Hacker News new | comments | show | ask | jobs | submit login
Health Insurers Are Vacuuming Up Details About Customers (propublica.org)
193 points by marchenko 3 months ago | hide | past | web | favorite | 253 comments



Whenever someone says that AI and IoT would automate insurance underwriting, I start to fret — because it very quickly starts to imply more and more data collection. This is like pre-crime but for your health. Meaning, you start paying high premiums right away because later in life you might be at a high risk for a specific condition. (I know this already happens for smoking, but that is declared on a form — not by a company sending a drone to spy on you)

Since this is a startup forum — I believe health insurance to be so dark and morbid (with things like companies haggling with living relatives about ventilator care) — there is got to be a better way! (I realize this is more of a lament than a constructive suggestion)


"there is(sic) got to be a better way!"

There are two better ways - each at a different end of the spectrum.

You can give up entirely on government intervention in health insurance and social "goods" being pursued - everyone is on their own and "healthcare" is a private, personal matter. You can play these agency/incentive games with insurers for better or for worse and you're on your own.

OR

We declare "healthcare" to be a public, common good and completely socialize it. Like roads and fire departments.

What these two different strategies have in common is that both of them are intelligible, reasonable and give people a framework for planning and making long term decisions.

Anything between these two points on the spectrum is unintelligible and unsustainable. You would probably be better off with (the option above that you like the least) than any option between them.


> Anything between these two points on the spectrum is unintelligible and

... very fucking profitable. I mean, the most significant part of "health insurance reform" was to penalize people if they choose to opt out of patronizing these private companies. Some reform!

I'd actually nitpick and say there are sane ways to combine the two regimes. For instance, a base level of common care, and then a functioning market for elective care, additional care, and upgrades.


> I mean, the most significant part of "health insurance reform" was to penalize people if they choose to opt out of patronizing these private companies.

Citation needed for excess profits. As I understand it, now that that requirement has been removed, most companies have dropped out of the Obamacare-market. That seems to me like they were previously only making near the bare minimum that made it worth their while.


Leaving the "Obamacare-market" doesn't imply a health "insurance" company is then operating as some bastion of the free market. The entire sector is rotten, easily demonstrated by providers not publishing a uniform list of prices for every single customer.

In general, a lack of legibility to consumers means they are unable to choose efficiently, which implies that the other party is likely taking an outsized amount of profit. Much of that profit goes to paying the paper pushers who keep the system opaque, but from the consumer's perspective that's little consolation.


> The entire sector is rotten, easily demonstrated by providers not publishing a uniform list of prices for every single customer.

Why does that imply that the sector is rotten? Supermarkets don't publish the amount they pay for food, for example. It's a valid negotiating strategy; it means that offering a low price to one consumer doesn't mean that they have to offer it to another.

I suspect that the care-providers and care-purchasers are too close, and that collusion is a source of the extra cost that Americans experience. (They also have far reduced waiting times, which is a genuine expense).

In the UK, the NHS is funded from taxes. I don't get a choice whether I pay that or not. Mandatory insurance (or an equivalent) for all is a common factor in well-run healthcare systems worldwide. Without it, it's a bit like allowing car drivers to not purchase insurance until after they've crashed.


> Why does that imply that the sector is rotten? Supermarkets don't publish the amount they pay for food

Supermarkets do publish the amount they charge people for food. In fact, they often push it to you every week whether you want it or not!

It seems like you're trying to flip around the analogy and apply it to insurance companies rather than medical providers. But my point is that in a functioning market, we would expect there to be cash customers for many services - people who have the means to accept a higher variance for a higher expected value and thus forgo some level of insurance. The lack of uniform transparent pricing discourages this, pushing such customers into buying "insurance" to avoid being ripped off in an uncompetitive consumer market.

And yes, opaque pricing is certainly a "negotiating technique" - right out of Oracle's playbook. This is not a justification though!


Sorry, I was talking about insurance companies. I forgot that you can actually pay cash in America for medical services. It's a totally alien idea to me.

Insurance in America is supposed to be buyers of medical services clubbing together to get a better deal, similarly to people unionising for better conditions.

Allowing people with no negotiating power to purchase services is a bit nuts, but I'd hope the high prices would put most people off. It's like letting people by food on trains. Of course it's overpriced, you're a captive market (sometimes literally in a hospital).


From a USian perspective I think it's worthwhile to think in terms of the "base case" of individuals paying cash - from the perspective of the median person, our "health insurance" system is primarily a way of getting upfront pricing.

I don't focus on the market dynamics to argue against a single payer system (it does seem to tackle the problem better than we've currently got), but to point out the utter hypocrisy of labeling the current regime as anything remotely market-based. As I said above, I'm personally open to a fusion of the two different philosophies when they're sensible together - not the worst of both as we tend to get in the US.

To go with the train analogy - it's like knowing snacks are $8/ea on the train, so you're encouraged to buy a $20 pass for "all you can eat". Then you get hungry and find out that the pass just means you can wait in line for an hour to get one small snack at a time. The pass wasn't actually a solution to the high prices, and making buying the pass mandatory certainly isn't going to help the overall situation. Barring an honest train operator, the only thing that will keep prices down is actual competition - in this analogy the people who plan ahead and pack their own snacks obtained from an outside vendor.


> I suspect that the care-providers and care-purchasers are too close, and that collusion is a source of the extra cost that Americans experience. (They also have far reduced waiting times, which is a genuine expense).

You've got it completely backwards - the providers and payers are dramatically less connected in the US compared to the NHS in the UK.

In general, the US is moving towards more captitated models, but if anything, this is bringing their incentive structure closer in line to what providers in the NHS already experience.


Sorry, I meant the somewhat cosy relationship between the drug companies, the insurers and the doctors. Care provider was probably a poor choice of words.

Maybe it's because of the newspapers' portrayal of NICE as a death panel here, but I find it hard to believe that they're cosy with anyone.


> Sorry, I meant the somewhat cosy relationship between the drug companies, the insurers and the doctors.

Yes, and this is exactly what I'm talking about.

> Maybe it's because of the newspapers' portrayal of NICE as a death panel here, but I find it hard to believe that they're cosy with anyone.

NICE is many things, but they're certainly not "nice". And where that shows the most is in treatments for complex conditions (especially cancer).

But beyond that: providers under the NHS have dramatic leeway in determining appropriate steps for care (that's inherent to the practice of medicine itself), and they are both explicitly and implicitly expected to consider costs as a factor in that decision-making.


> In general, a lack of legibility to consumers means they are unable to choose efficiently, which implies that the other party is likely taking an outsized amount of profit.

This is wrong. Not only is it possible for an inefficient market to produce a state that is suboptimal for both buyers and sellers, but in fact this is literally the textbook definition of economic inefficiency.

Just because the consumers are suffering from the inefficiency, that doesn't mean that the insurers aren't as well. It's not surprising that neither insurers nor patients are happy with the situation.


> You can give up entirely on government intervention in health insurance and social "goods" being pursued - everyone is on their own and "healthcare" is a private, personal matter.

Except Kenneth Arrow showed market based health care doesn't work. That was in 1963. Since then the US has pursued market based heath insurance for ideological reasons and... that doesn't work without vast government subsidies. The government pays enough subsidies to cover a socialized system.

http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf


> Except Kenneth Arrow showed market based health care doesn't work.

That is a really disingenuous reading of Arrow's work. Even if you ignore the myriad of ways in which the global heathcare market has changed in the last 55 years and how those affect the US (which is the largest player in the global system), that's still an unjustifiably broad interpretation of his research.


> That is a really disingenuous reading of Arrow's work

You say so, but provide no examples. So your argument is an unsupported conclusory one.


> Since then the US has pursued market based heath insurance

I wouldnt consider hundreds of millions of dollars of bribery 'market based'

https://www.opensecrets.org/lobby/top.php?indexType=s

Physicians are one of the biggest reason healthcare is so expensive. Ive seen studies saying physicians account for 10-20% of all US healthcare spending.

Physicians play that off like- Oh only 10%?

But the reality is that the hospital parking lot, the IT, the nursing staff, the electricity, the software, landscaping etc.... all go into that. So 10% of spending being on Physicians is quite high.

Its a cartel that they continue to regulate to make more difficult to be part of.

I genuinely hope medical tourism becomes established because US physicians are corrupt.


The point that I didn't really make is.

Companies that are successful working inside an open market don't bribe the government to provide them subsidies and protection. The system we have is the result of 50 years of market failure and government intervention.


> We declare "healthcare" to be a public, common good and completely socialize it. Like roads and fire departments.

1. Lots of places have private roads without much trouble. France's autoroutes are perhaps the most famous example.

2. Many of the world's most successful universal healthcare systems are run at least partially privately. The first point of contact one has with the NHS, for example, is through a general practitioner via medical practice, all of whom are private businesses (free at the point of use).

I don't see why you think a hodgepodge of private and public, as exists in many places already, would be such a problem; I totally fail to see how making everything completely private would be a better solution than that. You'd end up with horrendous lemon-dropping.


It's like when the government tries to address an oversupply of luxury apartments by renting them at full price and re-renting them at subsidized rates to consumers. I forget where this happened, but it was covered on Marketplace a few months ago.

That "solution" is objectively worse than either the extreme libertarian position or the socialist position (though there are economically sensible positions between, this just doesn't happen to be one). It preserves artificially high demand for these luxury apartments, costs taxpayers a ton of money, and around the waste-cycle we go.


There is a better way, it's called single payer universal healthcare!


Please no, I don't trust the government at all to handle healthcare efficiently. And I enjoy my insurance company through work, its the equivalent to a significant raise each year


> Please no, I don't trust the government at all to handle healthcare efficiently.

If only we had literally the entire rest of the developed world to demonstrate that it's doable, with dramatically lower costs (and yes, that includes the tax portion) and similar health outcomes.


In the entire rest of the world it is much easier to mandate things to the people. It is much harder in America as many voter will see it as a slippery slope against individual liberties. "First its my health care, next its my guns, and finally its my freedom of speech" will be the argument preventing it from occuring


You're moving the goalposts. First "government can't do it efficiently," which is wrong, so now it's "it's not politically palatable."

The first step to making something politically palatable is actually making the case for it and building momentum. If you frame it with political palatability as the metric for whether you actively pursue the policy, the whole discussion devolves into a chicken-and-egg problem.


[flagged]


> Okay we'll go back to the efficiency issue.

Oh, let's. https://en.wikipedia.org/wiki/File:OECD_health_expenditure_p...


I think that is proving my lack of faith in government efficiency


correction, rich in US are dominating. rest of us are nowhere near reaping the benefits of 'selective capitalism' here. case in point, elsewhere in HN today there was a story comment made by fed chair to that effect on economic growth.


> Please no, I don't trust the government at all to handle healthcare efficiently.

Universal healthcare doesn't mean the government handles healthcare.

> And I enjoy my insurance company through work, its the equivalent to a significant raise each year

You can still get your healthcare from your employer with universal healthcare. You'll just be covered in the event of losing your job. Probably paying less for it too.


There's nothing stopping companies providing extra private healthcare on top of government provided universal healthcare. It's very common in the UK.


This sounds like another way the rich get access while the poor are stuck with crappy government care.


"Crappy government care" is better than none. And it's only "Crappy" because of the following:

1. Cut funding to govt services

2. Complain about bad govt services

3. Repeat


idk, the US spends more than any country on their education, but we dont produce the smartest students.

Money is minor compared to the culture found in a government agency


> the US spends more than any country on their education

From a general review, it appears we're in the top of spending. There's a good reason why: government services have been privatized and contracted out. So when the govt could have did it for X$, the for-profit private entity charges 2*X$. And this happens across the government at all scales.

I work in a regulated industry and have called three letter agencies over computing issues. 95% of the time, I end up getting another contractor.

> but we dont produce the smartest students.

But we create rich companies who suck on the public teet.


You really found a way to do mental gymnastics around this.

None of this is avoidable. Give money to the government, they are going to give it to their friends.


The problems with governments (notice the plural) is that their activities and expenditures are not public and transparent. Having how the money is flowing, and for what and to whom would clear this up tremendously.

And frankly, when companies get their hands into it, they are going to extract profit from it. Government isnt bound by shareholders or profit-seeking behavior. Doing things at cost is not only acceptable, but expected.

There's times and places where governments providing the service makes a great deal of sense. It's times for libertarian types to actually realize that game theory does indeed show good reasons for govt services.


Or they could work where there is better healthcare. Even as a lot boy at Home Depot the healthcare was pretty reasonable and much better than the governments


DO you trust it with defence, etc.?


To play devil’s advocate, a government’s primary duty has been defense since the dawn of organized government. The U.S. government began in an armed rebellion. Moreover, there’s no reasonable alternative to the government having a monopoly on defense.


I trust it with defense and that's about it. I don;t even trust local governments to efficiently maintain roads


except that every major industrialized nation out there has figured out how to do it well except us. if it works for them it can work for us.

BTW what happens if you lose your job? do you know what the helthcare options for next job are going to be? Heck, your own company can have a few bad quarters and goto a sh*t insurer and you are back to averages.. never ignore the base rates and base rates suck in us healthcare.


> except that every major industrialized nation out there has figured out how to do it well except us. if it works for them it can work for us.

"every other major industrialized nation" has a healthcare system that's deeply interconnected with the global healthcare market, which is itself heavily dependent on the revenue that is generated from the US market.

You can't compare the US to Europe without also factoring the massive benefits European patients get from the high costs in the US.


> You can't compare the US to Europe without also factoring the massive benefits European patients get from the high costs in the US

Luckily for us all the major pharmaceutical companies are public and we can can see exactly where they generate their revenue. Maybe you can show us exactly by how much the US subsidises Europe then. I suspect not by much.


> Luckily for us all the major pharmaceutical companies are public and we can can see exactly where they generate their revenue. Maybe you can show us exactly by how much the US subsidises Europe then. I suspect not by much.

All pharmaceutical companies - including those based in Europe - derive the lion's share of their revenue from the US market, despite the US having half the population.

That's pretty obvious from the relative prices of drugs in the US versus Europe and the quantities sold, but take a look yourself if you want.


> All pharmaceutical companies - including those based in Europe - derive the lion's share of their revenue from the US market, despite the US having half the population.

Again, not true. And easily verifiable. Take Norvatis for example, one of the biggest pharmaceutical companies in the world. Europe 36%, America 34%. [0]

> That's pretty obvious from the relative prices of drugs in the US versus Europe and the quantities sold, but take a look yourself if you want.

It's not obvious at all. Drug spending is a fraction of health expenditure in the US. Just because a drug is expensive it doesn't mean that money goes to the manufacturer. There's a lot of factors involved that increase the price (for profit insurance companies taking a cut as an example) and it's true in all industries.

[0] https://www.novartis.com/investors/novartis-annual-report/no...


The US government already pays more per capita (that is, more for every single living person in the USA) for healthcare than any other nation on earth.

This is entirely WITHOUT universal public insurance, the US could easily save money by making public insurance avalible for everyone.


With public insurance you would have no customer base besides those who are high risk. As a healthy individual there is absolutely no way I would sign up for universal healthcare. Thankfully the government won't be able to mandate it anytime soon as we have a first and second amendment protecting citizens


> As a healthy individual there is absolutely no way I would sign up for universal healthcare.

That's fine, because you don't have to. It's just there if you need it.

> Thankfully the government won't be able to mandate it anytime soon as we have a first and second amendment protecting citizens

The First and Second Amendments didn't prevent Social Security or Medicare. Why would it be any different for Medicare-for-all?


> The US government already pays more per capita (that is, more for every single living person in the USA) for healthcare than any other nation on earth.

The US also implicitly subsidizes all of the research and operations of the rest of the world. Over half the medical research in the entire world is directly funded by the US, and a significant portion of the rest is indirectly funded by sales in the US market. Biomedical and pharmaceutical companies in Europe make the lion's share of their revenues from the US, despite the US being half the population.

You can't compare the US and European healthcare markets without accounting for the fact that they're deeply interconnected, and the biggest beneficiaries of that interconnectedness are, in fact, European patients.


> And I enjoy my insurance company through work [...]

This is something that always bothered me about the American healthcare system. Isn't it profoundly un-American to depend on your employer for such a personal matter? I know that work is highly valued in the US, but this is almost a slave-like relationship... If you are going to be so dependent on some orgnanization, wouldn't it be preferable to depend on a democratically elected one?

I know that European-style healthcare smells too much of socialism to you guys, but doesn't your current system smell of feudalism?

Gibbon1 3 months ago [flagged]

Found that guy that's never ever had a serious health issue.


I had a few surgeries but nothing major. I enjoy my insurance but don't want to cover people who are overweight and/or lazy


So, you are fine covering people's stupidity when being active? Or you are only interested in not covering people you perceive as being a moral blight?


How would you feel if insurers prodded overweight people to exercise and eat better, or else their rates go up or coverage cut altogether?

How would you feel if insurers prodded lazy people to engage in healthier lifestyles?

Empowering insurers could be useful in this regard.


I would feel very good about both of those things. Insurers should be free to incentivize healthy behavior


> Found that guy that's never ever had a serious health issue.

No, people who have serious health issues are the ones who tend to prefer the more complex treatment options, shorter wait times, and customizable interventions that multi-payer systems have to offer.

People who don't have complex health needs are the ones best served by single-payer systems like the NHS - and the data around treatments for complex conditions (like cancer) backs that up very plainly.


Plenty of folks that have complex health needs are best served by single-payer systems. Especially if your complex health needs winds up getting you fired from that employer that pays for part of your premiums, works someplace with crappy health insurance, or pays too much out of pocket to afford proper care.

Besides, you can get those things with single-payer health care by purchasing private insurance on top of the single-payer plan or simply visiting private places instead of the state-funded ones. Here, the state still pays the private places their normal fees and the extra payment from the patient provides bells and whistles, generally including things like shorter wait times in some cases.

Just because you have a serious health issue doesn't mean you need a complex treatment option. A gall bladder can be a serious health issue. All interventions are customized to the patient based on medical standards lest you risk injuring the patient. You also aren't as likely to get the slew of run-arounds when changing health insurance or doctors (migraine sufferers often have to repeat treatments that didn't work or find their medication that works is no longer covered, even if their medical history reflects this). You aren't getting repeat tests because the others were out of a hospitals' network either (happened to my aunt).

Gibbon1 3 months ago [flagged]

> No, people who have serious health issues are the ones who tend to prefer the more complex treatment options, shorter wait times, and customizable interventions that multi-payer systems have to offer.

This statement shows an utter lack of experience navigating the insurance/medical complex with a serious health problem.


> This statement shows an utter lack of experience navigating the insurance/medical complex with a serious health problem.

It's pretty arrogant to assume that anyone who doesn't support government-managed healthcare has no experience with dealing with serious health problems, which you've done twice in this thread alone.

I'd encourage you not to do that. It doesn't lend itself to productive conversation, and shallow, pithy dismissals are against HN comment guidelines.


While its called its called Health Insurance, it should be called health care costs.

The US is the only 1st world country without universal healthcare. The thing is most of us already subsidize the healthcare industry. The hospital has to treat someone in an emergency if they take medicare or medicaid. A lot of times people are using the emergency room as their primary care since they can't afford primary care. The hospital increases the rates it charges everyone else to cover this.

You can use data to predict who is going to be more sick and charge them more. However do you want them to die or suffer. I wouldn't. So why not try to fix the big problem instead of all these little ones about data misuse and just cover everyone since you are paying for them anyway.


> The thing is most of us already subsidize the healthcare industry. The hospital has to treat someone in an emergency if they take medicare or medicaid.

The "subsidies" run the other way. Medicare reimbursements do not cover COGS, which means that providers cannot sustain themselves solely on Medicare reimbursement rates; they need to take privately-insured patients (whom they charge dramatically more) in order to stay afloat[0].

These costs get passed on to privately-insured patients in the form of higher premiums.

[0] Medicare acknowledges this, and in fact, Medicare even runs multiple stipend programs to essentially pay extra to hospitals who don't see enough privately-insured patients that they can make up the difference. If they didn't, those hospitals would close, because you can't lose money on a per-patient basis and still run a practice, even if you managed to recruit doctors, nurses, and staff who agreed to work for free as volunteers.


> Insurers contend they use the information to spot health issues in their clients — and flag them so they get services they need.

Horse shit. And I say that as someone who writes claims management software for the healthcare industry.

I challenge ANY health insurer to provide examples of this. Of course, they won't, because they'll cite "patient confidentiality", but that just doesn't happen.

They've wanted to do this for years, though, and try to. Requests to be able mine claim data for familial predispositions to diseases was one that we fended off multiple times.


You may have fended it off but I assure you there is a whole industry devoted to using claims and other health data to manage care and costs. Insurers are primary partners of these companies and act as both providers and consumers of the data.

Not just insurers, but big hospitals and provider networks, too.


We're going down some kind of bizarre path. Insurance is ultimately about risk sharing. If every risk is modeled then there is no insurance, just expensive prepayment.


This is the core problem of health insurance as currently structured in the US -- everyone will make a claim eventually so it's effectively a whole life insurance policy except the payout is sporadic and involves tons of bureaucratic crap. I personally would be fine with either universal healthcare or regulating the marketing to outlaw non-catastrophic health "insurance" thereby forcing routine care to be a direct payment relationship with your doctor.


The major problem with that is there is no price transparency. If I go see a doctor, I have no idea if I will end up with a $40, $400, $4000, or $40,000 bill until the bill comes months later and I have to pay it.

I’m relying on insurance because going to the doctor is such a financially risky gamble.


True, and the pricing issue goes even deeper. In my experience in shopping around between doctors while being in an exclusionary waiting period the doctors themselves often have no idea what anything costs.

That's why I think banning non-catastrophic insurance would be helpful. I'm confident if insurance companies were kicked out of routine healthcare you'd see a very quick shift to price transparency.

There's one doctor here in town that mostly caters to undocumented immigrants and he has a price board in his waiting room for cash price of most of the common services. BCBS (which is 90+% of the insurance market in my state) actively prevents other doctors from doing this. He can only do it because most of his patients don't have insurance.


> There's one doctor here…

We visit the clinicas here in L.A. as well, paid $130 for X-rays recently. Reminds me of trips abroad.

That's all I want from health care, simple and transparent.


> If I go see a doctor, I have no idea if I will end up with a $40, $400, $4000, or $40,000 bill until the bill comes months later and I have to pay it. NO IDEA.

This is what's really strange about the American healthcare system. For everything else in America you can either get a price up front or an estimate of total costs up front. Why should going to the doctor be any different than going to a mechanic? Pay advertised flat rates for issue diagnosis, and get estimates for the problem.

Yes, in cases of emergency you can't really shop around too much, but the majority of the time you're going to a doctor, you could at least call and get estimates of how much things will cost. It's not even possible to do this with most healthcare organizations. If you call your doctor's reception and ask "how much will it cost for this visit?" they'll tell you they don't do billing and they won't know until it's processed by insurance.

Price transparency in the healthcare market - or at least some decent estimate of it - would be a great thing to see. American healthcare is ridiculously inefficient because it appears wholly designed to be byzantine.


> This is what's really strange about the American healthcare system ...

It gets worse. Each entity in the system applies their own rules. eg a friend had an eye exam at the doctors and they took 11 months to bill[0]. The doctor group pointed out their small print says they have 12 months to bill. The insurance company had a shorter time frame and refused to pay. But it was a scam - the doctor had changed the diagnosis code to get more money, and the insurer would have refused to pay so they kept more money. My friend lost.

It is very easy to see which proposals will "fix" things. Look at which groups make less money due to the fixes (doctors, insurers, medical groups, equipment makers, drug companies etc). It is extremely rare for that to be shown, and all those groups will fight to keep what is "theirs".

> American healthcare is ridiculously inefficient because it appears wholly designed to be byzantine.

I like the word confusopoly https://en.wikipedia.org/wiki/Confusopoly

  Confusopoly is an economic and marketing term referring to a purposeful
  act by a seller or group of sellers to confuse the buyer in order to ease the sale
[0] those fortunate enough not to deal with USA healthcare are probably wondering how this could happen. The answer is that any visit now results in a blizzard of electronic and paper communication, including satisfaction surveys, "courtesy" statements with many dollar numbers all over them that don't add up, stuff telling you legal information, and more saying one party has done stuff (eg billed or paid) on your behalf but you are still liable if it doesn't all complete, co pays, deductibles, random others because of in and out network nonsense etc. And this is a superficial description - how would anyone know?


Or we could just have universal healthcare with government-set price controls, just like Japan does. The ultimate in price transparency. Everyone is healthier, lives longer, and it’s far cheaper.


I'd be fine with that, but I'm acutely aware living in the deep south that MANY people would not be happy with that. If we're talking about what's politically feasible within the US, "universal" healthcare is only really an option at the state level, or maybe with some federal maneuvering, as a multi-state regional coordination. It's simply not going to be accepted anywhere in the near-future on a national level.

For the parts of the country that are rabidly anti-universal healthcare, a more free market solution would be a nice consolation prize.


I disagree, I think they'd be extremely happy with it... as long as they were prevented from seeing the words "socialized" in any context around the program until they'd seen the benefits.

A large portion of the country working full time already has their employer offered health plans supplemented by Medicaid anyways.


There’s already tons of people on Medicare and Medicaid in red states and there hasn’t been an armed insurrection.

I think that working class people in these regions wouldn’t be adverse to Medicare being expanded to include them. I’m sure the Republican Party base of upper middle income and wealthy whites would be, but again, not so much everyone else there. It’s a matter of how and what constituencies you recruit and activate.


> I think that working class people in these regions wouldn’t be adverse to the program being expanded to include them

It’s so strange, the people who would most benefit from universal healthcare (and those that currently do, like Medicare beneficiaries) tend to be the strongest objectors to it, citing hard-to-understand ideological reasons.


> It’s so strange, the people who would most benefit from universal healthcare (and those that currently do, like Medicare beneficiaries) tend to be the strongest objectors to it, citing hard-to-understand ideological reasons.

It's not so strange if you allow yourself to question the assumption that they'd benefit from it in the first place.

Medicare is a great example. Patients can opt to receive their Medicare inpatient and outpatient coverage through a private plan instead of through the government-managed plan. Since this program was introduced, it's gained popularity rapidly, over a third of Medicare beneficiaries receive their benefits from private plans. Many private plans are the same price as Medicare or cheaper.

From the data, the private plans beat government-managed plans on the three major metrics: medical outcomes, cost, and patient satisfaction. On the last one, the difference isn't even close: the worst of the major private plans (by patient satisfaction scores) still manages higher scores than Original Medicare does.

People who haven't ever dealt with Medicare themselves directly (which includes most HN commenters) find this hard to understand, but it really isn't: dealing with Medicare is awful. I could give you my personal anecdotes, but they'd overfill the comment length on HN, and again, at the end of the day, the numbers speak for themselves. Medicare beneficiaries themselves are turning to private plans to replace their government-managed plans, so it's really not surprising if they're not the biggest advocates of expanding government-managed plans.


The private plans you refer to are mainly either simply administrators (the government pays them to administer the benefits) or supplemental providers or both. And their existence and popularity has more to do with their sponsorship by insurance funded politicians than anything else. Dealing with these administrators isn't generally better or worse than dealing with the government directly. Exceptions exist, but that goes without saying.


> The private plans you refer to are mainly either simply administrators (the government pays them to administer the benefits) or supplemental providers or both

No, they're much more than that.

> And their existence and popularity has more to do with their sponsorship by insurance funded politicians than anything else.

The programs are cheaper, provide better medical outcomes, and patients prefer them.

That doesn't mean they're perfect, but you have to bend over pretty far backwards to say that they're inferior and only popular because of "insurance-funded politicians".

> Dealing with these administrators isn't generally better or worse than dealing with the government directly. Exceptions exist, but that goes without saying.

It is monumentally easier to deal with private insurers than to deal with an Original Medicare plan.


59% of people support Medicare for All and 75% a public option. When phrased as "Medicare-for-some," support among GOP voters is 64%.

It’s a corporate-controlled media narrative that these things are unpopular.

http://www.businessinsider.com/poll-medicare-for-all-public-...


Be careful interpreting polls. Question wording bias is very powerful. If you ask them whether they’d be willing to pay higher taxes for Medicare for all, it’d much less popular. Just like how a huge majority support renewable energy in surveys, but the same overwhelming majority refuses to pay even 5% more for electricity.


Which only shows that opinion on these issues is malleable and not ideologically-fixed, as many would like to portray them. Understanding your constituency and being successfully persuasive is a fundamental part of any politics.


> If I go see a doctor, I have no idea if I will end up with a $40, $400, $4000, or $40,000 bill until the bill comes months later and I have to pay it. NO IDEA.

Totally right. Which means in practice insurance is covering the risk of pricing rather than the risk of you having health issues.


It’s a total racket. The worst part is that they’ve managed to tilt the playing field in their favor for even routine fees. Cash prices are higher than “pre-negotiated” reimbursements, unless you cry poverty and a billing clerk cuts you a discount after examining your tax return and assets as an alternative to collections. So you have to buy insurance which is an act that reinforces the hidden inflated prices model.

Average people only have one rational response to random prices: don’t go to the doctor voluntarily. But this can cost them their health in some cases.


Their health?

You mean their life. People actually die without health care. American health care is murdering Americans for profit.


Isn’t Amazon currently working on fixing this?

I recall seeing an article that Bezos was going to take on vertically integrated healthcare for his workers. And given Amazon’s history, the next step would be productizing that as a service for all comers with transparent a la carte pricing.


That's a good point and one I've never linked in my mind. My insurance company takes monthly payments from me in exchange for a certain amount of coverage, then they either mandate or strongly recommend that I go to the doctor regularly, which they will cover for a nominal cost to me... basically I'm paying for "insurance" for something that the insurance company has me do on a regular and recurring schedule (visit my doctor).

Whatever your politics on healthcare, it does seem insane that something as routine as visiting the doctor for a yearly physical could be so expensive that you need insurance to pay for it. Like you said, insurance should be to cover unpredictable catastrophic events. My homeowners insurance doesn't pay for roof maintenance until the old one fails. My car insurance doesn't pay for car maintenance until I've had a collision. Why is my health insurance covering routine maintenance?


"Why is my health insurance covering routine maintenance?"

Because the preventative care reduces the costs down the line, and there is no way for an insurer to check if people are actually doing their routine maintenance if they don't do it. So it's better to include it in the premium. It's different from your roof in that your HO insurance only covers freak accidents (not failure because of old age), whereas health insurance covers many old age related problems.


But going back to the car insurance example, making sure my brakes are working, making sure my headlights and turn signals and brake lights are working, making sure my tires are road-worthy, all of this highly decreases the chance that I will be in an accident that needs a payout from the insurance company.

In many states in the US, there actually are checks done for these things to make sure the car has had its routine maintenance performed... but they're not done by the insurance company. They're done by the government.


Don't forget regular maintenance to keep your warranty valid on a new purchase.


> In many states in the US, there actually are checks done for these things to make sure the car has had its routine maintenance performed... but they're not done by the insurance company. They're done by the government.

There are a whole lot of things that you can do to reduce your premiums for car insurance, homeowners' insurance, renters' insurance, and so forth. Those are determined by the insurance company, not by the government.


> Because the preventative care reduces the costs down the line

This is a common myth. Preventive care actually doesn't reduce costs, on net. It improves the overall quality of care, yes, but it doesn't (in aggregate) save more money than it requires.

For some conditions, early intervention is cheaper (and more effective) than delayed intervention, but that's not always the case - and either way, it's not considered preventive care.


> Because the preventative care reduces the costs down the line

I thought the evidence was that preventive care increases total lifetime care costs, but improves outcomes [0]. (Whereas, e.g., smoking reduces lifetime, though not per-year, healthcare costs, but made outcomes worse.)

[0] Which may still save your insurer money if it kicks costs down the road until your costs are covered, or at least subsidized, by Medicare. (Or change plans because of a different job, or otherwise are someone else's problem.) And even if it doesn't save the insurer payouts, it can make the insurer more money by keeping you alive, employed, and paying premiums longer—obviously, premiums are set so that on average the insurer makes money every year you are paying them, so if you are covered longer even if they are paying more bills on total, they are still making more money.


> My car insurance doesn't pay for car maintenance until I've had a collision.

You can buy prepaid maintenance plans for cars, they are just usually bundled with auto purchase rather than bundled with liability insurance the way some other coverage is; that's just a packaging detail, and there isn't a purchase-of-your-body to bundle maintenance plans s with.


Yes, the principle agent problem is truly the only problem that matters in US healthcare. Fix that and most of the rest of the system comes along with it.


You're right. In the US at least, health insurance is mostly a payment management scheme. Casualty insurance (for accidents, disasters, etc.) more closely resembles a true insurance product.


If I have a 1% chance of a car accident, I’d be happy to pay 1.5% the cost of hospital bills for insurance. Someone else with a 2% chance of an accident should be happy to pay 3%. That’s still insurance.

Only if you deny free will and assume perfect information and deterministic laws of physics, can every risk resolve to either 0% or 100%.


What is the practically relevant difference between 100% prediction capability and 99.999% prediction capability?


> What is the practically relevant difference between 100% prediction capability and 99.999% prediction capability?

If there were 100% prediction capability, there would be no risk to smooth, and there would be no reason to buy insurance, because the insurance would be more expensive than paying the costs of the would-be insured risk directly.


But with 99.999%, there is a risk to smooth in practice? How about 99.99999999999999999999999999999999%?


> But with 99.999%, there is a risk to smooth in practice? How about 99.99999999999999999999999999999999%?

Uh, I guess this question might be interesting from an academic perspective, but not a practical one. There's no risk out there which can be predicted with 35 nines of precision, let alone one that people are interested in insuring. And certainly not one in which the overhead of providing services wouldn't inherently dwarf any benefits to both parties.


In other words: There is no practically relevant difference between a prediction ability of 100% and 99.99999999999999999999999999999999%, which is exactly the point I was making: There is is nothing magical about the 100% mark--free will or assuming perfect information is irrelevant to the problem at hand, insurance becomes asymptotically less useful the better risks are modeled and used to set premiums where the premiums cannot work as an incentive to avoid the risks in the first place.


>just expensive prepayment.

you have discovered their business model.


PPACA legislation caps net income for health insurance companies at 15% of revenue.


… and now I have no incentive to press for lower health care costs, because if I succeed I get the same percentage of a smaller number.


Unless everyone had to sign up for insurance allowing enough population so that multiple health insurance companies can co-exist and compete on price.


There is a concept in insurance called "shirking," which is the principle of externalizing as much risk as possible.


All businesses are constantly externalizing costs.


I didn't mention costs.


Risk can be considered a cost. Expected value = sum of individual payoffs * their individual probabilities.


> We're going down some kind of bizarre path. Insurance is ultimately about risk sharing. If every risk is modeled then there is no insurance, just expensive prepayment.

This is completely backwards.

Insurance is about risk smoothing, across states of the world. Insurance should not have a positive expected value - that is, there should be no person for whom the total lifetime expected payouts exceed the total lifetime expected costs.

For a number of reasons, health insurance isn't actually insurance, and this is one of them. You can identify individuals who are dramatically likely to receive more money in payouts and benefits than they are to pay in their regular premiums, which means you're talking about a redistribution system, not an insurance system.


I think the point parent is making is that there's (nominally/supposed to be) smoothing across people too. The uncharitable description is that "healthy people are subsidizing sick people". Part of the reason we accept this is that each individual doesn't know whether she will get sick. She pays the premium, not because she knows she'll need it, but because she knows not having it is worse, if she gets sick. But the insurance also has price proportionate to the chance she will need it.

The more finely the chance it'll be needeed is known, the more closely individual prices will match the probability, and thus less smoothing will take place.


> I think the point parent is making is that there's (nominally/supposed to be) smoothing across people too. The uncharitable description is that "healthy people are subsidizing sick people"

That's a common refrain, but it's wrong and misleading. It's why people talk about young and healthy people being "necessary" to balance out the costs of the older and sick under the ACA. That's describing a redistribution scheme, not insurance.

> But the insurance also has price proportionate to the chance she will need it.

No, they don't. They price based on age, sex, zipcode, income, and smoking status. That's only very loosely related to the chance that she will need it. It's nowhere near enough to provide precise pricing.

> The more finely the chance it'll be needeed is known, the more closely individual prices will match the probability, and thus less smoothing will take place.

No, that's another common misconception. The price is not determined by the ability of the insurer to predict the probability of the risk; that's what determines the insurer's profit margins. Under a free insurance market, the price is determined by the relative demand and supply of patients and insurers.


As it in the US, that's already the case. It's amortized and expensive payments, and not "true" insurance.

Or rather, insurers like to take all of the pros of being an insurer, and none of the cons.

Risk pool didn't change by your entry into it? So what, if there's something deniable, we will. Etc, etc.


Very true. We're not perfect, but I am at least happy we made an ethical and moral (and in some cases legal) choice that I'm much more comfortable with than some others.


"You may have fended it off but I assure you there is a whole industry devoted to using claims and other health data to manage care and costs. "

If by "manage care and costs", you mean kick people off insurance and deny claims, then sure.


> If by "manage care and costs", you mean kick people off insurance and deny claims, then sure.

The prohibition of pre-existing condition exclusion and the associated practice of rescission in the ACA largely ended the “kick people off insurance” practice (and the limitation of profits to a percentage of actual paid bills eliminates some of the incentive on the other), though the current Administration’s drive to reverse those policies combined with the way the industry is vacuuming up personal data could make them return with a vengeance.


At what cost? Specifically, at what price point are the insurance co's limited to charge for PECs? Mandating w/o cost-controls is an invitation to charge as much as necessary to rid themselves of the liability, no? So my question is, where does it mandate what PEC costs are allowable to avoid abuse by providers?


> So my question is, where does it mandate what PEC costs are allowable to avoid abuse by providers?

The ACA prohibits denying coverage or charging additional premiums based on, or limiting in any way coverage for services because they are related to, pre-existing conditions.

(Now, within the existing state and federal rules on minimal coverage, insurers may limit coverage for particular conditions, but can't differentiate based on whether they were present before the person sought coverage.)

The real big deal, though, is the linked prohibition on rescission: before the ACA, insurance companies would frequently do focused investigations to find evidence of non-disclosure pre-existing conditions, however minor and unrelated to the current condition, when an insured person incurred high covered expenses, then use any discovered pre-existing condition as an excuse to retroactively cancel their insurance avoiding the high pending bills and dumping them on the patient.


They will return with a vengeance.

20 Republican states are suing to remove it arguing it unconstitutional and the Republican party gutted the penalty for not having insurance it was tied to. The Republican Party President, Donald J Trump, argues this mandate is inseparable from the entirety of the ACA. The Republican controlled Judicial Branch politically favors of the Republican Party.


Right. Given the aims of the current administration, unless something happens, I don't believe that those protections will survive. There is currently a court case in Texas which is stating that the protections around pre-existing conditions are not legal. The makeup of the courts, especially if Trump gets to nominate another justice, makes me believe they will kill it, and then we'll be even worse off than we were before.


You'd be surprised - your not seeing the informatics side I'm guessing - they take all the data from the claims system and use it to check if a patient is over 55 and has had a colonoscopy, or female and over 45 and hasn't had her annual breast exam. Things like that are common practice for major insurance carriers (see unitedhealth, blue cross, humana, etc) to notify their customers of opportunities.


Insurers are paid in premiums, not health outcomes. An insurance company is incentivized to help avoid costly claims, but if you are likely to make costly claims, and they can't drop you, they are incentivized toward healthcare choices that kill you before you need long-expensive term care.


> An insurance company is incentivized to help avoid costly claims, but if you are likely to make costly claims, and they can't drop you, they are incentivized toward healthcare choices that kill you before you need long-expensive term care.

Insurance companies don't make the choices - providers do. In the US, insurers have very little control over providers' decisions in most care settings.

Ironically, under capitated care, the provider acts as the insurer, and is expected to balance both the medical outcomes for the patient and the overall cost to the system directly in their decision-making. For some reason, that's the model that people seem to advocate in this (and other) HN threads about healthcare, which boggles my mind: I can't understand why patients would want their medical provider to have an inherent conflict of interest from the start.


Because the choice for many is not mostly loyal physician vs. HMO or corporate employee doc. It’s HMO doc vs. no doctor visit.


> Because the choice for many is not mostly loyal physician vs. HMO or corporate employee doc. It’s HMO doc vs. no doctor visit.

Huh? Where are you bringing HMOs into this? Nobody's talking about HMOs.


To be clearer: There’s a spectrum between 100% cash market, to indemnify plans where you e.g. you have a flat 10% co-pay, to “in-network” plans like PPOs, and pre-paid plans with corporate employee docs (e.g. Kaiser). Not all HMOs have employee physicians as you noted.

My point is that third-party free medical services are out of reach of most Americans. Even if the doc is separate from the insurer, they have to follow their claims process. You generally have to take your employers plan. The less fortunate take Obamacare and its limited doc networks, or are totally out of luck!


I agree they can’t be trusted but they’re not being evil that way. They’re still trying to pick the low hanging fruit of easing lifestyle disease burden like heart disease, diabetes, and tobacco use.

Ruining your health just means they pay for $$$$$/day hospitalizations. That’s far worse than paying for your maintenance pharmaceutical cocktail and some specialist visits.


They do it in two ways that I have seen.

If you have a prescription for an off-label use of a drug that is commonly used for other diseases with high maintenance costs (say diabetes or asthma), you'll start getting newsletters about early management/intervention.

They also do subrogation. If you have something that is a high likelihood to be somebody else's (Worker's Comp, auto insurance) problem like a back injury, you'll have an investigator call to try to link an earlier incident, ER admission, etc to your current issue.

Most of the other stuff (familial predispositions, etc) are fraught with ethical problems. You can't send a random letter to a random person and suggest that they are predisposed to cancer or something.


I am curious if they will be able to use this data to raise rates if the pre-existing coverage is removed ( https://www.npr.org/2018/06/08/618263772/trump-administratio... )?

I presume that it would be smart now for people to use certifications of creditable coverage?


I have read a few stories about some small insurers who were using health data to address ongoing issues and help people get more consistent care.

The catch was for it to work it was a very labor intensive task to have someone work with the customer.

Granted it was more of a story about how things should work than how they do.


Sure. That's arguably more the job of the PCP, to manage ongoing issues, just as in my other role as a paramedic, we are running 'community medic' programs to handle non-emergent calls and patients who are 'frequent fliers'.

Using this data to spot "chronic conditions being treated acutely or not at all", I admit I can see. But beyond that, not so much.


Yup, cronic conditions and patterns like poorly managing that care. If they saw a lot of stuff related to problems with diabetes, they might schedule / send someone to the home to help establish better care and etc.


And people voluntarily spend money to send their DNA to some random websites. Sure, they don't use it in this way now, but for how long can they hold off on the temptation?


"The companies are tracking your race, education level, TV habits, marital status, net worth. They’re collecting what you post on social media, whether you’re behind on your bills, what you order online."

The only way they can do this and link it to you as an individual is if we have all been lied to about how everything is "anonymized" data being sent between the data brokers and sold to corporations. I've always assumed that the whole narrative about all this data being anonymized was complete and utter bullshit.

Now we know with certainty.


The companies that sell your data non-anonymously to brokers have always (unless they're shady af) said somewhere in their T&C that they will or may do so, and the brokers themselves have never said the data are anonymous (unless you're talking about the ad targeting space).


> The company, owned by the massive UnitedHealth Group, has collected the medical diagnoses, tests, prescriptions, costs and socioeconomic data of 150 million Americans going back to 1993

I think they just use their point of sales (primary care, etc) to collect data from the client and use it against the client. I know because I used to be in a very similar line of business.

It is easy because clients give you a permanent unique id for payment purposes (ssn), or other unique id (phone numbers) that varies with time (now less with people porting their number). Of course, the point of sale has a list of previous items, even from competitors (medical history) but that has become harder to use, due to laws. Still, most places ask for "emergency contact", which you can use to build a social network. Sick people cluster together. I don't know why, it just happens, and it is a good workaround.

Of course, you need enough data, but it is then a matter of scale (if you have 75% of the market, you have seen everyone in a county at least once) and trade (buy the same data from your competitors).

Personally, due to experience, I prefer to forego insurance and get my healthcare abroad. Better prices than paying deductibles, better services. But I can not recommend that for everyone.

Still this is a dirty business, and I strongly recommend to adopt basic opsec precautions if you get healthcare in the US: never give your ssn, give a phone number that is not used for anything else even better if it is prepaid so not linked to a ssn, never ever give an emergency contact, only list medical conditions that will not cause you legal issues.


> Personally, due to experienck, I prefer to forego insurance and get my healthcare abroad. Better prices than paying deductibles, better services. But I can not recommend that for everyone.

If you're in the US, that choice could bankrupt you if you ever need major emergency medical care, because of an accident or some condition requiring emergency surgery, like a brain hemorrhage.

https://www.nytimes.com/2017/03/29/magazine/those-indecipher...


My father went from having a comfortable nest egg to living on social security alone because he was unable to get insurance before the ACA. All it took was a trip to the emergency room and a heart catheterization, followed by another procedure a couple days later and he was penniless.


I wonder: did he go to court at any moment? Or did he just caved in and accepted to cough up the money?

Based on my experience, in the US, people rarely fight their debts. I have had debt go to collection before, I disagreed with it so I sent the collector a friendly letter saying the debt came from a breach of contract by the other party, so I will not pay it, and will be happy to go to court if they want.

It is very rarely worth the time for collectors. The debt will just eventually be resold, penny on the dollar.

In the very unlikely case it ends up in court, based on some friends experience, it can take a long long time for the problem to be resolved - if ever, because our lifetimes are finite.


Unfortunately, most Americans don't know that bankruptcy courts will almost always protect retirement savings. If you're staring down a giant health care bill and have only retirement funds to pay for it, you should just file for bankruptcy. You'll almost certainly come out of it with your retirement savings intact.


It's state dependent and retirement account dependent, too. 401(k) and other employer sponsored plans have better protection than IRAs. Texas, for one, has unlimited protection for IRAs, as well as protection on accounts funded by withdrawing from your IRAs.


I am lauching my business, I need more money NOW. Healthcare abroads cover everything (eyes, teeth...) and is much cheaper than a deductible even when paying everything cash. And no weird haggling with the insurance or provider to see what is covered, what is not, what is the copay, etc.

This may not cover edge cases, but for most of my personal financial decisions, I follow the example set by governments around the world: I spend in the present without caring too much about future, betting on growth of my resources.

In other words, if I do have a brain hemorrhage, the last of my worries will be bankrupcy.

Why should I bother? If I fail my business, I will be bankrupt anyway.


Uninsured are often refused treatment. Consequence is you die unnecessarily. Depleting your net worth compounds the stress of sickness or injury, effectively choosing between your money or life. At least get a catastrophic plan with a high deductible.


Which country?


In this thread, all of our user id are numbers, which means we prefer not to share too much details. This is one of these details.


>If you're in the US, that choice could bankrupt you

This is literally the point of bankruptcy...

The system is designed to save people who would otherwise be rejected care or put into slavery/debtors prison.

How many safety nets do we need?


Exactly why I won't do those genetic-sample tests for "ancestry" or anything else. Eventually, those data will be sold, even if the entire company is sold with it. Eventually, we will be much better at decoding the DNA for predispositions to medical problems like heart disease, diabetes, alzheimers, and so on.

That information will also be used against our kids and maybe our other relatives even if they don't undergo the testing.


Data is forever. The Genetic Information Non-Discrimination Act could be repealed in the future. Even governments can change.


Heard about this article on NPR this morning. Thought the concern was valid but a little on the alarmist end of things.

Most of the data they need to know if you are going to be an expensive subscriber or a cheap one you're required to give them directly: Your age, your gender, your home address and the list of services you received at your doctor's visits that they were billed for.

Both healthcare providers and insurance providers know that the most efficient way to lower your healthcare costs is to get the patient to go to preventive care visits and keep them out of the ER. It doesn't matter how much money you give them each month, if they can prevent you from going to the doctor all together it's 100% (roughly) profit.


I work alongside healthcare informatics and I got to say this is entirely the case from what I have experienced - the less you go to the ER the more the insurance profits. All of our research and data collection revolves around people getting tests and treatment PRIOR to something major happening. Regular bloods tests, proactive bp and a1c monitoring, etc lead to better heart disease and diabetes treatments so you don't go into a crisis. The collection of data allows treatment to be better for the population not to charge a higher rate to specific people. Keeping you out of the hospital is monumentally cheaper than a couple doc visits a year for a couple lab tests.


> But patient advocates are skeptical health insurers have altruistic designs on people’s personal information.

It's funny that the article felt this needed to be said. Just how would an altruistic insurance company have survived in such a competitive market?

I think I learned the insurance business model early in life. I lived near a horse race track, and used to collect the programs and assemble giant (paper) spreadsheets with various data on horses and their win/loss records. Does the jockey make a big difference? Does the wetness of the track? I would have used any measure that gave me an edge in betting, with zero "altruistic" regard for the horse, its owners, or anyone else but me. You know, like an insurance company.

It turned out that there was a datum that significantly improved my odds, and converted me from a regular loser to an irregular net winner. And it didn't come from a program. I figured out that I could just watch the horses as they paraded to the starting gate, pick the one that I thought looked like it wanted to win, and could, and ran to place a bet on it before the race started. Far from perfect obviously, and I didn't win big, but I started winning more than losing.

I'd bet that insurance companies wish they could do something similar: Have experienced medical underwriters examine and interview potential customers and then make gut level decisions, then judge more by underwriter stats than patient stats.

But that approach seems to be increasingly prohibited, so they make do with what data they can get. It's hard to find that surprising, unless somehow you've confused "insurance" and "altruism" to be related terms.


I think there's something to be said IN FAVOR of the notion that person A's health risks don't trade off against person B's health risks at a 1:1 rate.

The crucial thing however, in a data protection sense, is that there are too many people who don't realize the implications of giving away data about themselves. A shopper signing up for a loyalty card scheme in a grocery store might sign a blanket waiver allowing the scheme operator to pass the data on to whoever they please to be used in whatever way they want, without thinking about the possibility that it may end up in places where it won't serve their best interests.

So there should be something similar here to health warning on cigarettes. Kind of like "Warning: Signing up for this loyalty card may make you uninsurable."

Also, I think there should be legal infrastructure in place to ensure that there are certain rights that you can't sign away as part of a contract that, in practice, you don't have the option not to sign (like Google's general terms & conditions).


Which is also why you should use a fake phone number, name, etc for those loyalty cards.

Also a neat trick is to just (XYZ)-867-5309 as someone already signed up with the number from that song and it’s not a real number.


It's a real number in the 401 area code.

https://www.askgem.com/

See the contact info in the lower left of the page.


I agree that "gaming the system" is usually the most practicable way to deal with this stuff in real life, but that doesn't mean it shouldn't be sorted out on a more principled basis eventually.


A recent-ish book that talks a little about this (surprised the article did not mention QuintilesIMS):

"Our Bodies, Our Data: How Companies Make Billions Selling Our Medical Records"

https://www.amazon.com/Our-Bodies-Data-Companies-Billions/dp...


Isn't this super illegal? Who are the lawyers at these companies who are signing off on these projects?


No. Using that data might be. In any case, it's only illegal if the Supreme Court interprets it to be illegal. If you have been following the recent years of Supreme Court decisions/dissents it will not be comforting.


Can you point to the cases that concern you? I haven't been following it closely enough.


I'm sorry, I can't right now in detail. The general trend started with Citizens United and followed through Masterpiece is a increased set of precedents for corporate personhood, with some harsh dissents from the Alito/Thomas/Gorsuch contingent in cases where that was at issue (but corp. personhood side lost). When Kennedy retires and of Kavanaugh is his replacement, that will give put an awful lot on Robert's judgement as the swing decision. If I'm really getting picky, the lack of consistency in Trump v Hawaii and the Masterpiece case shows a certain amount of prioritizing partisan concerns over logical consistency (imo, ianal).

edit: taking corporate personhood to logical extremes reverses a lot prior precedent and I would have doubted it would have happened until recently.


What would be illegal? As long as corporate profit is viewed as more important than human health and safety, there will be no laws against such things. The Republican-controlled supreme court likes to rule that corporate "rights", due to corporate personhood, cannot be contained or curtailed in favor of human ones.


I wouldn't be surprised if people are denied care and left to die due to exorbitant prices based on random, undoubtedly wrong algorithms. Here's where the cost of personal data really becomes huge, at in life or death. Insurers have played god like this since their inception and nothing is going stop them from making more money by shutting out anyone who is a threat to their bottom line. We've only had a law that prevents discrimination on pre-existing conditions for a few years. I'm sure the insurance companies will lobby hard to get rid of it so they can let the very sick suffer and die rather than be forced to pay for their healthcare. This is an end run to that goal in case lobbying to murder people legally fails.


I buy data from LexisNexis. AMA.


What is the pricing model? (eg per request?) Roughly what is that cost?

Is there an "all-you-can-eat" access level that other organizations have?

How granular are the data fields per record (/person) ?

Do requesters generally cache the retrieved data on their own stores, continually re-retrieve it, do analysis in large batches, or what? Would we expect to see big caches of this data sitting around outside of Lexis's vaults?


> What is the pricing model? (eg per request?) Roughly what is that cost?

Across all the products I've used (web, batch, API), the price is per-request (where a batch is multiple requests). The actual price can vary by several orders of magnitude depending on what you're requesting. If we're talking about list pricing, it ranges from about 10 cents to tens of dollars per request. There are significant volume discounts available, of course.

>Is there an "all-you-can-eat" access level that other organizations have?

I have not seen one myself and I doubt they offer one even to their largest enterprise customers. However, I am fairly certain that they offer it to certain government agencies. For example, I have seen federal government RFP's that require it.

>How granular are the data fields per record (/person) ?

It depends on the kind of response/report you're looking at, but as a general matter they are highly granular. For example, provided the data are available, I could itemize a list of every car you've ever owned by make/model/year, infer whether you're in a same-sex relationship, or see what the grounds were for granting your divorce.

>Do requesters generally cache the retrieved data on their own stores, continually re-retrieve it, do analysis in large batches, or what?

Aggressive caching is an absolute requirement for API users. That is proximately because Lexis's server does not "remember" your requests. They are logged and have unique transaction ID's but if you run the same search twice they will not check the request against a log cache to see if it's the same as one you ran recently. Instead they'll just charge you a second time (a very easy way to accidentally run up a big bill when running tests against a production endpoint). In combination with the high price per request, you'd be stupid not to cache the whole response.

>Would we expect to see big caches of this data sitting around outside of their vaults?

Yeah certainly. You can't arbitrarily run requests and store the data (e.g. in order to resell it), but you can store the results of requests you've made.


> How granular are the data fields per record (/person) ?

You can see a lot of the data they have on you yourself, by requesting your own report(s):

https://personalreports.lexisnexis.com/access_your_full_file...

I don't think you'll get everything they have on you this way, but I got a printout that included about a dozen individual reports when I made my request.


What do you have from the healthcare part now? Drugs, diagnosis, lab test (from the like of labcorps), or just point of sale addresses because hipaa?

How is the data linked? ssn, phone numbers? (just a best guess, in case you spotted some linking anomalies)

Is the primary key still a number internal to lexis nexis?

How detailed is the social network now? (just people living together and neighbours, or does it includes relatives and family members)


>What do you have from the healthcare part now? Drugs, diagnosis, lab test (from the like of labcorps), or just point of sale addresses because hipaa?

Nothing. The data at issue in this article belongs to a category called "Non-FCRA" (Fair Credit Reporting Act), which means they cannot (really, are not supposed to) be used for things like credit and hiring decisions. Most of the data are from the public domain, although there are some data that are only quasi-public (meaning they're nominally public but you must have special privileges to see them). I haven't seen any truly non-public data.

>How is the data linked? ssn, phone numbers? (just a best guess, in case you spotted some linking anomalies) ?Is the primary key still a number internal to lexis nexis?

The primary key is an internal UID, where each person has his/her own. There are edge cases where people in their DB do not have UID's at all or where a single person has multiple UID's.

They obviously have some linking but I've seen little indication that they have a robust graph under the hood. For example, Lexis may "know" that you've cohabitated with a member of the opposite sex about the same age as you for 10 years starting when you were 30, and also "know" that you're married to someone with the same name as the cohabitant, but fail to identify that person as your spouse because the marriage records are siloed in their back end.

>How detailed is the social network now? (just people living together and neighbours, or does it includes relatives and family members)

There are lots of data available on your relatives and family members, but again, the linkages are piss-poor. For example, your record may say that your name is "John Smith Jr." and you lived with a man who is 30 years older than you named "John Smith Sr." until you were 18, but fail to identify that person as your father.


Very interesting, thank you!

I thought they would have improved the linkage since I last saw - especially the marriage records and name changes.

They are still weak on that, so basic opsec will work.


> Drugs, diagnosis, lab test (from the like of labcorps), or just point of sale addresses?

If they had access to that, wouldn't it be a HIPAA violation?


Yes, there are laws now. I edited my comment to mention that.

Outside the US, labs are still a goldmine of data: time indexed numerical value that are used by providers to decide medical interventions. Except medical record or insurance history, you can't get any better than labs!

Still I noticed in the US that labs selling directly to clients (like private md labs, only in some states) insist that the patient provide an accurate phone number.

Given how phone numbers are used in the industry, I think they may want to keep the database accuracy for "future uses" when the law will change.


What kind of bulk data products do they sell?

I'm almost certain they are one of the companies that does the legwork to directly ingest public records information from government sources, but I'm unsure if they sell that bulk data on to other companies.


They have separate divisions for FCRA and non-FCRA data, so which products and data points you have access to depend upon who you are and what you're doing with the data. I believe the data at issue in this article are non-FCRA, which puts it in a category I'd call "enterprise-grade public records search" (as opposed to consumer-facing public records companies like Intelius and Instant Checkmate).

Yes, they are one of the few companies that does the legwork of directly ingesting public records. For example, they buy and resell a lot of data from DMV agencies in states where the DMV is authorized to sell it (Google DPPA for more info). It is otherwise nearly impossible to get these data. I have tried, with the help of the right lawyers, and concluded that the only way to do it would be to sue the DMV.


> They have separate divisions for FCRA and non-FCRA data, so which products and data points you have access to depend upon who you are and what you're doing with the data.

Do they still any of that data in bulk, or only in a productized form for a particular requested person or group of people (e.g. a company's customer list)?

Just trying to get a sense of how extensively their data might be getting repackaged and sold by others.


It depends on what sort of data broker you're talking about. For companies like Lexis, I'm pretty sure the answer is no. You can't just blindly buy a giant batch of data (this may have to do with regulatory requirements governing access to certain data points).

However, you could totally do that with a marketing/"lifestyle" data broker like Acxiom, BlueKai, Epsilon, etc. I once directly asked a sales rep if they would sell me, say, all of the data they have on everyone in San Francisco County. Their answer was yes, with the caveat that it would be really expensive.

Edit to answer:

>Just trying to get a sense of how extensively their data might be getting repackaged and sold by others.

Reselling is certainly not prohibited, provided the broker understands and approves of the purpose of the resale. I would guess that most consumer-facing background check tools are really just reselling data from one of the big public records brokers (Lexis, WestLaw, TLO, etc.). Some will just charge you higher monthly minimums for the privilege of reselling. The marketing/"lifestyle" data brokers are much stricter about prohibiting resale.


This is complete nonsense and entirely speculative. They admit as much when they inform you they can find no evidence of any individual underwriting decision being made based on this data, which the companies strongly deny, and would be illegal. Insurance is highly regulated, both on a state and federal level. Pricing algorithms and variables are public in most states (albeit obfuscated).

What does seem to be happening is the companies are using third party data providers for marketing and market analysis, as literally every other company from your local HVAC guy to McDonald's does.


There are certain dimensions that it makes a lot of sense to discriminate around: For example, if you're a roofing contractor, I really think you SHOULD be paying higher health insurance rates than I do, as an office worker. You'll just price it into whatever you charge to make roofs, which means the price of a house will start getting closer to what it actually costs the economy. Since I rent, I would otherwise end up subsidizing other people to build or buy houses for themselves, and I don't think that's how an economy should work.


> For example, if you're a roofing contractor, I really think you SHOULD be paying higher health insurance rates than I do, as an office worker.

Why? Your sitting eight hours a day is remarkably unhealthy, and roofers (at least where I'm located) are typically separately insured for on-the-job injuries.


Don't get unduly bogged down with the example: It works equally well with "horse trainer" or whatever. Clearly some professions have a bearing on your risk profile with regard to certain types of insurance, and there is not always a clear distinction between risks you incur as a private person and risks that your business needs to indemnify you against. -- Like, if you're in a job that involves a lot of travelling and being away from your family for extended periods of time puts you at greater risk of developing mental health conditions etc.


I think the numbers may not come out the way you think they will. Sedentary lifestyles are by far the largest medical expense in the country as a whole, so office jobs I would expect to have much higher premiums.

Sure you're not gonna get your sternum crushed by a falling 2000lb pallet - but those situations are already typical covered by workmans comp and other company insurance.


That's not really true like you think, though.

They simply have different health risks than you. It is a deep hole here - should an employer be penalized for a bad work environment (stress, working long hours, lack of sick leave, and so on) that many office workers face? After all, these things lead to more sickness and a greater chance of mental health issues.

How do you figure the risk of accident for the roofer compared to the risk of obesity, carpal tunnel, and back issues tied to a nice office job? Does your risk of injury while jogging for exercise increase? How about that increase in detrimental health effects from the commute? Do you give the roofer bonus points for leading an active lifestyle due to their work? Doesn't an active lifestyle carry its own risks?


Considering how inaccurate some of Fitbit's measurements are( resting heart rate, for example ), I would sue my insurer if I found out they were using that data. My doctor shouldn't be using it either.

RHR is normally measured within the first 30 minutes of waking while lying in bed, which is something Fitbit can determine. What I've noticed is that on days when my RHR that I've measured using their monitor after waking is 54 BPM, they report up to 61 BPM. There's a very long chain on their forum about how inaccurate the measurement is.


I work for Fitbit but am speaking only for myself.

I'm guessing that this is the chain you're referring to since it echoes the "30 minutes after waking while lying in bed" claim: https://community.fitbit.com/t5/Charge-HR/Resting-Heart-Rate...

Other sources I checked did not echo that claim. As one commenter in the chain pointed out, RHR is not minimum HR.

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/G...

https://www.mayoclinic.org/healthy-lifestyle/fitness/expert-...

https://www.health.harvard.edu/blog/resting-heart-rate-can-r...

Also, one of the critics in the chain thinks Fitbit must be inaccurate after his RHR rose from 68 to 71 after "hiking at altitudes up to 14,200 feet" then fell back to 68. I think this criticism stems from a misunderstanding about how altitude affects oxygen levels and how oxygen levels affect heart rate.

All that being said, even if the devices are generally accurate, there are defects and they aren't designed as medical devices. To the extent you voluntarily share your data with a doctor or insurer (which is the only way they'd get your data), your doctor or insurer should treat it the same way they treat other useful but potentially inaccurate information.


Thanks! This is way more informative than any of the responses I've seen from your support team in that chain.


Most people who work for medium or large sized companies in the US are working for companies that are self-insured, meaning your company is taking on all the risk, so if anything your own employer is incentivized to do this and not the insurance company itself.

When I first heard of the Amazon/JP Morgan/BH heathcare initiative my thought on what that company would actually do is surveillance on their collective millions of employees to better predict if they are prone to disease and use predictive analytics to lower their own claims cost.


> When I first heard of the Amazon/JP Morgan/BH heathcare initiative my thought on what that company would actually do is surveillance on their collective millions of employees to better predict if they are prone to disease and use predictive analytics to lower their own claims cost.

...or avoid claims in the hiring process.


> meaning your company is taking on all the risk

While I wouldn't say there aren't any companies out there that are absorbing the entire cost of insurance premiums, most are splitting this in some proportion with the employee.


by risk I mean that the company is liable for all claims cost, but right premiums can come from the employee, employer, or both.


As a college student I work taking phone calls for a biz that attends entirely US customer base, my colleague asked why our clients were often leery about sharing things like their photo ID with us, despite being customers with us for many years.

As one of the few who lived in the US amongst us I'd have to say it might have to do with how much companies involved in risk assessment really know about you and how much of it goes to the government -- they have no interest in having us show up in their credit or what have you.


That's ok with me? I wish it were like life insurance where they can ask you anything and then you get that rate locked down for the term.

I also actually liked the proposal in Congress that got rejected: allow people to make their own groups. So if you are a person who likes to work out and get your fat levels tested once a year, you could join a group of like minded individuals and insurance companies would bid to insure your group.


Incentives are different. Life insurance companies have an incentive for you to not die. Health insurance companies have an incentive for you to not live (e.g. you don't that organ $$$$$$ transplant you need to live).

Health insurance is cheaper when more people are in it, not fewer. If you start offering discounts to the healthiest people, it gets more expensive for unhealthy people. So let's say the sickest people no longer have insurance. Now there's a new group of unhealthy people in the insurance pool. So you raise prices for them, and they get kicked out, too. Eventually you get to the point where insurance is not useful, because nobody needs it at all, as the insured people don't get sick. Until they do get sick, at which point they get kicked off the insurance plan. Health insurance that doesn't insure is basically fraud.

If you want to drive down the health related costs of healthcare, reduce the things that make people sick.


>So you raise prices for them, and they get kicked out, too.

They only get kicked out if no one will offer them prices that they can afford and that they want to pay for. Why do you expect that would happen?

>Until they do get sick, at which point they get kicked off the insurance plan.

It seems like that would be solved by treating health insurance like term life insurance as the person you're replying to suggested.


When you get older & sicker, I'm guessing you'll feel differently. It's all fun & games until you can't afford a basic prescription.


What do you think I said that I will feel differently about when I'm older and sicker? You made a bunch of claims about the nature of the health insurance market, and I pointed out that your claims were bogus. What feelings are involved there?


I used to sell life and health insurance. I saw how the underwriters made decisions on things. I simply think you have no idea what you're talking about, and I'm sticking a fork in this thread.


If I do indeed have no idea what I'm talking about, you have done nothing to change that.


> That's ok with me? I wish it were like life insurance where they can ask you anything and then you get that rate locked down for the term.

That's an understandable attitude for a healthy person.

What is the person born with a disability or a gene making cancer, Alzheimers, heart disease, etc. likely supposed to do?

"Your insurance premium is $25k/month. We take checks!"


For the vast majority of people, this is all the healthcare they need, and an efficient system should/could run that way!

I think you misunderstood something I said, however. A "risk pool"'s rates can only be decided by non-preventable risk factors of that pool. The examples you give don't reflect that well: some cancers are preventable, Alzheimer's cause and treatments are not well understood, and most heart disease is preventable.

For someone with a childhood disease, for instance, they could possibly fit into a certain risk pool, but they likely won't. Any "risk pool" based insurer will not have the funds to cover them anyway, and forcing them to cover the extreme cases has shown to leave more people without healthcare. [Take the case in Iowa, where a single person caused 30,000 individuals to lose their insurance. That is not an acceptable outcome!]. Right now, the best answer on how you handle these extreme cases will have to be a combination of Medicare and Charity, as they are the only organizations with a pool of money big enough to help them.


If they can't afford to pay anyone enough to insure them, they should ask for charity, because that's what they need.


Shockingly, it turns out that most charities don't have the financial resources to dedicate a hundred thousand dollars for a single heat transplant.


Also shockingly, if you already know you need a heart transplant, you're well beyond the point where any market-based risk pool is going to offer to pay for your transplant in exchange for a premium that's below the cost of your transplant.

You need charity, not a market.


> Also shockingly, if you already know you need a heart transplant, you're well beyond the point where any market-based risk pool is going to offer to pay for your transplant in exchange for a premium that's below the cost of your transplant.

Everyone is at potential risk for needing something like a transplant eventually. Making the pool large enough allows reasonable premiums, just as I can pay a couple hundred bucks a year to replace my entire house if it burns down.

The rest of the developed world defines the risk pool as "everyone", and the end result is healthcare costs half of ours (including the tax component) and similar outcomes.

> You need charity, not a market.

You need government, not a charity.


>Everyone is at potential risk for needing something like a transplant eventually.

Not everyone is at equal risk, and many choices people make can have an impact on that risk. That's the point of this thread.

>Making the pool large enough allows reasonable premiums, just as I can pay a couple hundred bucks a year to replace my entire house if it burns down.

What is 'large enough'? The populations of many entire European countries are dwarfed by the number of subscribers to several health insurance companies in the US. Of course we don't know how large health insurance companies would get in a market without heavy government interference, but do you have some reason to believe the size of pools in a market with less interference would result in unreasonable premiums?

>The rest of the developed world defines the risk pool as "everyone", and the end result is healthcare costs half of ours (including the tax component) and similar outcomes.

And our health care system requires subscribers to insurance companies to pay those insurance companies to A) provide charity to people who wouldn't be able to afford to buy insurance in real market and B) pay for routine care (i.e. care where there is no risk to insure against - you know you're going to need it). And of course the health insurance company is going to collect its cut of the money that the government has forced subscribers to funnel through those companies. Is it really any surprise that system gets expensive?

>You need government, not a charity.

You need charity, whether it's administered by a public organization or a private organization or funded by private individuals or taxpayers.


> do you have some reason to believe the size of pools in a market with less interference would result in unreasonable premiums?

Demonstrably so. Just look at pre-Obamacare "high risk pools" for concrete examples. https://www.kff.org/health-reform/issue-brief/high-risk-pool...

You'll also see it in other insurance markets, like life, house, car, malpractice, etc. - many people are largely uninsurable in these markets.

> What is 'large enough'? The populations of many entire European countries are dwarfed by the number of subscribers to several health insurance companies in the US.

It's not so much raw population as how much you're allowed to slice it up. A decent sized city is big enough - many corporations of a few thousand people self-insure as it's cheaper.

The problem is when you allow insurance to pick their customers. They just pick the healthy ones, if allowed.

> And our health care system requires subscribers to insurance companies to pay those insurance companies to A) provide charity to people who wouldn't be able to afford to buy insurance in real market...

You are using some very weird definitions of "charity".

Obamacare's subsidized premiums aren't shouldered by the insurance companies, they're provided by the government. Those insurance companies are making bank, not providing charity.

Single-payer or income-based subsidized healthcare isn't "charity". Insurance paying out more than premiums taken in for a particular subscriber isn't "charity", it's how insurance works.

> Is it really any surprise that system gets expensive?

Oh, not at all, but that's because we've picked the least cost-effective bits of both private and public healthcare systems to combine into a monstrosity.


>Demonstrably so. Just look at pre-Obamacare "high risk pools" for concrete examples.

I'm obviously not talking about individuals who are so expensive to profitably insure that they can't afford the premiums. I've already stated that the market isn't going to work for them. It's not the size of the pool that's causing problems here; the contents of the pool are the problem.

>They just pick the healthy ones, if allowed.

They also pick the less healthy ones that are able to afford to pay the higher premiums it takes to make it worth it for the insurance company to cover them, assuming the insurance company is allowed to charge such premiums. There is plenty of money to be made there. Where there isn't any money to be made is in people who know they have high expenses and can't afford to pay them.

>You are using some very weird definitions of "charity".

Are you taking issue with my characterization of government welfare as charity? Why should it be excluded from such a broad category?

>Obamacare's subsidized premiums aren't shouldered by the insurance companies, they're provided by the government.

That's not what I'm talking about. I'm talking about people who have pre-existing conditions, who are definitely going to cost the insurance company more than they're going to be paying in, regardless of subsidies, who the health insurance company can't charge more money to and can't deny coverage to.

>Insurance paying out more than premiums taken in for a particular subscriber isn't "charity", it's how insurance works.

Actually that hinges on whether it's known before the agreement is made that the particular subscriber is going to have more paid out on his behalf than he is going to pay in. If it is known, then that's not insurance. It's charity.


They should go to the emergency room, iirc its free if they can't extract the money.


You can't get stuff like chemo or a transplant at an ER.

They are only required to (attempt) to (temporarily) stabilize you.

"Just go to the ER" also is pretty much the most inefficiently stupid way of handling healthcare for the needy you can come up with.


You're okay with a society where people die on the street because they didn't have enough wealth?

How much money you have isn't a determinant of the moral worth of your life, it's not even a proxy. So why do consider it as a relevant detail in the allocation of healthcare?

Why should the obese, smoking trust-fund kid get the heart bypass but the obese smoking poor guy not? Liberalism (classical or otherwise) requires some base level at which we treat people as equals, it seems the ability to continue living would be about as base as we can get.


>You're okay with a society where people die on the street because they didn't have enough wealth?

I didn't take a position on whether or not I'm okay with a society where people die in the street if they don't have enough wealth.

All I said was that people who can't afford to buy health insurance need charity, whether that charity is public or private. The market is not going to help them. Attempting to fit that round peg into a square hole is going to cause a lot of issues that are very obvious to predict, in addition to all of the issues that are less easy to predict.

>How much money you have isn't a determinant of the moral worth of your life

Neither is anything else. The 'moral worth of your life' is fundamentally an opinion, not a fact.

>So why do consider it as a relevant detail in the allocation of healthcare?

Because that's how we allocate most goods and services, and it does a fairly good job at it.

>Why should the obese, smoking trust-fund kid get the heart bypass but the obese smoking poor guy not?

That's a pretty complicated question that comes down to an individual's own priorities and that individual's assessment of the potential effects of various alternative policies on the attainment of various goals.


>people who can't afford to buy health insurance need charity, whether that charity is public or private. The market is not going to help them. Attempting to fit that round peg into a square hole is going to cause a lot of issues that are very obvious to predict, in addition to all of the issues that are less easy to predict.

So, a free market is ineffective at allocating resources in healthcare.

Unless we redefine healthcare to mean "care for people who are not sick," which does not really make it healthcare at all, does it?


>So, a free market is ineffective at allocating resources in healthcare.

It doesn't suspend reality, that's for sure. If you don't have the resources to pay for your own healthcare, and don't have the resources to pay someone else to pay for your healthcare, then you are going to have to get someone else to volunteer their resources for it, or you're going to go without.

>Unless we redefine healthcare to mean "care for people who are not sick," which does not really make it healthcare at all, does it?

Plenty of sick people, or people who become sick, are perfectly capable of having their healthcare needs met through the market. There are many, many people who have enough money to buy health insurance, even if they have some chronic conditions and therefore would need to pay someone a lot more than a healthy person would to cover their health care expenses.

If your standard for effectiveness in allocation of resources in healthcare is that no one's ability to get health insurance is affected by their current health status, then yes, the market is going to be ineffective by your measure.

If your standard includes, for example, having financial incentives for people to limit their own use of health care services, like how we have financial incentives for people to limit their use of basically every other resource out there (e.g. houses, cars, land, anything else that costs money), to ensure that resources are left available for other people to use, and you don't want to deal with heavy-handed government approaches to that problem, then by that standard, a health insurance market is very effective.


By that measure, then, the extent to which sick people are covered simply comes down to how much "charity" healthy people are willing to volunteer. Sticker price for my child's medication is $1000 for 4 weeks' supply. I require it to keep him from dying.

How much are you willing to forfeit for my cause, charitable neighbor?


>By that measure, then, the extent to which sick people are covered simply comes down to how much "charity" healthy people are willing to volunteer.

That is reality. If you can't afford something yourself, then you're going to have to have other people pay for it for you, or else you won't get it.


I do not think that this is a good idea, for various reasons.

1) Letting peer pressure and self censorship to police our habits is the end of individuality and freedom. This is exactly what China is trying to achieve with that horrible social credit system. It also inverts the logic behind healthy practices: today you run because it makes you feel good; tomorrow you run because you can't afford to be left behind and lose insurance. This kind of thing really lowers the bar on the respect of privacy and dignity because it is basically large scale surveillance in exchange for cheaper insurance.

Take car insurance: are you willing to give insurance companies full access to your GPS and tachometer data just so you can prove you're a good driver (in their own terms) and pay a little less?

2) What is healthy today might not be healthy tomorrow. Imagine some food is considered healthy in 2020, and you happen to eat lots of it, but in 2050 it turns out it's the other way around.

And 3) this all boils down to the reason why, in general, associating people in groups and then judging individuals accordingly is unconstitutional in so many countries. That group may be gay people, black people, people that voted Left or some other group that you cannot leave or join because of some arbitrary definition. And is also worth considering that the group to which you belong can vote a change on its definition that leaves you out with no appeal, the worse case being some AI deciding that you're done.


That does souns appealing. I'm all in for a mandatory annual weigh in and fitness test


I’d go a step further and give people discounts if they even try to eat healthy. Amazing how long I can go shopping cart peeking without spotting a single vegetable or fruit.


Agreed. It'd be pretty easy to create a proxy for that via blood pressure or cholesterol or some type of improvement metric combining the two


My employer used to provide additional funding in employees' HSAs (Health Savings Accounts) if they participated in a health screening. The health screening involved measuring height, weight, blood sugar, cholesterol and other lipids. There was also a questionnaire about lifestyle choices related to health in terms of how physically active you were, smoking, drinking, etc.


I've been saying this for years. That discount card you use at the grocery store tells your insurance company how much bacon you eat.


LexisNexis said there is no web page to submit a request for info. I tried their chat option and that person said I had to call. 888.497.0011 After 30 min on hold I spoke to someone. They wanted my personal info including SS# and Drivers license# They saifd they would mail out the info in 10 days.

I guess this 'personal touch' is a security measure.


In WA state to price out insurance all you need to provide is your age, gender, and smoking status. I don't see how insurance companies can use any other information in setting the price?


Has anyone done any research to map out the relationships between the different data brokers? E.g. who has what data to sell, and who's selling what data to who?


I could tell you who is selling what, and a little bit of who is selling what to who, but I don't think any one person has a complete picture.


Would it be too much trouble to share what you know? Even just a list of the players would be helpful.

I'd really like to understand more about this industry, but from a consumer perspective, it's very opaque. It's easy to find people search websites (and articles about them), but much harder to understand how they got your data or what else about you may be getting sold.


I'll do my best to explain. I need to start by noting that, as far as I'm aware, there's no generally accepted nomenclature for this stuff. Accordingly, I've invented my own terms (some of them as I write this).

At a high level there are two different kinds of brokers, which I'll call "primary brokers" and "secondary brokers." Primary brokers are companies that primarily aggregate their own data and sell it to other businesses. Secondary brokers are companies that primarily buy data from primary brokers and resell them to other companies or to consumers.

Each broker can further be defined by the kind(s) of data they sell. Generally speaking, there are 5 categories of data:

1. FCRA records. These are mainly credit records and credit-related data that are permitted to be used in making credit determinations.

2. Non-FCRA public records. This is stuff like birth, death, marriage, property records, DMV records, criminal records, etc. These are explicitly not to be used for credit and hiring determinations (not sure about renting, off-hand).

3. Hiring data. Frankly I'm not entirely sure what these are beyond criminal background stuff, but they are allowed to be used for making hiring decisions, where permitted.

4. Marketing/Lifestyle data. This is stuff like purchase history, magazine subscriptions, hobbies and interests, data sold by companies whose products you sign up for for free, etc.

5. Insurance underwriting data. These tend not to be explicitly tied to a non-anonymous person. However, given someone's street address, you'd be able to pull some info on their property or something.

Most brokers sell data belonging to multiple of the above categories.

The big primary brokers for FCRA data are, as you might expect, credit agencies (Experian, Equifax, and TransUnion).

The big brokers who deal in mixes of data are LexisNexis (a Reed Elsevier company), Thomson Reuters/WestLaw, and TLO (a TransUnion subsidiary). They are primary brokers of Non-FCRA and hiring data but secondary brokers of FCRA data (I believe they mainly purchase it from the credit agencies). There are a couple small companies that are primary brokers of things like hiring data (e.g. Checkr).

The big primary brokers of marketing/lifestyle data are companies like Acxiom, BlueKai, Epsilon, US Data, and a number of others. I have heard that credit card companies sell certain kinds of data but I am not sure what exactly and have not used their products myself.

The big primary broker of insurance underwriting data (along with a couple other categories) is CoreLogic.

The big secondary brokers of Non-FCRA data are Intelius and Instant Checkmate. I do not think they are primary brokers under my definition because most of what they sell is basically an identical copy of what the primary brokers sell, but for a lot more money. It's hard for me to imagine them taking on the expense of aggregating the bulk of their own primary data when they can run a search against a primary broker DB for a few bucks and resell a pretty version of the response to a consumer for $50. They probably aggregate some of their own data but I'd guess it's low-hanging fruit.

There are also some purely social media-driven secondary brokers, like Pipl.


To play devil's advocate, I think data should be used to manage rates for things that a consumer can reasonably change, like diet/exercise. Smokers are already penalized.

e.g. "Our data indicates your average sugar consumption is over Xg per day over the last 6 months. If you commit to reducing this to Yg per day over the next 6 months, your insurance rate will drop by 10%. Otherwise rates will increase by 20% to cover your increased risk for diabetes, heart disease, and stroke."


On that note, my insurer helpfully put a note in my file that the doctor should tell me about being more physically active based on my BMI. When I listed everything I do, he turned to his intern and said "this is an example of how BMI doesn't tell the whole story." Then he deleted the note. So it has to be the right data and the doctor needs to be the final arbiter of whether it's meaningful or not.


That'll end well.

"our data indicates you're probably a women and therefore have an above average risk of having kids, if you commit to gender reassignment surgery your insurance rate will drop by 30%"

Or if that's not allowed they'll just use other things that are a rough proxy for a protected class.


The 2010 ACA law considers employee wellness discounts of 30% or more coercive and potentially a way to get around the ban on individual medical underwriting. While monetary incentives are powerful, people are not completely or even close to rational actors. If poor health and prematurely dying (often painfully) aren’t motivators to take care of your health, what will? Health promoting culture like teaching all kids to cook and eat healthier, encouraging fitness through less car centric infrastructure, etc. are needed to address the metabolic syndrome epidemic.

Frequent reminders, small sub-goals, reinforcement, role models are probably more effective than a four figure fine for being unhealthy. Some people can overcome big problems on their own because they are committed, but once you get out into the wider population a lot of marketing, hand-holding, and gimmicks are needed to get everyone to make significant permanent change.


> And it could raise your rates

And it could lower your rates.


> And it could lower your rates.

Lack of a national competitive market for healthcare insurance in the US ensures an oligopoly within each state, and thus argues against your reply. Also, keep your eye upon demographic rate trends, not individual rates.

In other words, for the same demographic over time, have rates been going up or down as the insurance market consolidates players over the past few decades? The trend is inarguable [1]; it is a monotonic function. What data do you have that convincingly advocates including data brokering of lifestyle data into insurance actuarial calculations makes a material change in this function or the marketplace?

[1] https://www.thebalance.com/causes-of-rising-healthcare-costs...


No, it will never be used for that.


Please be serious here: stuff like this never causes prices to go down, only up. As information becomes perfect, the "problematic" expensive patients will see their premiums rise to the level of their actual cost to the system-- which is huge and impossible to pay, so they'll drop out-- and premiums for everyone else will stay the same, except with the added anxiety that anything you do could cause your rates to go up at any time.


Aren't there obvious GDPR issues with this unless you're limiting the analysis to US insurers?


Just clicked for me why “healthcare” companies spend so much money on hard discs and data storage.


We desperately need some privacy legislation in the US, years ago.


Free'ish healthcare is the only way...


Whelp, just one more reason why we need Medicare for All. There's no need to enable these people whose business is to find ways to deny people healthcare, just eliminate their industry completely and save money in the process too.


This will ensure the death of the private healthcare system. It won't happen overnight, but eventually the private/hybrid healthcare system will have no redeeming qualities other than to extract as much profit as possible out of anyone's health issues. That's when no one will support it anymore (except the politicians taking bribes to support it).


> will have no redeeming qualities other than to extract as much profit as possible out of anyone's health issues.

We're already at this point, but I don't see why you think that will be the death of the private healthcare system, see:

>politicians taking bribes to support it


Why the downvotes? He's right. The thing about insurance is that the only reason it works is because of imperfect information about the future. The more accurately people can be priced, the more pointless private health insurance becomes: the expensive patients (pre-existing conditions, or just people with bad luck) will get accurately priced and have impossible premiums and won't bother, and the cheap patients will realize they probably don't need it, take a gamble and also not bother. Microtargeted health insurance will be its own undoing.


It sounds like you're doing something that most people do, despite it being incorrect. That is, conflating "health care" and "health insurance". Everybody has gotten so conditioned to the idea that "health insurance" pays for everything health related, that we all seem to take this for granted. But it doesn't have to be so.

I believe that our goal should be to reduce the cost of health care so that most of it can be afforded without insurance - with insurance then returned to its role as a hedge against the more extreme/unlikely events.


>Everybody has gotten so conditioned to the idea that "health insurance" pays for everything health related, that we all seem to take this for granted. But it doesn't have to be so.

Try this experiment. Walk into your doctor's office and ask what a procedure would cost. Ask the doctor, the receptionist, the billing clerk - ask everyone. No one will be able to give you an answer. That's why they are conflated. Fix that (very ripe for disruption) problem and you'll fix health care.

PS: I agree with you, it should generally be affordable without insurance.


> Try this experiment. ...ask everyone. No one will be able to give you an answer.

Funny you say this. A friend just went through this. Not even the insurance company could say. The calls to everyone got so ridiculous that I had to construct lawyerly questions so that people couldn't default to weaselly answers. The provider billing staff seemed to feel put upon that they were being asked to coordinate w/the insurer to figure out patient out of pocket cost would be. And in the end they still couldn't figure it out.


Here's what gets to me as well... providers love to talk about how little they get reimbursed from medicare and from many insurers. But, for example, I'm not going to have a surgery that I would really like to have (and that a doctor agreed I should have) because nobody can tell me what the cost would be. The 15 minute appointment with the doctor who recommended it to me was $700 out of pocket - so I'm unlikely to return if that's the kind of bill I get hit with for having a cup of coffee with them. So, I'd like to believe that at some point, given the current environment in which people are paying for insurance but can't afford to go to the doctor, that we'll see providers realize they are losing out on revenue opportunities by not actually serving their customers.


>I'm not going to have a surgery... because nobody can tell me what the cost would be.

Exactly this! I thought having my friend appeal to the provider's interest in being paid might spur them to figure it out. Surprise! It didn't. Even when explicitly mentioning that the point of asking for this information was to ensure that (s)he had the $$ to pay them, the provider('s billing team) still balked at being asked to figure out out of pocket cost(s). When (s)he threatened to cancel the procedure, they just said "Fine."

(s)He tried w/another provider, who was a little more diligent in trying to figure things out, but the best that they could do was figure out that the insurance company would approve the procedure, and what some of the involved parties were billing. Mind you, (s)he was actually dealing with the hospital where the procedure was to be performed. But of course, since all of the people involved are not hospital staff, they "can't" figure out everything.

It's all ridiculous and the result of bad policy and planning.

On a separate note, I once noticed a billing error. When I called the insurance company to ask if they had any standards/definition for what constitutes delivery of a particular service/procedure, the rep said, "No. We just look at the amount charged and pay if it makes sense."


> of bill I get hit with for having a cup of coffee with them. So, I'd like to believe that at some point, given the current environment in which people are paying for insurance but can't afford to go to the doctor, that we'll see providers realize they are losing out on revenue opportunities by not actually serving their customers.

The customers from which the providers drive revenue are the ones who can afford to go to the doctor. The ones who can't (even if they pay for insurance) are ones providers wouldn't be getting revenue by serving.


But you are missing my point and that of joc815 below you - if I knew the cost, then I could determine whether or not to become a customer. In the absence of a clear cost structure, I can't answer the question of whether I can afford the care or not.


> But you are missing my point and that of joc815 below you - if I knew the cost, then I could determine whether or not to become a customer.

“If you have to ask, you can't afford it.”

Or, more to the point, medical procedures often have an unbounded upper limit on potential billed costs, without the opportunity to stop work and inform the customer and get new instructions when it is realized that the original estimate will be exceeded, and even getting a reasonable idea of the statistical distribution of charges for a particular procedure under costly comparable conditions by the same provider wouldn't be easy.

Now, providers could adopt a flat fee structure and eat the risk of long-tail costs, but that creates a lot of risk (and some perverse incentives) for providers.


> “If you have to ask, you can't afford it.”

Unless we're discussing medical care as a luxury good-- and if that's the way that we really want to approach this, okay, let's just be honest about that-- this is incorrect. In my experience, med professionals have made assumptions about what I could and couldn't afford based on their mental databases of flawed correlations. Things they thought I probably couldn't pay for, not only could I have if necessary, but didn't need to because my insurance was willing to cover it any way.

I'm not going to address the rest of what you've written because, quite frankly, I have a difficult time believing that you are being serious, for a number of reasons. If I'm mistaken, then I thank you for sharing an interesting thought pattern and apologize in advance.


Try this experiment. Walk into your doctor's office and ask what a procedure would cost. Ask the doctor, the receptionist, the billing clerk - ask everyone. No one will be able to give you an answer. That's why they are conflated. Fix that (very ripe for disruption) problem and you'll fix health care.

Agreed.


This will ensure the death of the private healthcare system.

We don't have a private health-care system, and haven't for a very long time. The government and big corporations[1] are so deeply entwined into the current system that it barely approaches anything that could be called "private".

[1]: Corporations are a legal fiction which depend on the State for their existence.

More

Guidelines | FAQ | Support | API | Security | Lists | Bookmarklet | Legal | Apply to YC | Contact

Search: