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Amazon, Berkshire, JPMorgan to Create Healthcare Company (bloomberg.com)
1070 points by uptown on Jan 30, 2018 | hide | past | web | favorite | 520 comments

> The three companies said they plan to set up a new independent company "that is free from profit-making incentives and constraints."

I wonder if they will be setting it up as a health insurance cooperative, an organizational structure in which the primary goal is to serve its members, rather than to generate value for external shareholders: https://en.wikipedia.org/wiki/Health_insurance_cooperative

It's not at all unprecedented for publicly traded companies to create cooperatives for their employees. Employee credit unions are one example.

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.

> distributism

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.

This is a type of utopia that many of us yearn for, but never appears to have worked at the level of large nation-states. I mean, here are some things that are not taken into account:

- People who can not work because they simply can't hold down a job, period.

- Externalities such as neighboring (or even distant) communes dumping wastewater into rivers etc., or polluting the ground, or air... you get the idea. What about natural calamities, such as earthquakes, tsunamis, volcanic eruptions, and such?

- Conflicts over scarce resources. Water, for example. Communes that rely on a common source of water will likely have conflicts. How are they resolved?

- Any commune is exceedingly unlikely to be good at producing all the things it needs. Trade will need to develop. Does 'self-reliance' exclude the possibility of trade?

- How large should a commune be, to enable innovation? Without innovation, there will be stagnation that will harm the commune in the long run.

- How would a commune handle people that are 'different'? How about criminals within and without?

Probably best to distinguish between "self-reliant economically, but connected to the world economy" vs "closed system". Trying to be self-reliant in terms of physical inputs doesn't work in the oil age. Whereas the various small and micro-states manage to be economically self-reliant while importing staples.

I don't think distributism requires a closed system.

How familiar are you with distributism? It certainly does not advocate for communes! Distributism is merely an (admittedly aspirational) economic system where the ownership of productive property is widespread.

A few of its guiding principles may answer your concerns:

* Subsidiarity teaches that things should be handled at the lowest or least centralized level that is competent to handle them. That doesn't mean that small organizations should be expected to bite off more than they could handle. It may very well be that a giant, multinational corporation is the lowest-sized organization that can handle operating something like an airline, and that is not inconsistent with distributist principles.

* Distributism, as an economic system, is not at all incompatible with things like a strong social safety net. However, it is worth pointing out that if the ownership of productive property were to become more widespread, the need for such a safety net would be decreased.

This is not at the expense of the large nation state, it just limits the power of the nation, preferring to push down the responsibilities to the lowest level possible, rather than aggregating up the moment that any benefits can be found from that aggregation.

We live in a world where (to quote GKC [1]):

> Lancashire merchants whenever they like > Can water the beer of a man in Klondike > Or poison the meat of a man in Bombay; > And that is the meaning of Empire Day.

The advantage of centralization is that we can stop the poisoning all at once (because there is only one place doing the poisoning). However, when the meat is poisoned many more people suffer food poisoning than would if the food packaging were distributed.

  [1]: http://www.gkc.org.uk/gkc/books/Songs_of_Education125.html

Why is this form of self-reliance a virtue? To me, it looks pathological; certainly not something we should collectively be working towards.

I'm upvoting you just for engaging in this conversation, even though I thoroughly disagree with you. :-)

The "distributism" described above is the dream of virtually every rural community. People choose to live in rural communities because it's a little piece of heaven for them: they are surrounded by people they know, they have clean air, the earth is right beneath their feet, the stars are bright, the pace is slow, and so on. They want to serve their neighbors and receive services from their neighbors. How is that mindset pathological?

I am always encouraged by innovations that help rural folks be more self-reliant so they can work toward their dream of self-sustaining, independent communities.

The problem is that a small community can’t develop or even maintain advanced technology, including that required for sanitation and healthcare.

So, you either choose total independence and low technology or interdependence with other groups and advanced tech.

Certainly. There will always be interdependence and rural communities understand that; that's why they drive modern pickup trucks rather than horse-drawn carriages. Still, they are always looking for ways to reduce their dependence on cities.

Distributism includes the principle of subsidiarity, it doesn't exclude the fact that you need large organisations to produce some technology, just that you should tend towards the smallest organisation that can achieve what you need. Capitalism seems to be tending towards the opposite where the winner takes all.

Well, at least until we reach the science fiction utopian dream of nanoassemblers that can make nanoassemblers. Then rural communities could truly be independent.

Although that independence would be like a group of proto humans that knew about fire and how to use it, but not how to make it, and thus carefully guarded it and kept it fed, lest it go out.

Do you think that we'll be able to escape making this tradeoff in the future? I don't think it's unreasonable to think that sanitation and healthcare technology will advance to the point that they can be implemented in smaller communities at similar levels of quality that could be seen in big cities.

I hope we will have healthcare services that don’t require advanced knowledge or infrastructure to operate, but we’ll still need advanced tech to produce them.

I don’t see a way around this, since you always have to start from the same raw materials.

Wouldn't it also be possible to see that as rural residents putting on a brave face? The general trend has been towards urbanization globally for the past century or more, and relatively few young people growing up in rural communities seem to be interested in staying in them in the US[1].

1: https://www.bloomberg.com/view/articles/2017-06-20/rural-ame...

That's not true. Almost every person I know in my generation is working hard to buy a piece of land in a rural community.

While your experience might tell you that the reality is that is simply not true. You're countering a statistically sourced statement with an anecdote.

There are two actually statistics underlying the discussion here, and from my reading both points are right (though disagreeing that we're urbanizing is incorrect)...

1) Our general trend is towards urbanization, humanity is now more urban than rural, and every quality of life index shows cities give more good to more people better.

2) Millennials, hipsters in particular, in American markets with crushing real estate prices have recently begun reverse-migrating away from the cities and to more rural areas with romanticized lifestyles creating some new demographic, and real estate, trends.

In terms of pure statistics we're looking at a sub-group with a different trend than the overall group. Most potatos aren't from my backyard, but those potatoes are only getting prettier while the many thousands at the market are getting uglier ;)

I'm totally in the camp who wants to move back to the Midwest and buy some acreage- my point was mainly that the person I responded to flat out stated that the parent commenter was wrong which is not the case.

Statistical significance aside, blanket statements such as what I responded to are simple, not true when compared to reality. I do not believe that humans can be unbiased when interrupting data to form a conclusive hypothesis. This is why the scientific community has a peer-review process to filter out biases.

However, I will agree that my initial response was lacking and would have been better if not stated at all.


And every person I know in my generation is working hard to buy a flat in a major urban center. The plural of anecdote is not data.

Isn't that just a reflection of where jobs are, which is in turn a reflection of our increasing specialisation. I know there are almost no jobs for computer science graduates within ten miles of the village I live in. The choice is to move to the city or work in the local supermarket.

Too many bad actors involved to have a clear sight. Better to start from a clean slate.

Reducing interdependence in human society mitigates systemic risk. It absolutely is a virtue to be collectively working towards.

Systemic risk reduction is one effect of reducing interdependence. What are the others? On balance, are they net-negative or net-positive?

I can't say if it's better or not, but we do know that human organizations function poorly at scale. The larger the group, the more difficult it is to communicate, the easier it is to feel powerless, the more the problems of a large chunk of the group are remote and abstract (and thus ignored/missed/downplayed/deprioritized)

I suspect that you also have more corruption and/or abuse of power because (a) the previous entries all empower sociopathic individuals, (b) you have a larger pool from which to find such sociopaths, and (c) you have more positions of power for said sociopaths to fill.

You have all of these problems in small groups, but many of our policing/accountability systems don't function well in very large groups.

I'm not sure any of your claims are backed up by data. Is our larger society more corrupt? Is it more difficult to communicate?

I could just as easily argue that smaller, more insular groups promote distrust of outsiders and lack of empathy, which might lead to more wars. I have no idea if that's true, but it sounds plausible to me.

In the end, actually examining data is what's needed. Until there are facts to assess, we're just spouting wild conjecture.

> I'm not sure any of your claims are backed up by data.

https://en.wikipedia.org/wiki/Dunbar%27s_number has a decent collection of the research I know of. There is a little hand-waving involved when it comes to "why", but it's notable that multiple researchers over decades disagree about the number, not the base concept. Likewise, studies related to the base concept of the non-technical Brooks Law support the non-linear impact on communication as a group grows (off hand I can't find a study on that, but I know I've read of multiple).

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.

> The corruption/abuse item is not part of the research, which is why I separated that as "I suspect"

My main point was that the theory was labeled as something you suspect, but the evidence you listed to back up that theory sounded like it was being presented as fact. You've provided resources to back up the claim, at least to some degree (as you note), which is what I was looking for, so thanks. :)

> You could, and I'd actually be interested to see any research on the topic because I've not thought about that one but it does match our general experiences about exposure and tolerance to social differences.

I don't have any, but I also would be interested to see it. I was using it as an example of something that sounded true and that I suspected was true that I had no real evidence of, and thus should be hesitant to assert as true. Unfortunately, by its nature that makes it interesting to a certain type of person, so it ends up teasing us. :/

> [people] can be self reliant and exist without jobs from corporations, or help from the state. Naturally people would organise as a cooperative or a market of services, exchanging services for services, because they have little money and no corporate jobs. Yet they can work, so they can create a kindergarten for children of the neighbourhood, or a medical clinic, or a mechanic repair-shop, or a construction company, and so on.

How is that self-reliant? It’s different from most of the current developed economies, but it’s still division of labour and relying on others for some things.

> There is no purpose to automation that does not exist in the service of humanity at large, but only for a few.

There certainly is, to the few that are served. Increased productivity that doesn't require manpower/hours has been captured for centuries.

A capitalist economy provides many incentives to privately hold productivity gains from automation, while providing virtually none to relinquish them to the public.

The earth can't physically support the existing human population without great cooperative ventures such as the production of electricity and nitrogen fertilizer. It can't support life at anywhere close to the present day level of prosperity without additional great ventures such as transportation, medicine, telecommunications, money systems, and electronics manufacturing. All known means of operating those ventures depend on the state, including the entitlements granted to corporations.

Giving up these ventures would require such a massive reduction to the quantity and quality of human life, that it would be unacceptable to the vast majority of people.

The Haber process ended humanity's hopes of creating a society based on self reliance.

By every possible quality of life metric, things have been getting better and better for humans.

People have predicted the population bomb many times for hundreds of years, and every time they have been wrong.

Scientists predict human population to peak in 2040 anyway. I think that we can make it till then.

The world supports the current population quite well, right now.

I hope I wasn't predicting a population bomb. What I was suggesting was that the existing population level is sustained by organized human activity at a scale that can't be managed by independent individuals or small groups. Thus a proposed restructuring of society requires a credible plan for maintaining or replacing some specific activities such as the Haber process.

> Distributism (also known as distributionism or distributivism) is an economic ideology that developed in Europe in the late 19th and early 20th century based upon the principles of Catholic social teaching, especially the teachings of Pope Leo XIII in his encyclical Rerum novarum and Pope Pius XI in Quadragesimo anno.

> According to distributists, property ownership is a fundamental right, and the means of production should be spread as widely as possible, rather than being centralized under the control of the state (state capitalism), a few individuals (plutocracy), or corporations (corporatocracy). Distributism, therefore, advocates a society marked by widespread property ownership.

> Distributism has often been described in opposition to both socialism and capitalism, which distributists see as equally flawed and exploitative. Thomas Storck argues: "both socialism and capitalism are products of the European Enlightenment and are thus modernizing and anti-traditional forces.


So not to be snarky, but how is this anything more than simple "Marxism, minus the parts that don't work with Catholic religion, plus Catholic religion"?

Properly understood, Distributism is capitalism limited by an understanding of the purpose of capital. Just as there is no mathematical system that can prove all of its first principles, so there is no system of capital that can within itself articulate a just distribution of that capital.

The assertions of Distributism are that:

* Everyone has a right to private property (ad contra of Marxism) * That right to private property is not absolute (ad contra of laissez faire capitalism) * Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means (ad contra of if-it-is-not-100%-it-is-not-a-monopoly capitalism)

This is inspired by Catholic principles and promoted by Catholic thinkers, but it is certainly something one can come to without being Catholic.

>Laws should aim for the maximum distribution of the means of production, rather than the optimal throughput of productivity possible with those means

Won't you just get run out by others who are focused on productivity and can beat you in trade and undercut your prices while delivering higher quality?

By a lot of accounts nomadic life was much better than early farm life. Didn't help the nomads in the end though.

Shared ownership vs individual ownership, I think?

Well, achieving the Marxist utopia involves forcing the genuine owners of capital goods ("the means of production") to surrender those to the state, in practice usually requiring imprisonment, execution, and initially a certain amount of genocide to avoid revolt.

Clumsily named, the aspects of "distributism" being lauded here only seem to involve convincing people to partly own instutitions rather than simply transacting with them as a third party. Seems to me that this reading of "distributism" is just capitalism plus a social norm of a bias toward involvement and ownership, rather than just employment and consumption.

> Well, achieving the Marxist utopia involves forcing the genuine owners of capital goods ("the means of production") to surrender those to the state, in practice usually requiring imprisonment, execution, and initially a certain amount of genocide to avoid revolt.

That is Communism, not Marxism.

No, it's the Marxist part that makes it not work, doesn't matter which inspired party adds their flavour. If you want Marx's society (not saying his analysis, especially of his surroundings, was wholely incorrect), it can only be had by force.

I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't, comfortably boiled frogs as the record shows them.

> I challenge you to convince me to willingly join in your Marxian ideal, until then I will fight it when it comes to my door, like so many in the USSR understandably didn't, comfortably boiled frogs as the record shows them.

a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.

b) Your view of history is perverse, and insulting to the many people that resisted and were killed off by Lenin & Co when they took power.

> the many people that resisted and were killed off by Lenin & Co when they took power.

Show me the scores of people taking a stand while being placed under arbitrary arrest. Yeah, sure some people resisted, a whole lot more memorable than the millions who walked with their captors straight to the grave. It's not like they didn't resist because they were bad people or something, they just had no tools to deal with any of this, who on earth did?

For the most part, you're taken by night or in transit, and they show up to dig up your trash to find your cherished letters or the wrong souvenir, you're still wondering if all the other people who were arrested did what they were accused of. What does resisting that even look like?

This was all to prove some fantasy of a man with a weak spirit and infinite capacity to look outside himself for fault; and for Lenin and Stalin it was just their ticket into town.

> a) I don't have a Marxist ideal, don't put yourself in a defensive position against an antagonist that is not there. I just don't mix up Marxist economic theory with Communism and Leninism.

I didn't say you had one, really, I said that if one were to be instituted, it seems it could only happen by force. Marx's conclusions are the fundamental source of the most inhumane behaviours of the USSR, the specifics are just gory decoration. It doesn't matter if the dissidents happen to be suppressed by genocide, imprisonment, or exile; only by suppressing the dissidents can you institute the envisioned solution. There is a considerable proportion of society which will simply not agree to have their life's work taken from them. Tell me what the important difference is between a solution which passively requires genocide, and a realized implementation of that solution.

Granted I'm underslept right now, so say whatever, I'll see it when I'm back on earth.

This already exists, and is in many ways a form of communism. Take a look at kibutz's in israel.

I think GP is referencing a type of Commune, where potentially services, possessions, and responsibilities are shared amongst those who live there. America has had communes as well

Communism is where all property is publicly owned and each is given what they need.

A commune is a self-reliant community, likely to be small - individuals need each other. A communist state is still a state, it is not decentralized like a commune, but very centralized. Instead of relying on each other everyone relies entirely on the state.

From a certain perspective I agree, and though I am a free market capitalist to my core, the free market doesn't preclude an organization behaving in a communist fashion; the free market simply doesn't require it. I very much encourage things like this.

You see it in my locality, none of the local farmers own their harvesting machines, as a group they own the machinery collectively. This is still a long way from communism though.

It's interesting to see your thoughts on UBI, how you connect it necessarily to the state. I think this doesn't have to be the case: https://joincircles.net

I am also very much in favor of distributed, self reliant communities. Yet I want to preserve the advantages of a global linked economy.

I hope that Blockchain technology will help us to achieve this.

I tried to capture some of the thought vectors here: https://gist.github.com/AndreasS2501/2dc6c5813f5fd8abc79aad4...

The problem is around 98% of farmers have to lease their land. Most farmland in the US is owned by a handful of people.

Really want to see a source on this one.

Not sure this fully backs the statistic above, but a detailed USDA report:


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:


This system already exists in Israel.

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.

This is something I've been thinking about for a while - what would insurance companies (and even other companies in every vertical) look like with some incentive other than profit? Paying good salaries is one thing, but doing it for the sake of external shareholders is a different case.

Newman's Own is one interesting (and successful) example I can think of that's an otherwise for-profit company acting effectively as a charity. Are there papers/books about how effective this would be in practice?

From ehealthinsurance.com: Kaiser Permanente is composed of Kaiser Foundation Health Plans (nonprofit, public-benefit corporations), Kaiser Foundation Hospitals (a nonprofit, public-benefit corporation), and the Permanente Medical Groups (for-profit professional organizations).

Our family have been members for over 20 years. I'd rate their health care as "good", but the real benefit is that we have NEVER had a billing dispute, because almost NOTHING is "out of network". On the rare occasions we've needed non-Kaiser health care (such as ER visits while traveling), we just give the bill to Kaiser, and they take it from there.

When the insurer owns the hospitals and contracts all the doctors, customer billing is almost friction-free.

Not only that, but Kaiser Permanente was formed for similar reasons. It was to provide healthcare for the employees of the Kaiser shipyards, a major industrial employer.

I would think the actual care would be the highest priority for most people. These companies are so closely watched that billing disputes are extremely rare.

I'm at a cooperative nonprofit insurance company - https://en.wikipedia.org/wiki/Univ%C3%A9 - basically, it's cheaper and nicer.

Perhaps Vanguard is an example of a mass mutual company that owes part of its success through its formation due to its ability to pass cost savings back to its customers in the form of lower fund fees?

My personal (unproven) theory is that the non-profit model works well for ventures that require very little entrepreneurial judgment, but poorly otherwise. Vanguard basically follows that: they mainly sell index funds, which a well-trained monkey can run.

Similarly, it makes more sense to have a non-profit coffee-buying employee group to buy coffee (at places that don't provide it for free) rather than pay a vendor to bring it in. But that's not because profit-making is an inherent drain on efficiency, but because the "judgment" that those profits are "buying" ... doesn't add much value.

Vanguard took decades to gain any traction and it was managed well enough to ensure it didn't prematurely burn out, and not only that but Jack Bogle spent his entire life evangelizing low-cost in an environment where "cost is no object" was a common mantra.

Not only that but the healthcare industry has extraordinarily high financial and legal barriers to entry.

>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.

Considering their already extensive ground in insurance and JP Morgan's financial acuity, Amazon is in good hands. I know I'm hoping they encounter some success.

> Managed well enough

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?

There are extraordinarily high expectations in the finance industry but the only barriers are regulatory compliance (with regards to fiduciary duty) and convincing people to throw money at you.

USAA would be a classic example

Absolutely. So based on what I know their financial products and customer service is awesome but I doubt if it comes at a price which is lower than the market (even after considering what they give back to its members).

Their insurance risk pool is far more favorable - those in the military are generally more healthy than the general population, and they have pretty much guaranteed income.

I think you may be thinking about Effective Altruism conceptually but from a corporate rather than individual angle.

This feels like a setup for a broader push into healthcare by these companies. The sector is still growing, Amazon is already working out the pharmacy space. "[F]ree from profit-making incentives and constraints" sounds like the strategy they've used so far to dominate sections of online retail.

I have some medical supplies that Amazon will sell me without a prescription. I used them last time because I neglected to order far enough ahead of time, and the game of tag between my doctor and my pharmacy would have taken too long - Amazon Prime to the rescue! Today I pick up a new prescription at my pharmacy, and I'm curious to know if my insurance copay is less than what Amazon charged. I'm guessing it could go 50-50 either way.

The verdict is in. Amazon with free Prime shipping: $18.90. CVS insurance co-pay: $22.50.

They can tackle profit from other angles - sell medical supplies, etc.

I think it would be irresponsible at best for Amazon to tackle the medical supply/device market before they can get their counterfeiting problem under control.

Presumably they wouldn't allow literally-anybody comingled inventory for that. It's trivial for them to regulate requiring first party or trusted party sales for that.

They already sell it: https://www.amazon.com/Professional-Medical-Supplies/b?ie=UT...

It would be irresponsible at best for Amazon to tackle the medical supply/device market before they can learn to ship 20 items from the same fulfillment center on the same day in the same box instead of in 20 oversized but mostly empty boxes.

Fulfillment centers are large enough that shipping them in individual boxes may actually be the cost-effective method at times.

I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.

> Fulfillment centers are large enough that shipping them in individual boxes may actually be the cost-effective method at times.

You missed half of what I wrote, "instead of in 20 oversized but mostly empty boxes." The context was in a single order from a single supplier, whose product was already at the warehouse, shipping on the same date, to the same address, for the same delivery date, using the same delivery carrier, of almost identical items that almost assuredly are on the warehouse shelves right next to each other.

> I've also heard they play a bit of a game of tetris to fill truck trailers in a way that completely stuffs them full enough that packages don't move around.

That may be the case, but I am referring to the incorrect packing of boxes not trucks.

> incorrectly packing 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.

Hard to say without knowing the supplier's volume, the nature of the products, etc., but it's entirely possible given the nature of Amazon's warehouses that those "almost identical items" could be scattered all over.

They could have arrived from the supplier in small batches (or even one-by-one) over time if it's a low-volume sort of thing. Amazon might intentionally spread them throughout the fulfillment center in some situations to expedite packing and reduce the distances their robots have to travel.

They might have just needed twenty boxes to finish the tetris puzzle to send a truck out the door.

It may not be incorrect. It seems that if it was significantly affecting their bottom line it’d be a low-hanging optimization that they’d have tackled by now. FWIW this issue infuriates me also - to a degree

One of the benefits a profit motive brings to insurance companies is pushing back on improper billing by providers (doctors/hospitals) and negotiating lowest possible care and drug rates. Tech-focused insurers like Oscar also invest heavily to help guide members toward better care paths, which if done well lead to better care at less expense (for both the member and insurer).

Unrelated: one of the worst parts of insurance is the customer service quality. How does an internal, non-profit insurer staff itself to do this well? If they commit to this even at the risk of it being unprofitable, that would be most awesome —- but I’m skeptical.

You're correct that a profit motive leads for-profit health insurance companies to push back on improper billing and negotiate prices, because whatever profit they are able to eek out goes to its shareholders.

But the same motive applies to co-ops. The member-owners of a co-op don't want their costs to be inflated by improper billing or inflated prices, because if they are able to reduce their expenses, then the member-owners benefit in the form of lower premiums.

In both cases, the shareholders want to get their money's worth, it's just that in the case of a for-profit company, those shareholders are often external investors, but in the case of a cooperative, all shareholders are also members.

For companies like Amazon, JP Morgan, Berkshire, it's blatantly clear they have a massive financial incentive to beat down the run-away cost of healthcare. They've got a million employees all up and down the economic tiers. It's a very big boon to their business, to have a smaller share of cost going into healthcare, where they can instead redirect that money into eg competing for labor with higher wages (especially relevant with the U3 at 4.1%).

Healthcare costs are so bad they're now a large, direct competitor to the Amazons and Berkshires and JP Morgans in a business well-being sense, as resources are finite. I like having these giants stepping up to the plate and targeting the healthcare system on cost. They tend to get their way; if a political rock (eg insurance companies) gets in the way, it'll get moved out of the way.

It reminds me of the 450 hospitals getting together to set up a not-for-profit generic drug company recently -


> One of the benefits a profit motive brings to insurance companies is pushing back on improper billing by providers

And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies.

I think the causality flows the other way: the system being so complicated to navigate creates huge barriers to entry, which result in huge profits for whoever can navigate the whole system.

Whenever I want to feel sad, I think about how the most brilliant minds of our times are probably making a fortune at such zero sum transactions as gaming the health system and tax code.

> And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies.

Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.

Medicare is relatively simple compared to most insurance companies and their rules.

Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates.

Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.

The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.

> Medicare is relatively simple compared to most insurance companies and their rules.

As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D.

> Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on.

This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself.

> There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.

Yes, that's true. And that would be true even if you only looked at Medicare patients.

It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare.

Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers.

A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance.

Medicare isn't simple, it's just a small piece of a very big shit sandwich.

> A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar.

This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous.

> Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich.

As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.

This thread reads like you two are talking past each other, are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?

> are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?

I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.


> It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare.

They are actually overlapping problems, since some of those private lines are Medicare Part C or D plans (and some are Medicaid managed care plans, and some are both Medicare Part C and Medicaid managed care plans.)

> Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.

Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly.

The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.

> One of the benefits a profit motive brings to insurance companies is pushing back on improper billing by providers (doctors/hospitals) and negotiating lowest possible care and drug rates.

The ACA requires insurers to spend 80% of the premiums they take in on direct healthcare costs for their members. Inflated billing and high drug costs are actually helpful if they want to make a nice big profit. To a point, at least - they've gotta find the right balance between profit and people being unable to pay their premiums.

That only applies to the individual market, not employer insurance (small and large group.

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.

Actually systemic higher costs do help. An older industry analysis found insurance to be competitive so they only way to grow profits for the industry was to grow costs. The trick is for insurance companies to find ways to get other insurance companies to pay more even if they have to also carry those costs.

AKA, 10% of 2 trillion is more than 10% of 1 trillion.

This is diametrically opposed to the facts. People need to stop making arguments like this about profit driven insurance when our system has the US spend the most per capita amongst modern nations with mediocre results.

That’s in large part because the costs of healthcare are crazy high, not the cost of insurance.

They are interrelated, yes. But fundamentally we are at a place where providers, especially hospitals, are billing insanely high rates for services compared to other countries.

It's nutty to me that yours is the first comment that I'm reading in this thread that has mentioned that. The provider part of this shit sandwich (to steal a phrase used elsewhere in this thread) is by far the more problematic piece.

When you use a service without paying for it (e.g., television, radio, Yoogle, Facepage, and so on), you are not the customer but the vector to get to the real customer who is paying. No, buying a TV or paying your ISP is not paying for the services you are accessing.

What Americans think of as “health” “insurance” fits this model. Providers are in the business of soaking their customers the various tax-favored third-party payers for all they can. Of course prices rise continually. People are stirred into a frenzy about rising costs and demand that politicians just do something! The insurers get more tax-favored money that providers happily mop up.

Medicare is also more expensive per capita than most modern nations and its publicly funded.

A non-profit ensurer staffs itself to have high quality customer service by pushing back on improper billing by providers and instead of returning that savings to its members investing it into higher quality employees, more training, and better systems to ensure that hospitality is a paramount concern.

Not always - the other way to mitigate billing inflation is to increase premiums (which would explain the last 20 years).

It's both. But there are also laws that limit an insurer's ability to push back. For example, ALL out-of-network emergency services must be covered, including all follow-up work that occurs as part of being admitted due to an emergency.

Out of network means the insurer and provider have not previously negotiated a rate. And emergency services are among the most expensive bills out there.

My guess is that they’ll build a super HMO.

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.

A large problem with this system I can see is it doesn't help those who either 1) don't work there or 2) want to switch jobs. This merely pushes back on health insurance companies which is great but it doesn't fix the general issues that occur when access to healthcare is tied to employment.

Would having an Amazon Prime "Membership" likely count enough to expect to see Amazon offer this to consumers (possibly at enough of a discount to make it competitive with employer insurance)? I would think that having access to medical records to determine that someone needs a few more OTC allergy med suggestions might make this a long term goal of the project. In that same vein, fully expect to see an Amazon Credit Union someday as well and possibly part of a complete "Amazon Member Benefits" bundle.

It's quite possible they are simply setting up a captive third party administrator company. All of the companies will fund health insurance which will then have benefits designed for employees and care overseen by this third entity which would be a not for profit. This entity would then have to go out and negotiate contracts with providers, drug companies, lab testing facilities etc. Given the size of these entities, they would have significant negotiating power with providers and hospital systems which could keep costs down for members.

Here's what this is about. Large successful companies contract out their health insurance and care to external companies. Most of those companies are profit centers- they provide a service, but they take a very large profit on it. Much of that profit is just waste- it's money that goes to people who aren't innovating, or providing value, just acting as gatekeepers (note: this is just my opinion, not provable fact).

Companies like Amazon know they can provide that same service- or a simplified version of it that focuses on effective treatments that don't cost a lot of money- far more cheaply, because they have willingly forgone short-term profits.

Whether this saves money and provides adequate care remains to be seen.

Insurance companies, by and large, are gate keepers to capital. The "best" have a lot of highly innovate algorithms, machine learning, and data collection, but they're all designed to maximize the profit of the company by accurately pricing premiums. An accurately priced premium means customers who don't their services less pay less; in effect, they're using data to increase premiums for the customers who actually use their service, while increasing revenue in order to fund their massive, inefficient bureaucracy.

The last few insurance companies Ive delt with seem to act more like banks giving loans. Twice now, they have priced premiums for our company policy low in the first year before increasing them the following year based on how much was claimed. One agent actually admitted it was to "recoup costs".

We joked that the meme where actuaries were being replaced by machine learning was actually just the insurer firing actuaries because they figured out they could just demand the money back from the client after a claim.

The companies involved in this new venture were already self insured. They were paying for employee health care via third-party administrators, not buying insurance.

we're talkign about HMOs here, not Insurance Companies. There is a big, big difference.

Also, the companies aren't particularly inefficient, because that gets in the way of making profit.

I'd call this liberal-communism. We just have to put our trust in benevolent billionaires to solve our problems for us with no oversight or democratic controls whatsoever. The idea that this is anything but an attempt to squeeze even more money out of the system for quite literally the richest people on Earth is naive. In Ohio, 10% of Amazon employees are on food stamps[1] while Bezos is worth over 100 billion dollars.

[1] https://www.policymattersohio.org/press-room/2018/01/05/more...

Isn't that just conservative-capitalism? Specifically the US Republicans? Get rid of regulations, lower taxes on corporations and billionaires and put our trust in benevolent billionaires to solve our problems for us with no oversight or democratic controls whatsoever.

He probably means liberal as in inspired by classical liberalism. These days, the buzzword for it is neoliberalism.

Squeezing money out of the system by paying less money to health insurance providers?

Are you really going to argue that for profit insurance providers are more deserving of that money?

No I would argue for a single payer system like Medicare for All.


What's next? Anarcho-Capitalism?

> What's next? Anarcho-Capitalism?


I strongly feel that what needs to be changed is employer-based healthcare itself. It is really kind of crazy, if you think about it, how closely the quality of our healthcare and the healthcare of our dependents is tied to the company we choose to be working for at the moment.

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.

I have a choice of exactly two health insurance companies because that's who my employer selected for me. Both are for profit companies, with Aetna just posting record profits, and we see our premiums rise year upon year.

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).

This is what was talked about in the book "Redefining Health Care." The employer based model is totally broken.

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.

> People don't pay individually for private security/police. We don't pay for fire.

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.

Germany is one of very few countries with a robust public insurance scheme which also allows private insurance, but I wouldn't expect that to last too much longer - there's a growing consensus (57.6% in a recent poll) around the idea that receiving faster or better care because you can pay more is fundamentally unfair.

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.

So, for example: should the government provide free LASIK for everyone who wants it, or should they make it outright illegal to even pay for LASIK out of pocket? What about vasectomies? Abortions? What if it's something my doctor and I agree would be a good course of treatment, but the health care bureaucrats don't agree with?

The UK has similar. Single payer rather than public insurance, but people can buy private insurance if they want. It's certainly a small minority who do: it's largely a perk for some senior jobs, along with the BMW. It's relatively cheap (around £50/month for a non-smoker in their 30s), because all of the basic stuff is already covered by the NHS. The private insurance is mostly about getting shorter waiting times for elective surgery, and maybe a nice room.

> 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.

If everyone is super, then no one is.

> receiving faster or better care because you can pay more is fundamentally unfair

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.

> (57.6% in a recent poll) around the idea that receiving faster or better care because you can pay more is fundamentally unfair.


… the idea that receiving faster or better care because you can pay more is fundamentally unfair.

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?

Tieing insurance to employers is yet another way to limit class mobility. Want to start a company? Better be young, healthy, and lucky.

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?

You program still treats health care as a market commodity, which it isn't: unlike the usual perfect market model, there isn't any upper bound on the utility function. You'd be willing to pay any price, even a non-rational one, for health. So prices are lower bound. What more, your program assumes health care isn't a right, as even if it makes it more affordable, it still keeps it at a constant rate: that is, me and someone who makes half of what I'm making would pay the same, but that would be a different chunk of our paycheck. And unlike, say, going to a fancy restaurant vs cooking at home, you can't substitute health care.

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.

70% of americans live paycheck to paycheck. There is no money to put into an HSA - let alone to put into a savings account.

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.

This is a fantastic plan, similar to Singapore's - they have among the best metrics for health outcomes and an inexpensive system where primary care is paid for out of HSA-like tax-incentivized accounts and catastrophic care is funded by the state. It's a fantastic meeting of markets and a giant risk pool.

> It is really kind of crazy, if you think about it, how closely the quality of our healthcare and the healthcare of our dependents is tied to the company we choose to be working for at the moment.

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.

As some other people have mentioned below, the much lauded[1] vertically integrated health provider Kaiser Permanente started this way, as the health provider caring for the workers of an enlightened large employer, Kaiser Steel, which at the time was a massive shipbuilder for the Navy and others headquartered in California with a major presence in the SF Bay Area.

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.)

[1] http://www.nytimes.com/2013/03/21/business/kaiser-permanente...

I’ve been with Kaiser for over a year after having been on One Medical which is aiming to go in the opposite direction (many small satellite offices with good tech and more personal private care).

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.

Agreed. Kaiser does well for the vast majority of problems and for the averafe person, but anything specific, out of the norm, or challenging Kaiser fails. You sometimes need to see someone not in network and that's the main reason for insurance. Anyone really can help treat you for common ailments, but when something unique comes it's better to have the options to see the best in the field.

This happened to my family as well. My wife broke her ankle and is an avid amateur sports nut. She wanted to go see a top sports doctor (KP has none) and couldn't get KP to cover any of it. To pay out of pocket was anywhere between $20k-$30k. We ended up flying to the UK because it was cheaper and she had a trusted top tier sports injury surgeon she knew there.

Well that's how it works. If you want healthcare to work for everyone, you cannot expect that insurance will reimburse treatment from top doctors outside of rare conditions (where top doctors are the only doctors). Sport related injuries are extremely common. Why should an insurance reimburse an incredibly costly treatment when a normal treatment is good enough for most people? By definition, you cannot have an insurance that covers everyone but sends you to a top 1% doctor. What would the other 99% used for?

I'm not discrediting that notion. My point was to echo the sentiment that a closed-loop healthcare system has it's downsides when it hits edge cases.

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.

Do you pay the same as an individual or through an employer?

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.

Not sure about open market to be honest. I'm currently on COBRA (left a FTE position that had access to both). Will let you know in 9 months :)

Most of the "top 1% doctor" is marketing hype and BS. Reminds me of the "America's Top Doctors" ads you see on airplanes.

I don't know the kind of therapist you're going to but I was able to still see my therapist after I changed over to Kaiser. You might want to contact yours and ask if they're under the Beacon Health options plan. There are sometimes roundabout ways to get it done and I managed to do such.

You might be on the West coast. Kaiser does individual therapy on the East. Maybe your company isn't willing to pay for individual...

They do it on the west coast as well. You might be right that it's coverage related, but Kaiser in my experience let's you pay out of pocket for anything not covered. Could be that they don't do individual therapy for certain issues or simply can't due to staffing issues.

I'm with Kaiser Permanente (switched from a PPO) and have been for two years and I absolutely agree with your comment - in SF they have brand new world class facilities in the dog patch neighborhood near me and I can book and see a doctor and orthopedic specialist and get an xray and scan in the same day and in the same building, and be about $30 out of pocket all in. That is awesome health care.

Is it an HMO? Because those can bankrupt you if you go out of network...

It's a Health Plan. People go out of network in Kaiser all the time- basically, once Kaiser's default system can't handle you (complex organ transplants, advanced rare cancers, etc), they send you to a place like UCSF, and have negotiated the cost structure.

There's no guarantee KP won't bankrupt you, but it seems better than most.

If you voluntarily go out of network for non-emergency care, then yes, you pay a ton. If you have an emergency and go to an out of network ER, that is still covered (at least for plans purchased on CoveredCA) because of provisions in the Affordable Care Act. The billing may be a logistical challenge, but it should not bankrupt you!

Kaiser has both HMO and PPO plans, although depending on your employer you might only have access to the HMO (e.g. if they went with another insurer for the PPO).

Thus proving the inherent value of the network!

I'm new to the area and have Kaiser. Are you talking about UCSF Medical Center at Mission Bay?

The Kaiser facility is very close to that UCSF facility next to the 101 on Owens street.

I'm also a big fan of Kaiser, and can share a couple of anecdotes to illustrate why.

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.

I'm with Kaiser and my favorite thing compared to the PPOs I've been with in the past is the integrated IT health records. Any doctor, specialists, ER, can see my whole history of ailments and drugs and lab test results. When my doctor orders up a specialist or a pharmacy I don't have to re-explain anything, it's all in the system. I'm sure it helps reduce medical errors.

They were the first 'big' client of Epic Software. Many other hospital systems around the US now use Epic, and have similar features.

The difference is when you're on something like BlueCross you have a "network" of hospitals and independent doctors and labs and pharmacies that you can choose from. But those are not on all on one IT system and a lot of times they have no way of communicating with each other. With Kaiser it's all vertically integrated under one company that can impose a system-wide IT system.

You may be amused to hear about the programming language they use.


I've known two people who loved Kaiser until they had a serious issue. Not privy to a ton of the details, but it appears that they Kaiser is not immune to at least a divergence of interests with their patients when the figures get big.

I've been with kaiser my whole life. 3 open heart surgeries from 2 to 32, ongoing medical of all kinds (psych to phys). Kaiser was 2nd in the nation for cardiac care for awhile. I have had nothing but great experiences and have transferred to their Washington state system, which is basically the same, except the facilities and staff seem less sophisticated overall.

I've heard horror stories from all kinds of people with all kinds of insurers. For example, a neighbor of mine uses California Pacific Medical in Nob Hill. It's the hospital that caters to San Francisco elite. This past year his doctors mistook skin cancer on his eye for a sty for like 6+ months. He went back several times complaining before they caught their mistake. It's too soon to tell, but that serious issue may turn out to be a fatal one.

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.

EDIT: I meant CPMC in Pacific Heights (Upper Fillmore), not Nob Hill. Judging by the people coming and going, Saint Francis on Nob Hill seems to mostly serve the Tenderloin.

Hence health insurance should be strictly separate from health care. A strong insurance body could even ensure proper competition in the health care space.

Ditched my BlueShield PPO for Kaiser and costs went down dramatically. There's tons of costs to be saved in healthcare and glad to see the private sector making an effort.

I tried applying to Kaiser and they rejected me for having a pre-existing condition which couldn't be helped given that I was born with it.

Good for everyone else, I guess. :/ I ended up moving back home where the government covers my treatments.

They are a business not an ONG.

US is a shithole country in relation to healthcare systems

Side note, but I really think pre-existing conditions should be covered by welfare, not private corporations who have the requirement of turning a profit.

isn't that illegal now?

The incident happened before the ACA, though insurers have found clever ways around it: https://www.theguardian.com/commentisfree/2016/oct/27/obamac...

the tactic doesn't involve denying coverage though. The poster above said he/she was rejected.

That was my understanding as well.

Kaiser is available up and down the west coast, having completed the acquisition of Group Health last year. https://www.seattletimes.com/seattle-news/health/kaiser-perm...

Second that. I was covered by Kaiser for more than 10 years. It really is a great provider. You just show up to a clinic and everything is there - all the specialists, doctors, labs all under one roof. They have all the records already, everyone in the chain can see each others notes, lab results etc.

Yeah with my plan I don't have access to outside doctors, so far however I didn't need them.

I had Kaiser for a while and loved it. One appointment and you get two doctor visits and blood tests done the same day.

That's pretty cool. I grew up with Kaiser, going to the one-stop-shop hospital in my youth. I didn't think much of it, it was icky and grey.

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 was with Kaiser for a long time because I never needed a doctor. When I did, I had to fire kaiser. They nearly killed me. Talking to my coworkers, it turns out this is quite common. They hire a lot of people that received their medical degree in countries with much lower standards. It's actually quite concerning how many people I know IRL that lost friends due to misdiagnosis by Kaiser. It doesn't help that you can't (easily) sue them. You agree to a non arbitration clause.

I see a lot of folks praising KP in this post and it's very concerning.

If you want to convince me, show me the relevant statistics. Medical errors are not unknown from other health providers.

I am not looking to convince anyone. I know what I experienced. My friends know what they experienced. That is more than enough for me to have left KP and to warn my friends regarding my experiences. I have advised various agencies of my experiences.

They're mostly based in California, though they recently acquired Group Health Cooperative (largest healthcare provider in Washington State).

They’ve been doing a big ad campaign in WA. Now I understand why.

Kaiser is no longer a low-cost provider. They actually are quite expensive. We go through a very large group to get a better rate but it's still much higher than many of the other options that we have in our plan.

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.

I'm downvoting you because you stated this as if it is a fact for everyone. We're in a small group plan and paying about the same for Kaiser as we are for Blue Shield, not "much higher". So, I think here's it's more "your mileage may vary."

To be fair, Blue Cross/Blue Shield are usually highway robbery for terrible plans, so...

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.

She can wait until an incident happens and then activate cobra. You don't have to pay for it upfront.

This is not true of all COBRA plans. To be safe, she can delay premium payments a maximum of 45 days and still have coverage for claims that occur before the initial premium payment.


This was really good to know, had no idea.

I think you can retroactively pay for COBRA, yeah?

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.

>I think they're just pocketing the difference between the market rate and what their costs are.

This is baseless and not really possible.

Insurers must spend 80% of premiums (85% for large group plans) on providing care for their insured.

> "There is no such thing as a legitimate price for anything in health care,” says George Halvorson, former chairman of Kaiser Permanente, the giant health maintenance organization based in California. “Prices are made up depending on who the payer is."

When you can game the pricing you can always just slice 80% from an ever increasing pie.

That's not really how it works. The "ever increasing" pie would have to come directly from increasing subscriber premiums, not from cutting costs and pocketing the difference the OP indicated.

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.

There is a whole lot of backscratching with the profiteers taking their cut of the 80%. That is why we get $30 Tylenol pills under the guise of "care".

Hospitals aren't charging insurance companies $30 for Tylenol and then paying insurance companies under the table if that's what you're alleging.

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.

None of the stakeholders in American for-profit healthcare have any incentive to reduce costs so everything just keeps ratcheting up. Growth can't be achieved by increasing the population of sick people so the only other option is to raise prices. The insurance companies do benefit from this. They agree to cover the inflated pricing so that their 20% cut can be bigger. If ACA permitted rational price controls this whole problem would have been reigned in.

How does this have anything to do with

>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.

An allowance 15-20% overhead for health insurance seems like pretty low bar for the industry...

And yet, it was groundbreaking when it was signed into law. People received refund checks after it went into effect.

And immediately after, administration costs shot up to ooh, 15-20%...

Yes, I suspect it ends up as something of a perverse disincentive to control costs

They were already above that. Especially the not-for-profits (e.g. Blues) had to scramble to get under the cap.

There was a huge amount of waste in the system. 15-20% is a marked improvement.

Cancer care at Kaiser was outstanding. They may be spending the money on extra staffing and facilities, not just pocketing it.

The only place where I believe Kaiser falls short and gives the impression of pinching pennies is mental health care.

Is there any private non-university health chain in the country that does mental health well? Every contact I've seen with any acute mental health care system --- except at the University of Michigan --- has been a catastrophe.

Go Blue!

(Hope you’re feeling better)

My employer has a very good kaiser plan, basically I pay $15 for any office visit, and nothing for lab tests, etc. The total unsubsidized price is $1450/month for two people.

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.

It's been a while since I've worked for a company that had Kaiser as an option, but my recollection was that it was more expensive too. The quality of care in a given service region might be higher, but there's a reason that they haven't completely taken over their market.

Kaiser is great compared to other US providers (although that's not such a high bar).

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.

Kaiser is almost a monopoly in Hawaii (only a handful of providers they haven't bought). Interests can diverge when they are the sole provider for both insurance and every health need. Example: hiring practices of cheap vs competitive doctors and staff. Anecdotally every doctor and nurse I know refuses to take their family there.

I really like the doctors at Kaiser. All very smart and caring. But their billing department is awful. I paid my bill every month but still got sent to collections multiple times. They would always recall it, but it was a giant pain in the ass.

KP was in North Caronlia in the 90's and if it wheren't for boneheaded mismanagement would have been completely dominant in the market there now. One of those other futures that slipped away in the night :(.

Kaiser Permanente has a huge presence in the Washington, DC area.

They are the main healthcare provider for a large swath of federal government workers in the DC area.

I love Kaiser. One stop shop for most things, easy, efficient, unified records. Highly recommended!

Agree that Kaiser is great for normal cases.

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?

Kaiser is also available in Colorado.

They're in Colorado

It's not just the cost. It's the incredible inefficiency of the operations, and, the gerrymandering of coverage. Under the ACA, I had to choose between allowing my family to continue to see their lifetime care givers, or, paying in network rates, for the full year, because the insurance company I chose gave me incorrect information when they were trying to get my business (my wife is less kind in evaluating their motives). I paid $30,000 in health care expenses out of pocket that year for what was essentially a healthy family. I was not permitted to change insurance companies once I learned they had misled me.

Buffet calls them a tapeworm, I call it the next, ongoing rape of the American middle class.

I had the same unfortunate experience that in angers me to even think about it.

- I leave my last employer on July 21, 2017

- My old employer rols me off system on last day of July 2017

- On June 2017, they switch HR providers from TriNET to Namely and now the payment processor is Discovery Benefits and the Dental/Vision are now in Guardian. (So it went from Aetna to Aetna/Guardian and two other companies).

Since my wife is high-risk and I have thyroid issues, our best bet was COBRA ($1,000 / mo) because the new startup I joined did not offer group health coverage.

What followed next was this:

- The HR person who was handling my COBRA papers left during all of this. Switched jobs.

- Thanksgiving break

- Weeks of "the system will update this weekend with your information."

- "They were suppose to process your dental, but they never did"

My wife and I tried using our new AETNA IDs once we had gotten them and they still told us that it did not work. I had to have an expensive thyroid blood test pushed back. Multiple dentist appointments postponed. Everything.

FINALLY, once I got my SSN and ID for my coverage on AETNA, I had to pay back premiums all the way back to August 2017 just to keep using my coverage. So that's $4,000 USD for services I could not essentially render. $4000 of my hard-earned money. Gone. For nothing -- basically.

They had the gall to tell me (AETNA did) "Sir, if you paid for anything out of pocket during the time of your retroactive coverage, we can pay you back any cost you incurred."

The whole reason we get insurance is to avoid those high prices.

I'm so spent. I'm not an angry man but these health insurance companies really drove it home for me.

I feel taken advantaged of and it really stinks.

"The whole reason we get insurance is to avoid those high prices."

But only for unpredictable, irregular events. Anything else is uninsurable. If someone sells you "insurance" for wellness checkups[1], regular, scheduled screenings ... or tires on your car ... you can be absolutely assured that they are taking from you as much, or more, in premiums than the cost of those services.

What you are looking for is socialized, state sponsored medical care. There is no problem in looking for that and I make no value judgement here on that.

The first step would be to stop mischaracterizing this as "insurance". It's not. It can't be.

[1] Yes, certainly wellness checkups and things like them can be enormously economically beneficial for the provider since they spend up front preventative dollars instead of emergency, acute dollars later but it still doesn't change the fact that those are not underwriteable as they are regular, on-going expenses - very much like the tires on your car.

It's rather entertaining to see the fallout of costs becoming more transparent in America's healthcare system. There is a reason why the medical field is so lucrative in the US, and it's because for decades it's been subject to extreme price obfuscation. This is great for the merchants (pharmaceuticals, doctors, hospitals, medical software providers, nurses, etc), especially for such inelastic goods such as healthcare.

Now that organizations in the US have reached a breaking point, those costs are becoming clear to the consumers and they don't like it. You're absolutely right that the term insurance is bastardized in the healthcare setting, but people will have no choice but to understand.

If people want to blame somebody, they can start with the doctors union that restricts the number of residency positions open.

Residency programs are more restricted by funding for residency spots, not by the AAMC. Funding is, very weirdly, provided by Medicare. It's all a tangled mess with lots of weird stakeholders, but saying "doctors are using rent seeking behavior to limit new entrants to the field" is a bit disingenuous.



Doesn't the AAMC regulate the number of nurse practitioners? My understanding was that increasing the pool of nurse practitioners would help alleviate the cost of treatment for basic ailments, but that number is capped by an administrative body.

From what I've read, a lot of that is due to the prices set by the RUC:



Good for the doctors though, at least they're smart enough to bargain in their own interest.

Nothing in these articles supports your contention. The "tangled mess" is by design. By the people who stand to profit from it.

Allow foreign doctors to work in the us with a reasonable, attainable testing period of one year, and you will find no shortage of doctors in the us within the year.

I explained it to someone recently as this: "This biggest problem with the healthcare industry is that incentives are terribly misaligned and patchwork. Because most of the market is formed by accreted law rather than naturally, even incentives for a given participant (e.g. an insurance company) are usually different than what you'd expect."

Your comment seems to overlook the fact that insurance companies negotiate better rates on many (most?) services than an individual would get going at it alone. From that perspective, I think it's reasonable to say that in our current system, insurance can allow you to essentially avoid high prices even for things that are predictable/regular.

I worked in health care and saw so much money wasted. The ACA was suppose to bring the same risk factors to everyone, so you got the same premiums based on age, gender and smoking status. Big companies got big breaks for employees and the rich paid less.

This might have worked if everyone was required to buy from the market place and there were no employer plans. Obama's famous "You can keep your existing health coverage" was a terrible, terrible decision.

I watched the Medicare/Medicate group for my company and they might have complained about not getting enough money, but I really think they did. Things had fixed prices and there'd be plenty of money if BlueCross didn't spend money on advertising, useless wellness programs and shitty IBM technology.

Everyone should just get Meidcare/Medicade. The government won't control healthcare, it will just get contracted out to providers. They'll have to cut costs and not waste so much money (they waste A LOT!)

Capitalism + Health care is a failed experiment. Socialized health care does work, in every high income country that's not the United States. Australia fought against the Abbot government when they wanted to introduce copays. That's right, Australians don't have doctor co-pays (they kinda do now, but wavers are in place and the plan was effectively defeated).

The fact that the US government requires us to buy private health insurance at insane rates is absolutely insane and the Supreme Court should have struck it down. You are not a car. Your body shouldn't have a fee for existing.

It shouldn't have a fee for existing so long as you're cool with me not paying a fee for when your body breaks down.

This is not clear, in that "concierge doctors" or cash only doctors to some, seem to have rates that are lower than what the insurance companies claim they are billed for a service. That would suggest they are lousy negotiators.

For the doctor, a great benefit of being cash only is you don't have to do billing, a non-trivial task.

I don't disagree, but I observe that if the interests of getting the lowest cost were aligned with the insurance company, and if the complexity of billing was a significant cost factor, it should be well within the capabilities of the insurance company to simplify the billing (by simplifying the requirements) in order to lower overall costs. And yet here we are :-)

I don't think this is true at all. The doctors have to justify their costs and the insurance companies have to validate that they are worth covering. Neither of those seem simple unless the insurance companies simply said, "Whatever the doctor wants to do, and whatever they charge is fine."

How do you come to that conclusion? I've seen a number of articles and cases like [1] where a company decides to charge apparently "what ever it wants" and the insurance company said "fine" and paid it. This article[2] talks about the wide range of prices for the exact same procedure within the same area. Is it your understanding that each of those different doctors justified their costs and the insurance company validated them?

[1] https://www.law360.com/articles/940691/fla-compounding-pharm...

[2] https://www.usatoday.com/story/news/politics/2016/04/27/huge...

Each doctor offers hundreds of services/procedures. Each one has a different price. The insurance company needs a certain number of doctors in the network to be competitive and they can't really have hard cutoffs for every single item. It's not that surprising that there are outliers.

Additionally, lots of doctors often bill incorrectly on purpose so that a particular services/procedure gets covered, so I am not sure we should keep "justified" and "validated" in these discussions.

Most doctors in my area will charge less in cash for people who don't have insurance vs. what they charge insurance companies for the same services.

You can also negotiate on your own. I've occasionally had medical bills that for whatever reason were not covered. I call the provider and if I owe $1,000 I'll say I can pay $500 today to settle it. That's more than they will get selling the debt to a collector so they will take it.

You generally can't negotiate in advance though, because most providers seem unable or unwilling to tell you what anything is going to cost.

That is because providers can't refuse healthcare to someone that needs it and can't afford it, so those costs get inflated just to be able to get a fraction of it. As rsync says, it's still not insurance, it's just the ability to be part of a group large enough to negotiate pricing, and has enough credibility for providers to trust them to be able to pay.

AFAIK that only applies to hospital emergency rooms. Your local doctor certainly can refuse service if you can't pay the bill.

Yes, of course. I meant to convey that for the providers that can't refuse, like hospitals or ambulances, sticker prices not realistic because the provider is having to gamble on which portion of the people they treat can and cannot pay, and how much, so they inflate their prices extremely high. And also to negotiate with insurers.

Not sure I get you. "But only for unpredictable, irregular events." But if I went into the Doctor's office without insurance, could they turn me away? The bill would be too high?

We looked into ACA... but we thought that the process of switching over from AETNA to COBRA would be painless (weeks at most). So we just went through with it. We did not know it would end up like it has.

The operations for insurance is a daunting, slippery rope. Can you not lay some fault onto insurance and its operations?

What would you characterize this as? People slipping up? That's how the "system has always worked"? People forgetting to process paperwork needed so people can get to their appointments?

I think the parent is objecting to the use of the word "insurance". By definition, insurance is a form of risk management, to protect yourself against unexpected cost or loss. You can't be "insured" for regular wellness checkups and screenings; that word just doesn't make sense there, as those are expected, regular costs. Coverage for that is more like a "health plan", which is, in reality, what we have, despite the industry's insistence on calling it insurance.

(But yes, admittedly, this is just pedantry.)

Ah, I understand - thank you.

I believe OP is talking more generally about insurance (not just health). Insurance covers you for unusual unexpected large-cost events at the cost of regular, predictable payments. They are useful in capping your risk exposure.

But if the events are rather certain, then the insurer can only act as a payment plan on the events. The risk is 100%, so at least 100% is priced into your premium (profits, a overhead, etc take it over 100).

Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs.

Even covered wellness care probably comes out a bit less than it would otherwise cost, because not everyone uses it even though it's covered. Some people, like me, just don't go to the doctor.

This is why the poster called it a socialized system. You are literally spreading the costs to the society of individuals in the plan. That is not insurance.

Now, it is common for "socialized" to be a scary word. So that people try and name it other things. But you aren't spreading the risk here. You are only spreading the costs.

Well, I'd also argue that you are spreading the benefits. Which is a good thing to me. Point being, though, it is not insurance.

"Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs."

This is why I used wellness checks and tire changes as examples - they are regular and universal.

I'd say that healthcare is just one of the fields where bureaucratic incompetence is horrifying. There are many others, like the legal system confusing two people with the same name in the same town.

The takeaway is that one shouldn't predicate success on lawyers creating a Borges-fidelity 1:1 mapping of the real world into law.

This isn't quite correct for American health care. It is absolutely cheaper to pay insurance premiums than to pay directly for medical bills. The insurance company takes in more premiums than benefits that they pay out but the price that insurance companies negotiate for a procedure is dramatically lower than what you would be able to get if paying directly.

This echoes my experience during the mortgage crash so much it gave me flashbacks.

- 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.

That sucks. I hope you bounce back...

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.

Thanks, I have. This was a while ago near the beginning of the housing crash and I've since been able to get a house with a local mortgage provider.

How has foreclosure been? Hard to get new loans? Hope you bounce back.

Already have, thanks. Actually bought another house after the 3 year mark when I was eligible for an FHA loan. Luckily, my credit score is pretty excellent.

This was back in the early 2000's just before the actual market crash. It was insane to me that banks were willing to work with people that bought houses they couldn't afford but that they wouldn't work with me on a loan modification because I wasn't delinquent.

People feel that politics are tedious, but this is exactly the reason to pay attention. Look farther than your case and systematically review overall national stats of healthcare costs in the US vs other nations. We pay the most of any developed nation, double on average other developed nations, almost triple the best run healthcare of other nations. We not only pay much much more, people die sooner and go bankrupt more under this system for completely preventable reasons.

Edit: And great that there might be a new value conscious private competitor out there - but I'd note that all those other developed nations that are individually, collectively, and vastly outperforming our health system all have some form of government control on drug and procedure prices. And a single private company would be very hard pressed to replicate the negotiation leverage of a government. I'd also note that I'd trust JPMorgan about nil to be concerned about customer value over company profits. Other nations have a health system, and at the end of the day we have a health market.

One of the nastiest things in the failed TPP from my perspective were provisions to make illegal a government agency in my country that successfully keeps costs of medication down by forcing competition and negotiating strongly.

The numbers are small by world standards but I guess the drug companies are paranoid of this idea catching on in, say the US.

I’m sure it will be regarded as communism, but hey, it makes the market actually work for us here.


I think it would have been incredibly foolish and costly for your government to sign onto that provision. It's funny that the arguments seem about single or multi or hybrid public private billing arrangements here - but if you look across the national stats, all of those arrangements perform better - because a root cause that I think there are in those nations, a regulation of cost by medical experts in that nation vs efficacy of various drugs and/or procedures. The dream that somehow laymen off the street can shop for medical care like shopping for a pair of socks and that would balance the market in price or knowledge of derived value is really naive in my eyes.

That's the way COBRA works though: you have 2 months to elect it, but if/when you do, you have to pay premiums starting from the moment you lost your original coverage (and have retroactive coverage).

Yep. And I elected ASAP. One of the first things I did starting new job.

But the I continuously got the "we have you down for this provider" when my COBRA admin told me that that provider could no longer give me coverage. I needed to AETNA to file me under a new provider.

Then I called AETNA and they still said "so and so" is listed as my provider. I told them to change it. "It's gonna be at least a week to update your information, sir."

Call back next week, "sir, you are still listed on 'so and so' provider."

It was exhausting.

The way COBRA works is that they can just start giving you coverage whenever they feel like finally getting their act together?

No, Cobra rules are all defined in Federal law. The OP could have gotten care at the time and asked the doctors to defer billing until the insurance resolved (or just submitted to the insurance company anyway and followed up later). If the doctor/hospital balks you can show them your Cobra paperwork to confirm it. But yes you have to pay the premiums.

In retrospect this is probably what I should have done.

edit: but the thing was, I trust them to give me good advice. The HR providers. I figured, well if they haven't said anything about deferred payments, it might not be applicable to my situation so I never brought it up...

It's all about that first postmark, when you start the paperwork.

I've also had lots of weird and frustrating insurance and doctor issues, but am surprised COBRA was your best bet or that your wife being high-risk was relevant. In the current system your preconditions shouldn't be a factor in the price.

I am also high-risk and have always found that the Obamacare market had prices close to or lower than the unsubsidized cost of an employer provided plan.

The most frustrating for me is that the doctors can't even guess how much their facility will charge for the treatment they decide is necessary, much less how much the bill will be after insurance gets their cut. It is a major barrier for me to get MRIs and blood tests. Especially blood tests, which seem to range in cost from practically free to thousands of dollars for a single blood test panel.

It's infuriating, and no matter how closely I read the insurance fine print I still cannot guess what the hospital and insurance plan negotiated ahead of time. Kaiser was way better, at least there the incentives were aligned to sane billing procedures.

I encourage you to contact your state's insurance commissioner. Further, in my state, they admin the COBRA program. In my experience, the state has been very supportive, helpful. Whereas the insurers and payers will do very little to help.

As someone who's on the same path as you were -- and has similar needs -- this is very concerning.

Have you been able to find a workable alternative or are you still stuck with AETNA?

Stuck with Aetna as they have lowest rates. Blue Cross was $200 per month more.

I feel Buffet and Bezos have the technical capacity and certainly the capital to tackle this issue.

They can't fix the entire HC market, but they can have a great start.

All involved players are mainly interested in lining their own pockets. The question if this will come at the expense of patients or other players in health care.

There is nothing wrong with “lining your own pockets” as a motivation. It is the fundamental driver of capitalism and the motivation for most entrepreneurs.

I think in healthcare, there is a problem with profit as a motivation, at least insofar as the ability to receive care. I think healthcare professionals should be paid, and paid well. But a for-profit company (or whether or not one can pay the premiums or deductible of any insurance company) should not be a gatekeeper to whether or not one can receive care at all. Inevitably, someone will be left out in the cold, or will end up paying inordinate amounts to receive care due to bureaucracy (or malice), as has been experienced by people elsewhere in this thread.

This is why I believe single payer healthcare is generally the best solution.

However, in the current situation, I think this idea to create a healthcare company dedicated to serving their employees, "free from profit-making incentives and constraints," is a great idea, one which I hope others will attempt if it ends up a success.

Single payer healthcare is the best soln. Agreed, However I can’t see it working more than a presidential term. America is too politically unstable.

What i’d love to see is a commercial business having vertical integration. Insanely cheap basics like X-rays, mris, and other checks. Heavy use of AI based diagnosis confirmed by doctors, and a big insurance pool where profits go back into scaling healthcare.

Basically current American healthcare is not scalable. Period.

> Single payer healthcare is the best soln. Agreed, However I can’t see it working more than a presidential term. America is too politically unstable.

I'm not too sure about that. It's taken an entire year for the GOP to start to actually succeed at chipping away at the ACA, and they have legislative and executive control. If we could get sweeping reform in a more favorable political climate, something not plagued with the implementation issues the ACA has labored under, it might stand a chance. The next administration might find it politically untenable to take it away if it actually works well.

Who is going to develop AI-based diagnosis platforms if there's no profit to be made?

Single payer does not mean non-profit, providers would still be for profit.

Why wouldn't you make a profit? You sell that technology to hospitals and such the world over.

You just might not have the option of telling someone it's 10 grand (with ridiculous profit margins) to get an earlier diagnosis and a chance at actually living.

Who is going to sequence the human genome unless its for profit?

I believe that insurance companies welcome legislation and regulation. It requires them to hire more people and buy more equipment and services. All of that cost then gives them added justification to raise prices, because ‘we are a public company and have a duty to return profit to our shareholders.’ All of that regulation is expensive to start with, and needs a profit on top of it.

Another true story, even with a Health Care provider and insurance company I don’t hate: after a routine visit, I had to spend more time on the phone with both of them than I spent in front of the Dr In order to have the service code corrected so the payment would count towards my deductible. The administrators I had to work with are paid employees, their costs not only have to be covered, but profitable. Very polite, capable and professional and completely unnecessary. I dare any non-American to come into our system and figure out in-network vs. out of network, co-payment, co-insurance, personal deductibles, family deductibles, lifetime maximums, deductible vs. non deductible services... and then write an App that compares plans, even within the same insurer’s portfolio and tells me which is the better plan.

Intentional value obfuscation, unnecessarily complex, adds to the bottom line.

My girlfriend is a doctor and says that working for the private care system she spends more time fighting with the insurance companies that treating patients - they want to pay for the cheapest drugs she wants to prescribe what is best.

Fortunately we have the option of publicly funded health care here in Europe which is what she recommends for anything serious.

If you profit off sick people, are you motivated to move toward a world with no sick people? If you profit from prisons, then you need to fill you prisons. Problem is, that as a society, we should aim toward not needing prisons at all. Therein lies the rub.

If I profit off of you being sick, then I need to keep you sick.

Generally speaking, insurance companies profit if they don't have to pay out, which is why they sometimes pay for prevention.

But this has other problems. Incentives are tricky.

Normally that would be true, but under ACA profits are capped at 25% of premiums. They can increase profits only by increasing premiums, which can be justified by rising costs. Private insurance companies in America have no incentive to lower healthcare costs.

Well, that's true if they hit the cap and have no competition. If they don't have a 25% profit margin yet, they can still try to increase profits by cutting costs. There is also the strategy of lowering prices to increase market share.

The downside I was hinting at is that as a patient, cutting costs isn't always what you want. If it means more prevention or paying less, it's good. Otherwise it'll probably mean worse service.

Insurance companies are more like gyms, actually.

They profit much more if you pay them money but never use their service.

My friend had an insurance company that reduced his premiums if he checked in at the gym a certain amount of times per month.

Two areas where the "free market" capitalism of America seems like a stupid idea.

As a European I would disagree. We have helathcare for the purpose of keeping people healthy rather than for profit. It seems to work out a whole lot better than your system in the states.

And at least in Germany doctors still have very nice cars so there is still a good amount of profit.

That's how you get healthcare lobbyists to get laws passed that screw over patients and how you end-up with medicine that rises 100x in price.

Healthcare should be nationalized. Then the government would also have other positive incentives meant to lower healthcare costs, like reducing pollution, sugar in foods, other dangerous foods on the market, and so on.

I'm as much a capitalist as the next man, but lining your pockets when you're already a billionaire, at the expense of middle class, is downright pathetic.

So you want a poor man on skid row to start a health care company?

Just because it is a fundamental whatever of capitalism, doesn't make it 'not wrong'.

Doesn't it? America is unapologetically a capitalist nation with a few notable and infuriating exceptions (looking at you, ISPs).

I mean if you want to make an anti-capitalist argument on a message board owned by a venture capital firm, feel free. But by definition "profit = good"

A venture-capitalist firm that's doing studies in Basic Income and its effects. So give them a little credit.

Yes however oligarchs don't want 99% of wealth to be in the hands of the 1%. Right now its something like 40% of the wealth in the hands of the 1%. If it shifts much more they will have total war on their hands. The rich will always be encouraged to keep that number down to prevent war - which is also convenient as those efforts can make them look like our lord and salvation.

I don't think there's anything necessarily anti-capitalist about BI, especially if it could be shown that a given level of BI substituting certain social programs was more cost-effective. Increasing benefits while lowering taxes without raising the deficit or incurring debt would be a pretty easy sell to both sides of the aisle, I'd think.

Its entirely orthogonal to Capitalism, surely?

I think that depends on whether or not one views regulation or state influences on the free market as being anti-capitalist.

true true, yesterday I saw someone make the argument "If popularity doesn't make something moral, what does" And on this thread it's "if capitalism doesn't make it moral, what does"..

There's an entire college course called Philosophy I that basically goes over 7 to 10 different moral compasses. The only one that seems to win out (aka the only one people remember after the class is Moral Relativism).

We have to distinguish between capitalism and functioning markets. The capitalists do great in the US health system, but the market doesn't function.

The problem comes from the drive for increased profit as time goes on, especially in healthcare.

Did anyone read the article? It’s going To be set up as an independent company without profit as the motive.

They know all their companies will earn more money if there is more money in everyone’s pockets. Look at how much some people are spending per year on healthcare. Someone in this thread mentioned $30k for his family in a year just for insurance. If he even saved a third of that, it’d end up being spent somewhere. A good economy benefits all those big companies. The losers in this are the healthcare companies.

Also, the number of employees these three companies have, put together, mean that setting up a non-profit health provider and using it to provide employee coverage saves them money in their normal businesses.

Amazon might decide to make their own networking hardware or their own power generation for their datacenters to save money, but they spend more money on headcount than on datacenters, and a huge chunk of the headcount expense goes to health insurance companies.

My comment is about publicly traded competitors to this new company. I suppose I could have been more clear.

Sorry, it seemed like others were making that assumption without reading the article.

As long as this company doesn’t go public, it seems like it will be able to stay away from that. It will be extremely competitive against companies trying to raise profits.

There is when that lining comes at the expense of the people that you're supposed to be helping.

Given that Buffett pledged to donate 90% of his wealth to charities, I'm not sure you can characterize him as "mainly interested in lining his own pocket."

Buffet seems like a good-hearted person, but nothing about Amazon or JPMorgan leads me to believe this will be an altruistic enterprise. Also, Buffett is 87 and not likely to be involved for too many more years.

Buffet I'll give you, but Bezos clearly is not in this to help anyone out. One only has to look at the negotiations with the guild at the Washington Post to see that.

Berkshire != Buffett

To me he is a character like Gates, Rockefeller or Carnegie. Ruthless, ever greedy businesspeople who get as much as they can out of business at any cost. Then they give a big part of it away. The question is whether the health care thing is part of the making money activities or part of the giving away activities.

You can always hope for the best so let's see what happens. Looking at the American health system I am not very optimistic.

I don't know. I don't pretend to be an expert in these things, but the impression I get of Buffett is a world away from Al "Chainsaw" Dunlap (CEO, more so than owner, I know), or even the Carl Icahn's of the world.

Why do you think this? His public and private actions generally seem to support the idea that he is ethically grounded, and I'm unaware of questionable behavior at any point in his earlier career. But I'm not that old, so I don't know who he was in the 70s.

I have nothing against Buffet. I just think that you can't become a multi-billionaire by being a nice guy. You have to be ultra (pathologically?) competitive and ambitious to get that far.

> I just think that you can't become a multi-billionaire by being a nice guy.

Berkshire is a holding company, all the not so nice decisions are made by the CEOs of the companies Berkshire owns.

And the guy on top is a nice guy who washes his hands clean from all unpleasantries. I don't think that's how it works.

Do you believe hospital Executives/VPs (which are more likely than not physicians) are not interested in lining their own pockets? Take a look at who sits on which boards and the rather obvious conflicts of interest within HC. The entire system is designed for billing. You realize clinicians make bonus on seeing as many patients as possible. See a patient for 15 mins bill for 1 hour.

let's see, in a battle between employers pushing down on insurance costs and the morass of corruption on the healthcare side, who is the least politically organized? it would be a miracle if individuals don't get screwed.

Buffet is the same guy that "fixed" other insurance markets by driving them away from mutual ownership to privately owned companies - a massive wealth transfer away from the common man. He shouldn't be commenting on tapeworms.

I'm genuinely fascinated by this comment. You're saying that mutuals offer lower prices (not typically true), but they were out-competed by private companies? I'm not sure that makes sense. In my sector (life insurance), there's no real pattern to mutual vs public company pricing, but maybe it's different in auto insurance, for instance.

It goes beyond pricing. Mutual insurance policy owners were paid dividends based on principle investment. Berkshire pays dividends to shareholders, i.e. Warren Buffet, while policy holders get nothing but insurance coverage.

> Berkshire pays dividends to shareholders

Berkshire has never paid a dime of dividends to anybody.

Capital gains are equivalent to dividends, just with better tax treatment. You are "technically" correct though, which is of course the best kind.

Buffet decoupled investments from insurance, because he thought (IMO rightly) they should be different products. And his companies only win to the degree that consumers choose them.

That’s a great thing.

Consumers don't as a group "choose" anything independently in the sense that their biases and psychological faults and the structure of incentives in our society are all used to make consumers act against their own interests and the interests of the whole. When our "best and brightest" are only committed to profit, we cannibalize ourselves. It isn't progressive. There is no scenario where shitting on the masses to help yourself results in a win for humankind. Not at this stage in history.

Not only has Berkshire never paid dividends, as another comment noted, Buffett decided three decades ago to give all of his wealth away to the benefit of less fortunate people.

What's your next premise?

In the abstract, giving away the proceeds to a cause you support isn't really a tremendous excuse for bad behavior.

I'm not evaluating Buffett either way with that statement, just pointing out that it is possible and probably necessary to evaluate his behavior without giving consideration to his pledge.

I was wrong, replace dividends with stock buybacks and buying up other companies, it's the same impact on the policy holder, who will still see no financial gain from holding the policy. Did you consider that some of those less fortunate people that he donates to might be less fortunate because they've been paying into an insurance system that for 40+ years years has provided them no return?

If you want an investment you can invest, if you want insurance you can get insurance. I'm not sure why you think overpaying for insurance and getting a dividend back sounds like a great way to do both. If you pay for insurance for 40+ years you certainly got something out of it--you have been insured for 40+ years!

>> If you want an investment you can invest, if you want insurance you can get insurance.

Most people used to do both at the same time and it seemed to work pretty well before Buffett came along. And there's a good analogy to your last point - someone who rents an apartment for 40 years when they could have bought an equivalently valued home two times over. They shouldn't complain when they die with a net worth of zero, they had a roof over their head for 40 years!

Also, mutual policy holders don't "overpay" for insurance as all dividends are returned to them. Only a private insurance company policy holder could overpay. Just thinking about it now, Buffett wouldn't be so rich if his policy holders weren't overpaying, as you're implying.

They didn't just have a roof over their head, they had a roof over their head without bearing the risk of fluctuating real estate value.

Insurance and investment are two different things. Why combine them?

Those aren't the problematic areas. its legislation that's the primary hurdle to the curren sitaution we have in the US.

Fortunately they have plenty of lobbyist which can be put to good use.

The most impactful thing would be price transparency. In no other industry do you agree to purchase something without knowledge of the cost.

But to be real here, the main motivation for creating this new venture is employer cost.

Some people might not be aware that the vast majority of large employers in the U.S. that offer health insurance are self funded (i.e. they collect premiums from themselves/employees and take on all the insurance risk), so anything they can do to lower any direct/indirect cost with plan administration, claims, drug cost (big one), healthcare utilization, etc. will save them billions easily.

Do you have anything to back this up? I work for an insurance provider, and this is not accurate in my experience.


>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.

back what up?

I’ve personally sent Jeff Bezos an email to take on more for-purpose capitalism.

Something can be good for the bottom line and good for society. It’s not one or the other!

You’re right, but respectfully, in the long term, “I want this specific provider at any cost” is somewhat of an edge case. A lot of (most?) people just want good healthcare and a low cost. That’s a complex but solveable problem.

No, its not an edge case. If you have a rapport with a doctor/care provider, you would want to stay with them. I have a genetic disease and an endocrinologist who helps me manage it. I wouldn't want to leave that doctor, who has seen me multiple times, has my charts, understands what Im working with, and so much more.

People want to believe that their medical condition(s) are a special, one-in-a-billion mix requiring years or decades of rapport-building and conversations. That's not the case for the vast majority of people, even with very complicated medical histories and diagnoses.

"Has seen me in the past" and "has my charts" are not indicative of medical efficacy. There are doctors I have rapport with, absolutely. I still have lunch occasionally with the physician who was my family doctor as a child and still sees my parents. But that doesn't mean his medical treatment is going to be any better than a doctor seeing me for the second or third time.

there is clinically proven evidence that seeing the same provider in the same setting improves outcomes:


There's also clinical evidence in favor of placebo usage, that doesn't mean that placebos increase medical efficacy, it means sometimes people just need to feel good about what's happening. And people - myself included - would probably prefer seeing the same physician long term.

Given the tiny slices of time doctors seem to have for each patient, it would seem that having time and history to have actually spent time with patients and their medical background would seem to be a common sense advantage. It's good to see that borne out in evidence.

Wait...except the decrease in care when transferring a patient to a new doctor is the EXACT reason health care professionals say we can't put a cap on working hours and introduce more doctors to help with the work-load.

They always says it hurts the patient's care. I think there is some truth to both sides, but we'll probably never know. Too many people are making out like bandits in the current health care system.

I'm sorry but that does sound like the definition of an edge case to me. You have a rare situation that requires a unique solution.

I bet that health outcomes are improved with longer term patient-physician relationships - Imagine having a new family doctor every year vs. a doctor who has known you for the last 15 years.

edit: This (quite extensive and longitudinal) study would suggest that it's true. Check out the sources on the paper for other studies with similar findings:


I'd like to see some evidence on that because I can imagine staying with one doctor might result in some conditions not being diagnosed.

Indeed - I am familiar with people who were misdiagnosed by a GP (in England) for over a decade before a visit to a different doctor yielded the correct diagnosis and treatment.

Updated my post - The introduction provides a decent overview of other studies (and and their limitations) suggesting the same results.

Each rare disease is rare, but it is not very rare to have a rare disease. There are just thousands of rare diseases. For example, it is estimated that 6-8% of the EU population has a rare disease: https://en.wikipedia.org/wiki/Rare_disease#Prevalence

Wanting to continue to see a provider that you know and trust is an "edge case" now?

We truly live in the darkest timeline.

But isn't that OP's point? By nature of your specific disease/condition you are a bit of an outlier no?

Obviously the ideal would be you have a system that accommodates "my kid has a fever/fell out of a tree and broke their arm" majority of medical issues who could be helped by basically anyone trained in basic medicine while also accommodating people who need a rapport with a highly trained/expensive specialist.

That's how I took the comment...apologies in advance if this comes off as insensitive to your condition, definitely not my intention.

I've had great luck with just using whatever specialist is in network by default, and just calling or emailing my old doctor for a second opinion if something weird happens. I assume not all doctors are so communicative, but I think many are happy to help as long as it doesn't take much time.

> “I want this specific provider at any cost” is somewhat of an edge case

Not really. I want someone I can trust. For my primary care needs, I have established trust with someone and know their capabilities, their business practices, and their character. I don't want to roll the dice with someone new when I can still go to them.

Example 1: My primary care provider(been seeing him for 10 years.

Example 2: My dentist (been seeing him or his predecessor for 30 years)

The OP reports the insurer misrepresenting their in-network coverage. I've had this experience with BCBS -- the list of in-network doctors on the website was wrong. Hard to prove incompetence vs. malice, but there seems to be zero accountability for this sort of thing.

Agreed. Care continuity is certainly important, but it's not $30k-out-of-pocket important...

Hearing the report on Bloomberg news earlier today. Isn't this just for the 900k employees and isn't it just focusing on wearable tech?

It sounded more like fitbit with cloud services than insurance.

>It sounded more like fitbit with cloud services than insurance.

If there are healthcare providers involved giving direct healthcare, there will need to be systems and development around medical records. That could easily be sold as a product to hospitals and providers outside of the AMZN/JPM/BRK company down the road.

Taking a "beginner's mindset" to me sounds like they plan on writing their own stuff, except for interoperation like HL7, which is great because most of the stuff from EPIC/Allscripts/Cerner is drowning in technical debt.

"beginner's mindset" was my favorite line in the article. Classic Bezos. Yes, it might indicate building their own stuff. I also interpret it that sometimes the experts are too stuck in their ways.

> Isn't this just for the 900k employees and isn't it just focusing on wearable tech?

I believe it's initially for the employees of those companies. If they can make it work for them, they have a great team (ecommerce, finance, insurance) to back a larger rollout. The announcement says it's about providing healthcare at lower cost with better results, which sounds like a lot more than wearables.

Stock market seems to confirm that theory. All the other healthcare stocks opened down this morning.

Kaiser Permanente was originally just for employees, so, you know, it could go somewhere.

Your desires are mutually incompatible. Imagine you’re contracting for cloud hosting services, and you start with the premise you’re not going to switch away from your existing provider. How do you achieve cost efficiencies in that situation?

I wonder if we could collectively use civil disobedience and refuse to pay for healthcare and insurance until major changes are made to the system. Non violent civil disobedience. Essentially a strike against the system.

You could until someone gets sick and needs medical services, hoping they don't go bankrupt due to their lapsed coverage due to non-payment.

The biggest problem I see are the costs. The healthcare industry can't even tell you why costs differ on so many levels of services. The industry isn't transparent and they'll fight this because it's too profitable for them.

What would you change?

So basically the new company told you 'If you like your doctor, you can keep them!'?

You should sue them for fraud.


Let's tear down on the government restrictions on the sell side of the market before we champion the glory of the market.

Repeal EMTALA. No patents. No certificates of need. Make Medicare and Medicaid fully opt in for providers. Create a path for additional private organizations to certify medical schools.

Anyone refusing to do all that stuff and face the political consequences for it just wants to pay less taxes.

Let's absolutely do all of those things.

Healthcare is a horribly overexpensive market precisely because of those things you mentioned.

I wasn't getting as specific as "championing the glory of the market". But in a general sense, what you are referring to the "market" is really the origin of control. Who is in control over your life and decisions in it and the consequences from it ... are you in control or some other party like politicians or bureaucrats who lord and decree and impose what you can choose if you have a choice at all, which invariably must include the ability to exclude oneself from matters that are not a common expense and value, which cannot be individually separated out like defense or cost of core governmental functions.

It's the age old question, who is a better person to make decisions for yourself, you yourself, or some person somewhere that believes they know better what is best for you in your particular set of circumstances. Some call it communism, some marxism, some authoritarianism, some totalitarianism ... but ultimately they are simply differing degrees and characteristics of the same question ... who controls your life?

Okay, lets start by repealing limited liability for investors.

If the government has no place simplifying the process of buying insurance (by making sure products are available, comparable and reliable), then the government has no place protecting people from legal consequences related to their investments.

If my employer buys health insurance for me, neither they nor I pay taxes on the premium cost. If I buy the exact same policy for myself, it is fully taxable to me. The amount of taxes is not small, about $1000 per month. So, the government is already imposing a very strong centrally planning effect on how health care works by tax policy.

Or it's the eternal struggle of a community whole trying to overcome ruthless selfishness of those in power.

Your naked partisanship is ugly and unhelpful.

>and are thereby inherently inefficient and wasteful

The many healthcare systems generally described as "socialist" are more cost-efficient than the American system.

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