespread, the need for such a safety net would be decreased.
We live in a world where (to quote GKC ):
> Lancashire merchants whenever they like
> Can water the beer of a man in Klondike
> Or poison the meat of a man in Bombay;
> And that is the meaning of Empire Day.
The advantage of centralization is that we can stop the poisoning all at once (because there is only one place doing the poisoning). However, when the meat is poisoned many more people suffer food poisoning than would if the food packaging were distributed.
The "distributism" described above is the dream of virtually every rural community. People choose to live in rural communities because it's a little piece of heaven for them: they are surrounded by people they know, they have clean air, the earth is right beneath their feet, the stars are bright, the pace is slow, and so on. They want to serve their neighbors and receive services from their neighbors. How is that mindset pathological?
I am always encouraged by innovations that help rural folks be more self-reliant so they can work toward their dream of self-sustaining, independent communities.
So, you either choose total independence and low technology or interdependence with other groups and advanced tech.
Although that independence would be like a group of proto humans that knew about fire and how to use it, but not how to make it, and thus carefully guarded it and kept it fed, lest it go out.
I don’t see a way around this, since you always have to start from the same raw materials.
1) Our general trend is towards urbanization, humanity is now more urban than rural, and every quality of life index shows cities give more good to more people better.
2) Millennials, hipsters in particular, in American markets with crushing real estate prices have recently begun reverse-migrating away from the cities and to more rural areas with romanticized lifestyles creating some new demographic, and real estate, trends.
In terms of pure statistics we're looking at a sub-group with a different trend than the overall group. Most potatos aren't from my backyard, but those potatoes are only getting prettier while the many thousands at the market are getting uglier ;)
However, I will agree that my initial response was lacking and would have been better if not stated at all.
I suspect that you also have more corruption and/or abuse of power because (a) the previous entries all empower sociopathic individuals, (b) you have a larger pool from which to find such sociopaths, and (c) you have more positions of power for said sociopaths to fill.
You have all of these problems in small groups, but many of our policing/accountability systems don't function well in very large groups.
I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy, which might lead to more wars. I have no idea if that's true, but it sounds plausible to me.
In the end, actually examining data is what's needed. Until there are facts to assess, we're just spouting wild conjecture.
https://en.wikipedia.org/wiki/Dunbar%27s_number has a decent collection of the research I know of. There is a little hand-waving involved when it comes to "why", but it's notable that multiple researchers over decades disagree about the number, not the base concept. Likewise, studies related to the base concept of the non-technical Brooks Law support the non-linear impact on communication as a group grows (off hand I can't find a study on that, but I know I've read of multiple).
Edit: Also https://www.psychologytoday.com/blog/how-risky-is-it-really/... points out some research about the distance/abstractness I mentioned.
Anecdotally, plenty of governing and/or economic systems (e.g. communism) have historical success in small groups and no examples of success in large groups, but that's a completely different kind of evidence.
The corruption/abuse item is not part of the research, which is why I separated that as "I suspect" Given the above, and what we know about leaders (executives, politicians) and how sociopathic tendencies are an asset to personal success I find it very plausible but I have no actual evidence, thus "I suspect".
> I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy
You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences. That's orthogonal to my point though, as I was only addressing internal workings, not interactions between groups.
My main point was that the theory was labeled as something you suspect, but the evidence you listed to back up that theory sounded like it was being presented as fact. You've provided resources to back up the claim, at least to some degree (as you note), which is what I was looking for, so thanks. :)
> You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences.
I don't have any, but I also would be interested to see it. I was using it as an example of something that sounded true and that I suspected was true that I had no real evidence of, and thus should be hesitant to assert as true. Unfortunately, by its nature that makes it interesting to a certain type of person, so it ends up teasing us. :/
How is that self-reliant? It’s different from most of the current developed economies, but it’s still division of labour and relying on others for some things.
There certainly is, to the few that are served. Increased productivity that doesn't require manpower/hours has been captured for centuries.
A capitalist economy provides many incentives to privately hold productivity gains from automation, while providing virtually none to relinquish them to the public.
Giving up these ventures would require such a massive reduction to the quantity and quality of human life, that it would be unacceptable to the vast majority of people.
The Haber process ended humanity's hopes of creating a society based on self reliance.
People have predicted the population bomb many times for hundreds of years, and every time they have been wrong.
Scientists predict human population to peak in 2040 anyway. I think that we can make it till then.
The world supports the current population quite well, right now.
> According to distributists, property ownership is a fundamental right, and the means of production should be spread as widely as possible, rather than being centralized under the control of the state (state capitalism), a few individuals (plutocracy), or corporations (corporatocracy). Distributism, therefore, advocates a society marked by widespread property ownership.
> Distributism has often been described in opposition to both socialism and capitalism, which distributists see as equally flawed and exploitative. Thomas Storck argues: "both socialism and capitalism are products of the European Enlightenment and are thus modernizing and anti-traditional forces.
So not to be snarky, but how is this anything more than simple "Marxism, minus the parts that don't work with Catholic religion, plus Catholic religion"?
The assertions of Distributism are that:
* Everyone has a right to private property (ad contra of Marxism)
* That right to private property is not absolute (ad contra of laissez faire capitalism)
* Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means (ad contra of if-it-is-not-100%-it-is-not-a-monopoly capitalism)
This is inspired by Catholic principles and promoted by Catholic thinkers, but it is certainly something one can come to without being Catholic.
Won't you just get run out by others who are focused on productivity and can beat you in trade and undercut your prices while delivering higher quality?
By a lot of accounts nomadic life was much better than early farm life. Didn't help the nomads in the end though.
Clumsily named, the aspects of "distributism" being lauded here only seem to involve convincing people to partly own instutitions rather than simply transacting with them as a third party. Seems to me that this reading of "distributism" is just capitalism plus a social norm of a bias toward involvement and ownership, rather than just employment and consumption.
That is Communism, not Marxism.
I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't,
comfortably boiled frogs as the record shows them.
a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
b) Your view of history is perverse, and insulting to the many people that resisted and were killed off by Lenin & Co when they took power.
Show me the scores of people taking a stand while being placed under arbitrary arrest. Yeah, sure some people resisted, a whole lot more memorable than the millions who walked with their captors straight to the grave. It's not like they didn't resist because they were bad people or something, they just had no tools to deal with any of this, who on earth did?
For the most part, you're taken by night or in transit, and they show up to dig up your trash to find your cherished letters or the wrong souvenir, you're still wondering if all the other people who were arrested did what they were accused of. What does resisting that even look like?
This was all to prove some fantasy of a man with a weak spirit and infinite capacity to look outside himself for fault; and for Lenin and Stalin it was just their ticket into town.
> a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.
I didn't say you had one, really, I said that if one were to be instituted, it seems it could only happen by force. Marx's conclusions are the fundamental source of the most inhumane behaviours of the USSR, the specifics are just gory decoration. It doesn't matter if the dissidents happen to be suppressed by genocide, imprisonment, or exile; only by suppressing the dissidents can you institute the envisioned solution. There is a considerable proportion of society which will simply not agree to have their life's work taken from them. Tell me what the important difference is between a solution which passively requires genocide, and a realized implementation of that solution.
Granted I'm underslept right now, so say whatever, I'll see it when I'm back on earth.
Communism is where all property is publicly owned and each is given what they need.
A commune is a self-reliant community, likely to be small - individuals need each other. A communist state is still a state, it is not decentralized like a commune, but very centralized. Instead of relying on each other everyone relies entirely on the state.
I am also very much in favor of distributed, self reliant communities. Yet I want to preserve the advantages of a global linked economy.
I hope that Blockchain technology will help us to achieve this.
I tried to capture some of the thought vectors here: https://gist.github.com/AndreasS2501/2dc6c5813f5fd8abc79aad4...
It doesn't clearly state how many farmers lease land, but 39% of acreage is rented.
The 98% statistic appears in the follwing item, but concerns white vs black land ownership, not rental vs. ownership:
There are Kibbutzim, full blown cooperative communities spread across the country (which were the initial backbone of the country but have decline over time). They share income depending on the Kibbutz, but some of these communities are very productive and very well off.
There are also Moshavs that aren’t quite as collective but still cooperative. Everyone in the Moshav shares a fixed piece of land in the community but production and income is controlled by the individual laborer. However, the community will still share costs together, like machinery, supplies, marketing of output.
Both are 70 year+ running models and proven to be successful no reason they can’t everywhere else.
Newman's Own is one interesting (and successful) example I can think of that's an otherwise for-profit company acting effectively as a charity. Are there papers/books about how effective this would be in practice?
Our family have been members for over 20 years. I'd rate their health care as "good", but the real benefit is that we have NEVER had a billing dispute, because almost NOTHING is "out of network". On the rare occasions we've needed non-Kaiser health care (such as ER visits while traveling), we just give the bill to Kaiser, and they take it from there.
When the insurer owns the hospitals and contracts all the doctors, customer billing is almost friction-free.
Lots of stuff: https://en.wikipedia.org/wiki/The_Co-operative_Group
Similarly, it makes more sense to have a non-profit coffee-buying employee group to buy coffee (at places that don't provide it for free) rather than pay a vendor to bring it in. But that's not because profit-making is an inherent drain on efficiency, but because the "judgment" that those profits are "buying" ... doesn't add much value.
Not only that but the healthcare industry has extraordinarily high financial and legal barriers to entry.
If there is a company with enough muscle to force themselves into the business, it's Berkshire.
Unlike Amazon and Berkshire, two of the best managed companies humanity has ever created?
> Extraordinarily high financial and legal barriers to entry
Unlike financial companies?
They already sell it: https://www.amazon.com/Professional-Medical-Supplies/b?ie=UT...
I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
You missed half of what I wrote, "instead of in 20 oversized but mostly empty boxes." The context was in a single order from a single supplier, whose product was already at the warehouse, shipping on the same date, to the same address, for the same delivery date, using the same delivery carrier, of almost identical items that almost assuredly are on the warehouse shelves right next to each other.
> I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.
That may be the case, but I am referring to the incorrect packing of boxes not trucks.
From Amazon's point of view, they're doing both correctly.
Their algorithm apparently optimises for packing completely filled tucks leaving the warehouse first, then optimises for minimal packaging second.
If they need a few more boxes of a particular size, to completely fill an outgoing truck, they will split some orders appropriately so that those boxes appear on the conveyor at the right moment.
This means that sometimes you receive an SD card in an A4 size box, because that was the only item that was available when they needed an A4 box to fill a truck - and the algorithm decided that the trade-off was worth it.
They could have arrived from the supplier in small batches (or even one-by-one) over time if it's a low-volume sort of thing. Amazon might intentionally spread them throughout the fulfillment center in some situations to expedite packing and reduce the distances their robots have to travel.
They might have just needed twenty boxes to finish the tetris puzzle to send a truck out the door.
Unrelated: one of the worst parts of insurance is the customer service quality. How does an internal, non-profit insurer staff itself to do this well? If they commit to this even at the risk of it being unprofitable, that would be most awesome —- but I’m skeptical.
But the same motive applies to co-ops. The member-owners of a co-op don't want their costs to be inflated by improper billing or inflated prices, because if they are able to reduce their expenses, then the member-owners benefit in the form of lower premiums.
In both cases, the shareholders want to get their money's worth, it's just that in the case of a for-profit company, those shareholders are often external investors, but in the case of a cooperative, all shareholders are also members.
Healthcare costs are so bad they're now a large, direct competitor to the Amazons and Berkshires and JP Morgans in a business well-being sense, as resources are finite. I like having these giants stepping up to the plate and targeting the healthcare system on cost. They tend to get their way; if a political rock (eg insurance companies) gets in the way, it'll get moved out of the way.
It reminds me of the 450 hospitals getting together to set up a not-for-profit generic drug company recently -
And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies.
Whenever I want to feel sad, I think about how the most brilliant minds of our times are probably making a fortune at such zero sum transactions as gaming the health system and tax code.
Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.
Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates.
Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D.
> Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.
This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself.
> There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
Yes, that's true. And that would be true even if you only looked at Medicare patients.
Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers.
A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance.
Medicare isn't simple, it's just a small piece of a very big shit sandwich.
This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous.
> Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich.
As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.
I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.
They are actually overlapping problems, since some of those private lines are Medicare Part C or D plans (and some are Medicaid managed care plans, and some are both Medicare Part C and Medicaid managed care plans.)
Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly.
The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.
The ACA requires insurers to spend 80% of the premiums they take in on direct healthcare costs for their members. Inflated billing and high drug costs are actually helpful if they want to make a nice big profit. To a point, at least - they've gotta find the right balance between profit and people being unable to pay their premiums.
Higher medical expenses don’t help. It only creates higher premiums, which members then blame on greed.
There are plenty of legitimate problems with providers, drug laws, and insurers. But insurers definitely don’t benefit from higher expenses.
AKA, 10% of 2 trillion is more than 10% of 1 trillion.
They are interrelated, yes. But fundamentally we are at a place where providers, especially hospitals, are billing insanely high rates for services compared to other countries.
What Americans think of as “health” “insurance” fits this model. Providers are in the business of soaking their customers the various tax-favored third-party payers for all they can. Of course prices rise continually. People are stirred into a frenzy about rising costs and demand that politicians just do something! The insurers get more tax-favored money that providers happily mop up.
Out of network means the insurer and provider have not previously negotiated a rate. And emergency services are among the most expensive bills out there.
The way to change the game in healthcare is to eject the legacy bullshit. Own the experience as a vertical, don’t accept Medicare/Medicaid and the price controls that come with it and you slice out a lot of the overheads.
Companies like Amazon know they can provide that same service- or a simplified version of it that focuses on effective treatments that don't cost a lot of money- far more cheaply, because they have willingly forgone short-term profits.
Whether this saves money and provides adequate care remains to be seen.
We joked that the meme where actuaries were being replaced by machine learning was actually just the insurer firing actuaries because they figured out they could just demand the money back from the client after a claim.
Also, the companies aren't particularly inefficient, because that gets in the way of making profit.
Are you really going to argue that for profit insurance providers are more deserving of that money?
What's next? Anarcho-Capitalism?
If you or a dependent take a very specific expensive medication that isn't covered by a plan a new employer might offer, then you pretty much can't take that job unless you want to pay out of pocket.
Employers can change the plans they offer every year as well, so really even at the same company you might face the same dilemma at the next open enrollment.
But beyond me, the fact that someone working minimum wage, unemployed, or at a startup using the Obamacare exchange pays more than an executive at a fortune 500 makes no rational sense. That's because the market has been silo-ed by employer instead of each individual insured.
The US would be in a much better state if everyone had to get their insurance from the exchange. One of the two political parties is constantly drumming the "competition" drum as a magical solution, but they're too scared to actually make the market competitive.
- Give everyone in the US a HSA (health savings account).
- Increase HSA contribution maximums significantly ($20K/year or more)
- Allow employers to give money, tax free, to employees via their HSA
- Allow employees to pay their insurance premiums via the HSA
- Ban employers from directly picking the employee's insurance or providing the insurance
- Employees (and everyone else) would pick insurance from the health insurance marketplace
- Medicaid would pay 100% of premiums, but Medicaid recipients still pick their own insurance
- The VA would move to a mixed model, help pay for regular insurance (via the HSA), and offer bespoke services specific to former enlisted personnel. Most common services would be received at regular healthcare providers, not VA hospitals.
Now instead of employers paying $1000/month for your health insurance they put that $1000 into your HSA, you then go onto the health insurance marketplace find insurance, and use your HSA to pay your premiums. Don't like your insurance company? Change. This is how you spurn competition.
Additionally if your employer doesn't help you with health benefits, you can contribute to your HSA yourself tax free and you won't be further punished (i.e. pay the same overall premium, with same tax benefits, as someone with a better employer, unlike now).
What you're describing is more open capitalism in health care where everyone is on an open playing field. I use to really believe in this at one point years ago, even when working in Health Insurance.
Today, I'm not even for this compromise. I think it should be taken out of our taxes in single payer. Insurance would still be contracted out to those private insurers (cause America). We might even be able to create a system where people chose which insurance provider they use, but it should be payed for by taxes .. it's there for everyone and everyone pays the same proportion of income and everyone gets the same level of coverage. If something is in short supply, then it's going to need a needs based + lottery system (just like organ transplants currently).
For profit and _non-for-profit_ (not to be confused with non-profits; most health care companies are non-for-profits which is a weird legal area) have no place when it comes to public welfare services. People don't pay individually for private security/police. We don't pay for fire. We don't pay a fee to visit a city park (and I'm against fee based national parks actually). The general good should be paid for equally by everyone to their abilities.
Sure they do. Rich people hire private security all the time. Heck, not-rich people do it too. Like your local Chuck E Cheese who hires a security guard on Friday night.
Same with fire protection. There are plenty of private fire protection companies.
Everyone gets those basic services paid for out of their taxes, but some people want more than basic service, and there is nothing wrong with that.
The OPs system would work great and you could modify it simply enough to account for your system too -- everyone pays a health tax, which is then redistributed as an HSA payment to every American, setting a base level of funding.
I'm actually a big fan of single payer, but not because of the social impacts, only because of the ease of administration aspects. But if you did OPs system and made sure everyone could participate, it would probably work just as well, because there would need to basically be a health payment cleaning house to make it work.
People need the health care that they need. Unless we're talking about small things like your own private bed in a hospital, there's no room in a just society for a "basic service" which does not provide the best possible care.
Unfortunately health care is still a finite resource, and you can't give everyone the best care. You either give some the best care and everyone else good care, or you give everyone pretty good care, but no one gets the best care.
Each has its merits, but my personal feeling is if no one gets "the best care", then we as a society will forget how to give such care, and medical innovation will become stagnant.
There is a reason that the health systems with at least some private participation (USA, France, Germany) also have the most innovation. We need a balance so there can still be a motive for innovation.
It's considered fair exactly the for reasons you have mentioned: you pay more for a premium product.
> there's no room in a just society for a "basic service" which does not provide the best possible care.
A regulated market that denies individual differences and enforces the same salary for different talents is incompatible with a "just society". In this case, healthcare workers with above-average talent would emigrate to a country where they can get a fair salary.
If you are worried about fairness, please consider the other side, the healthcare professional who provides the service.
Patients who pay basic fees are not entitled for the "best possible care". The provider of the "best possible care" can raise the price anytime. There is no economic justification for price rigging.
Is it unfair because it’s health care specifically or because of something else? Premium service offerings abound: priority mail delivery; first class passage; reddit gold; ongoing memberships or subscriptions to movie theaters, golf courses, publications, and podcasts; “freemium” model web services, and Amazon Prime.
… there's no room in a just society for a "basic service" which does not provide the best possible care.
Basic service and best possible care are at different ends of the spectrum for whatever good or service we’re talking about. What did you mean by this remark?
It's also a huge reason people don't want transparent health records, even in the cases where it would help automate discovery and prevention of disease.
I don't think state-based healthcare is the correct abstraction either. It involves dealing with a central organization that is too big to fail. What happens when they screw something up? What do corrupt regulations look like when lives are at stake?
If you take health care has a right (art. 25 of the Universal Declaration of Human Rights does), then there is a simple solution for the above, known as single payer. Of course, it won't work in the US, because it isn't as biased against the poor as the "free market" health care.
Medicare for all is the only sense making option, truly. Insurance doesn't make sense in the context of healthcare.
Everything else is just a half measure. Healthcare makes zero sense as a market; it is completely busted.
It's insane when you think about it from a people/citizen or a rational point of you. It's great if you are a large company because you get tremendous tax breaks for providing healthcare options and of course it heavily ties down an employee to the company.
It's why companies love H1B visas. It ties employees to the company else they get deported.
In the US, our system is so geared to capital and companies that such nonsense is allowed. Anything that gives an advantage to corporations, owners, business.
I was briefly covered by a Kaiser plan, and have a lot of old friends who are either covered, work there, or worked there, and can say people really appreciate not only the relatively low costs but also the ability to just come to one place no matter the ailment and know you'll be able to get an appointment quickly and be taken care of, and won't have to haggle to get the care you need or deal with insurance company roadblocks. To the extent there are downsides (and of course there are) they are around not being able to have your own doctor (though I do think there is an approximation of that) and overzealous cost cutting (see the kidney center scandal).
My understanding is Kaiser has not spread much beyond California due to regulatory issues.
(Interestingly, Kaiser Steel was a major setting for Atlas Shrugged.)
For simple, routine needs Kaiser really does shine. Easy appointments, quick, good staff. We recently had a baby through Kaiser and pre-natal and post-partum care as well as the actual delivery was a fantastic experience. Much more so than the experiences of my peers at other non-Kaiser hospitals. Cost is all covered in employee plan.
BUT as soon as you encounter specific issues, Kaiser breaks. I’ve had persistent GI issues and was never able to find consistent specialists on Kaiser. I also lost coverage to my therapist as Kaiser only does group therapy.
For the record, I pay the same for healthcare from UHC now and it would cover the $25k cost for the specialist because they're in the UHC network.
When my wife left her job several years ago (but post Obamacare) and needed to get insurance on the open market, her Northern California Kaiser plan was roughly the same price as her employee group plan (inclusive of employer contribution). Not too long ago my sister purchased a Kaiser Mid-Atlantic plan on the open market, which was also reasonable with nearly identical coverage to the group plans I've had.
As far I understand, Kaiser is largely an outlier regarding rough cost parity between group plans and individual plans. I'd be surprised if UHC cost the same as Kaiser for the same coverage on the open market, but if you confirm then I'll have to update my assumptions.
There's no guarantee KP won't bankrupt you, but it seems better than most.
A few years ago when I was working for a startup and had insurance through United Healthcare, I came down with a high fever and then started seeing blood in my urine on a Saturday. My only option was to go to the ER, which I did.
In the ER I had blood and urine tests, which determined that I had an infection in my kidneys. I was treated with intravenous antibiotics, and sent home a couple hours later with prescriptions for a couple more drugs to take for the next week or two.
IIRC my total bill for the 2-3 hours I was there was around $6,000, of which my insurance covered about $1500 and I was left with a $4500 bill to cover out of pocket. I remember thinking at the time that such an event would be financially catastrophic for most people - I was fortunate that I could afford it.
My wife has been with Kaiser for many years. Last year my wife started experiencing chest pains, which turned out to be pulmonary embolisms (blood clots in the lungs). She was admitted to the ER as well, where they ran some tests and got her on blood thinners. This was followed up with lung capacity tests and a few other things. Like me, she was in the ER for just a few hours, then sent home with appointments for follow-ups.
Total cost for my wife was about $50 all-in.
The magic of Kaiser is that when the insurance and the provider are both the same company, there's no dispute over pricing. There are no fights over bills, and no surprise costs that weren't covered. We have deductibles with Kaiser, but almost all services are a low fixed cost, so we don't eat into those deductibles much at all. This is not the case with other insurance companies.
In my mind the Kaiser model is what the US should have as a national health care system, that's really good at covering the 95% cases at a reasonable cost, leaving people the option to go to other providers for specialty care if needed.
Doctors aren't magicians, and they make plenty of mistakes. More to your point, no respectable doctor is going to ignore the cost and time element. Nor should he. There's no such thing as a cost-free diagnostic or procedure, even when money is no object. Even the very best doctor the world has ever seen is working with scarce time and resources; namely, his own. There's no avoiding conflicting interests and goals of some sort or another.
At the end of the day people should be choosing healthcare based on objective criteria. More importantly, our social policies should be built around objective criteria. By objective criteria Kaiser is one of the very best hospital systems in the country. There's plenty to complain about, but it's the nature of things.
Good for everyone else, I guess. :/ I ended up moving back home where the government covers my treatments.
US is a shithole country in relation to healthcare systems
Yeah with my plan I don't have access to outside doctors, so far however I didn't need them.
It wasn't until adulthood and having to navigate the fragmented world we have now, I realize how nice that was.
That and it was cheap(ish)!
I see a lot of folks praising KP in this post and it's very concerning.
When you look at how Kaiser is structured, they should be cheaper. I think they're just pocketing the difference between the market rate and what their costs are.
The whole thing is broken. A friend of mine is switching jobs and is going to forking over a third of her paycheck for COBRA until the new job enrolls her in their plan. Almost certainly, nothing will happen in that short time period, and she'll have wasted thousands of dollars. But if something did happen, and she didn't pay the extortion, sorry COBRA, she'd be up shit creek without a paddle and ruined.
You can enroll after an event and it'll be as though you had insurance the whole time. You'll have to pay for the retroactive coverage, but it's a pretty smooth way (assuming nothing happens) to avoid paying for COBRA while still technically "having coverage".
Though I think there's a time-limit on it.
This is baseless and not really possible.
Insurers must spend 80% of premiums (85% for large group plans) on providing care for their insured.
When you can game the pricing you can always just slice 80% from an ever increasing pie.
It doesn't matter how much they play with pricing on the back end, the company can't make more than 20% profit from subscriber premiums.
That's completely illegal and it's just too noticeable for them to do it large scale.
The OP was making a baseless claim because they didn't know what they were talking about, and you're now grasping at straws supporting their claim for some reason.
>I think they're just pocketing the difference between the market rate and what their costs are.
The OP had made a very specific claim about Kaiser. That Kaiser is reducing their costs but pocketing the savings and not passing them on to consumers.
I pointed out that there is no legal way for them to do that. You've made 3 posts and so far nothing you've said in anyway refutes that.
There was a huge amount of waste in the system. 15-20% is a marked improvement.
The only place where I believe Kaiser falls short and gives the impression of pinching pennies is mental health care.
(Hope you’re feeling better)
I don't know if $725/per person is good or not, but when I've looked around at other plan, I've found plans with far worse benefits (high out of pocket costs) for more money.
The issue I see is that they are very reluctant to refer you to specialists even when the issue seems way over the GPs head. And they are somewhat fast-food-ish. Go in, do whatever it needs to be done quickly, then off you go.
But still way better (and cheaper) than the competition.
That said, it is terrible when traveling. It's almost as if they don't expect people to travel for more than a week at a time.
What do people do during long term travel?
Buffet calls them a tapeworm, I call it the next, ongoing rape of the American middle class.
- I leave my last employer on July 21, 2017
- My old employer rols me off system on last day of July 2017
- On June 2017, they switch HR providers from TriNET to Namely and now the payment processor is Discovery Benefits and the Dental/Vision are now in Guardian. (So it went from Aetna to Aetna/Guardian and two other companies).
Since my wife is high-risk and I have thyroid issues, our best bet was COBRA ($1,000 / mo) because the new startup I joined did not offer group health coverage.
What followed next was this:
- The HR person who was handling my COBRA papers left during all of this. Switched jobs.
- Thanksgiving break
- Weeks of "the system will update this weekend with your information."
- "They were suppose to process your dental, but they never did"
My wife and I tried using our new AETNA IDs once we had gotten them and they still told us that it did not work. I had to have an expensive thyroid blood test pushed back. Multiple dentist appointments postponed. Everything.
FINALLY, once I got my SSN and ID for my coverage on AETNA, I had to pay back premiums all the way back to August 2017 just to keep using my coverage. So that's $4,000 USD for services I could not essentially render. $4000 of my hard-earned money. Gone. For nothing -- basically.
They had the gall to tell me (AETNA did) "Sir, if you paid for anything out of pocket during the time of your retroactive coverage, we can pay you back any cost you incurred."
The whole reason we get insurance is to avoid those high prices.
I'm so spent. I'm not an angry man but these health insurance companies really drove it home for me.
I feel taken advantaged of and it really stinks.
But only for unpredictable, irregular events. Anything else is uninsurable. If someone sells you "insurance" for wellness checkups, regular, scheduled screenings ... or tires on your car ... you can be absolutely assured that they are taking from you as much, or more, in premiums than the cost of those services.
What you are looking for is socialized, state sponsored medical care. There is no problem in looking for that and I make no value judgement here on that.
The first step would be to stop mischaracterizing this as "insurance". It's not. It can't be.
 Yes, certainly wellness checkups and things like them can be enormously economically beneficial for the provider since they spend up front preventative dollars instead of emergency, acute dollars later but it still doesn't change the fact that those are not underwriteable as they are regular, on-going expenses - very much like the tires on your car.
Now that organizations in the US have reached a breaking point, those costs are becoming clear to the consumers and they don't like it. You're absolutely right that the term insurance is bastardized in the healthcare setting, but people will have no choice but to understand.
If people want to blame somebody, they can start with the doctors union that restricts the number of residency positions open.
Good for the doctors though, at least they're smart enough to bargain in their own interest.
This might have worked if everyone was required to buy from the market place and there were no employer plans. Obama's famous "You can keep your existing health coverage" was a terrible, terrible decision.
I watched the Medicare/Medicate group for my company and they might have complained about not getting enough money, but I really think they did. Things had fixed prices and there'd be plenty of money if BlueCross didn't spend money on advertising, useless wellness programs and shitty IBM technology.
Everyone should just get Meidcare/Medicade. The government won't control healthcare, it will just get contracted out to providers. They'll have to cut costs and not waste so much money (they waste A LOT!)
Capitalism + Health care is a failed experiment. Socialized health care does work, in every high income country that's not the United States. Australia fought against the Abbot government when they wanted to introduce copays. That's right, Australians don't have doctor co-pays (they kinda do now, but wavers are in place and the plan was effectively defeated).
The fact that the US government requires us to buy private health insurance at insane rates is absolutely insane and the Supreme Court should have struck it down. You are not a car. Your body shouldn't have a fee for existing.
Additionally, lots of doctors often bill incorrectly on purpose so that a particular services/procedure gets covered, so I am not sure we should keep "justified" and "validated" in these discussions.
You generally can't negotiate in advance though, because most providers seem unable or unwilling to tell you what anything is going to cost.
We looked into ACA... but we thought that the process of switching over from AETNA to COBRA would be painless (weeks at most). So we just went through with it. We did not know it would end up like it has.
The operations for insurance is a daunting, slippery rope. Can you not lay some fault onto insurance and its operations?
What would you characterize this as? People slipping up? That's how the "system has always worked"? People forgetting to process paperwork needed so people can get to their appointments?
(But yes, admittedly, this is just pedantry.)
But if the events are rather certain, then the insurer can only act as a payment plan on the events. The risk is 100%, so at least 100% is priced into your premium (profits, a overhead, etc take it over 100).
Even covered wellness care probably comes out a bit less than it would otherwise cost, because not everyone uses it even though it's covered. Some people, like me, just don't go to the doctor.
Now, it is common for "socialized" to be a scary word. So that people try and name it other things. But you aren't spreading the risk here. You are only spreading the costs.
Well, I'd also argue that you are spreading the benefits. Which is a good thing to me. Point being, though, it is not insurance.
This is why I used wellness checks and tire changes as examples - they are regular and universal.
- Bank of America messes up my loan because the person doing my paperwork was a newbie. No biggie, right?
- Branch manager offers to fix the issue and prioritize it so that we can close in time.
- Branch manager is unable to fix it in time so offers to pay our closing costs and re-finance the loan afterwards.
- Branch manager leaves the company after our loan is completed.
- Don't qualify for re-fi because we owe more than the house is worth.
- Don't qualify for loan modification because we've never been late on our payments.
- Reported to FHA. Got in touch with local news station. Immediate response from BofA's Office of the President.
- Rep from Office of the President that was "assisting" quits 2 weeks later.
- Get another rep and they start a "forced" loan modification. Assign me another, lower rep and promise follow-up in 2 weeks.
- Repeat ad nauseum until I literally can't even and decide to foreclose because it's such a cluster.
Your last few sentences really strike a chord here. I totally feel for you.
I don't understand why it should take days to "update" a system. Now, I now next to nothing about how their current system works but information updated should not take so long.
The insurance industry needs a technological overhaul but I doubt it will happen.
This was back in the early 2000's just before the actual market crash. It was insane to me that banks were willing to work with people that bought houses they couldn't afford but that they wouldn't work with me on a loan modification because I wasn't delinquent.
Edit: And great that there might be a new value conscious private competitor out there - but I'd note that all those other developed nations that are individually, collectively, and vastly outperforming our health system all have some form of government control on drug and procedure prices. And a single private company would be very hard pressed to replicate the negotiation leverage of a government. I'd also note that I'd trust JPMorgan about nil to be concerned about customer value over company profits. Other nations have a health system, and at the end of the day we have a health market.
The numbers are small by world standards but I guess the drug companies are paranoid of this idea catching on in, say the US.
I’m sure it will be regarded as communism, but hey, it makes the market actually work for us here.
But the I continuously got the "we have you down for this provider" when my COBRA admin told me that that provider could no longer give me coverage. I needed to AETNA to file me under a new provider.
Then I called AETNA and they still said "so and so" is listed as my provider. I told them to change it. "It's gonna be at least a week to update your information, sir."
Call back next week, "sir, you are still listed on 'so and so' provider."
It was exhausting.
edit: but the thing was, I trust them to give me good advice. The HR providers. I figured, well if they haven't said anything about deferred payments, it might not be applicable to my situation so I never brought it up...
I am also high-risk and have always found that the Obamacare market had prices close to or lower than the unsubsidized cost of an employer provided plan.
The most frustrating for me is that the doctors can't even guess how much their facility will charge for the treatment they decide is necessary, much less how much the bill will be after insurance gets their cut. It is a major barrier for me to get MRIs and blood tests. Especially blood tests, which seem to range in cost from practically free to thousands of dollars for a single blood test panel.
It's infuriating, and no matter how closely I read the insurance fine print I still cannot guess what the hospital and insurance plan negotiated ahead of time. Kaiser was way better, at least there the incentives were aligned to sane billing procedures.
Have you been able to find a workable alternative or are you still stuck with AETNA?
They can't fix the entire HC market, but they can have a great start.
This is why I believe single payer healthcare is generally the best solution.
However, in the current situation, I think this idea to create a healthcare company dedicated to serving their employees, "free from profit-making incentives and constraints," is a great idea, one which I hope others will attempt if it ends up a success.
What i’d love to see is a commercial business having vertical integration. Insanely cheap basics like X-rays, mris, and other checks. Heavy use of AI based diagnosis confirmed by doctors, and a big insurance pool where profits go back into scaling healthcare.
Basically current American healthcare is not scalable. Period.
I'm not too sure about that. It's taken an entire year for the GOP to start to actually succeed at chipping away at the ACA, and they have legislative and executive control. If we could get sweeping reform in a more favorable political climate, something not plagued with the implementation issues the ACA has labored under, it might stand a chance. The next administration might find it politically untenable to take it away if it actually works well.
You just might not have the option of telling someone it's 10 grand (with ridiculous profit margins) to get an earlier diagnosis and a chance at actually living.
Another true story, even with a Health Care provider and insurance company I don’t hate: after a routine visit, I had to spend more time on the phone with both of them than I spent in front of the Dr In order to have the service code corrected so the payment would count towards my deductible. The administrators I had to work with are paid employees, their costs not only have to be covered, but profitable. Very polite, capable and professional and completely unnecessary. I dare any non-American to come into our system and figure out in-network vs. out of network, co-payment, co-insurance, personal deductibles, family deductibles, lifetime maximums, deductible vs. non deductible services... and then write an App that compares plans, even within the same insurer’s portfolio and tells me which is the better plan.
Intentional value obfuscation, unnecessarily complex, adds to the bottom line.
Fortunately we have the option of publicly funded health care here in Europe which is what she recommends for anything serious.
If I profit off of you being sick, then I need to keep you sick.
But this has other problems. Incentives are tricky.
The downside I was hinting at is that as a patient, cutting costs isn't always what you want. If it means more prevention or paying less, it's good. Otherwise it'll probably mean worse service.
They profit much more if you pay them money but never use their service.
Healthcare should be nationalized. Then the government would also have other positive incentives meant to lower healthcare costs, like reducing pollution, sugar in foods, other dangerous foods on the market, and so on.
I mean if you want to make an anti-capitalist argument on a message board owned by a venture capital firm, feel free. But by definition "profit = good"
There's an entire college course called Philosophy I that basically goes over 7 to 10 different moral compasses. The only one that seems to win out (aka the only one people remember after the class is Moral Relativism).
They know all their companies will earn more money if there is more money in everyone’s pockets. Look at how much some people are spending per year on healthcare. Someone in this thread mentioned $30k for his family in a year just for insurance. If he even saved a third of that, it’d end up being spent somewhere. A good economy benefits all those big companies. The losers in this are the healthcare companies.
Amazon might decide to make their own networking hardware or their own power generation for their datacenters to save money, but they spend more money on headcount than on datacenters, and a huge chunk of the headcount expense goes to health insurance companies.
As long as this company doesn’t go public, it seems like it will be able to stay away from that. It will be extremely competitive against companies trying to raise profits.
You can always hope for the best so let's see what happens. Looking at the American health system I am not very optimistic.
Berkshire is a holding company, all the not so nice decisions are made by the CEOs of the companies Berkshire owns.
Berkshire has never paid a dime of dividends to anybody.
That’s a great thing.
What's your next premise?
I'm not evaluating Buffett either way with that statement, just pointing out that it is possible and probably necessary to evaluate his behavior without giving consideration to his pledge.
Most people used to do both at the same time and it seemed to work pretty well before Buffett came along. And there's a good analogy to your last point - someone who rents an apartment for 40 years when they could have bought an equivalently valued home two times over. They shouldn't complain when they die with a net worth of zero, they had a roof over their head for 40 years!
Also, mutual policy holders don't "overpay" for insurance as all dividends are returned to them. Only a private insurance company policy holder could overpay. Just thinking about it now, Buffett wouldn't be so rich if his policy holders weren't overpaying, as you're implying.
Fortunately they have plenty of lobbyist which can be put to good use.
Some people might not be aware that the vast majority of large employers in the U.S. that offer health insurance are self funded (i.e. they collect premiums from themselves/employees and take on all the insurance risk), so anything they can do to lower any direct/indirect cost with plan administration, claims, drug cost (big one), healthcare utilization, etc. will save them billions easily.
>Only about 26 percent of employers with between 100 and 499 employees self-insure, compared with more than 82 percent of employers with 500 or more employees, according to data from the U.S. Department of Health and Human Services.
That being said, they don't usually take on ALL the insurance risk, they typically purchase stop gap insurance for very large claims.
Something can be good for the bottom line and good for society. It’s not one or the other!
"Has seen me in the past" and "has my charts" are not indicative of medical efficacy. There are doctors I have rapport with, absolutely. I still have lunch occasionally with the physician who was my family doctor as a child and still sees my parents. But that doesn't mean his medical treatment is going to be any better than a doctor seeing me for the second or third time.
They always says it hurts the patient's care. I think there is some truth to both sides, but we'll probably never know. Too many people are making out like bandits in the current health care system.
edit: This (quite extensive and longitudinal) study would suggest that it's true. Check out the sources on the paper for other studies with similar findings:
We truly live in the darkest timeline.
Obviously the ideal would be you have a system that accommodates "my kid has a fever/fell out of a tree and broke their arm" majority of medical issues who could be helped by basically anyone trained in basic medicine while also accommodating people who need a rapport with a highly trained/expensive specialist.
That's how I took the comment...apologies in advance if this comes off as insensitive to your condition, definitely not my intention.
Not really. I want someone I can trust. For my primary care needs, I have established trust with someone and know their capabilities, their business practices, and their character. I don't want to roll the dice with someone new when I can still go to them.
Example 1: My primary care provider(been seeing him for 10 years.
Example 2: My dentist (been seeing him or his predecessor for 30 years)
It sounded more like fitbit with cloud services than insurance.
If there are healthcare providers involved giving direct healthcare, there will need to be systems and development around medical records. That could easily be sold as a product to hospitals and providers outside of the AMZN/JPM/BRK company down the road.
Taking a "beginner's mindset" to me sounds like they plan on writing their own stuff, except for interoperation like HL7, which is great because most of the stuff from EPIC/Allscripts/Cerner is drowning in technical debt.
I believe it's initially for the employees of those companies. If they can make it work for them, they have a great team (ecommerce, finance, insurance) to back a larger rollout. The announcement says it's about providing healthcare at lower cost with better results, which sounds like a lot more than wearables.
The biggest problem I see are the costs. The healthcare industry can't even tell you why costs differ on so many levels of services. The industry isn't transparent and they'll fight this because it's too profitable for them.
Repeal EMTALA. No patents. No certificates of need. Make Medicare and Medicaid fully opt in for providers. Create a path for additional private organizations to certify medical schools.
Anyone refusing to do all that stuff and face the political consequences for it just wants to pay less taxes.
Healthcare is a horribly overexpensive market precisely because of those things you mentioned.
It's the age old question, who is a better person to make decisions for yourself, you yourself, or some person somewhere that believes they know better what is best for you in your particular set of circumstances. Some call it communism, some marxism, some authoritarianism, some totalitarianism ... but ultimately they are simply differing degrees and characteristics of the same question ... who controls your life?
If the government has no place simplifying the process of buying insurance (by making sure products are available, comparable and reliable), then the government has no place protecting people from legal consequences related to their investments.
Your naked partisanship is ugly and unhelpful.
The many healthcare systems generally described as "socialist" are more cost-efficient than the American system.