I would even argue they should take all of those bits of text and replace them with an on-hover tooltip element, with the icons indicating the degree to which those things are stored externally. It's a bit more alarmist than it needs to be as is.
This is such a great example of the kind of disruptive impact we can expect from LLMs.
It exposes part of how the health insurance industry works:
"Out of roughly 40 denials, she won more than 90% of her appeals, she estimates"
Most people don't have the stamina to dig in when this happens, so my guess is the entire insurance industry is designed around the assumption that a lot of valid claims won't be paid out.
It's obviously disgusting that the industry has incorrect denials baked into their business model.
If we fix that with LLMs, what happens? It's going to have knock-on effects, since it could eliminate the profit margin these companies have right now.
They could all merge into one giant insurance agency, perhaps a National Health Insurance.
Once they eliminate all competition the next target for optimisation is between the company and hospitals. They realise its cheaper, with better margins, to run primary care facilities rather than hospitals. The government see that they are a monopoly and force them to provide coverage for a minimal monthly cost. It seems like such a good idea that eventually the government agrees to give them a set amount each month for universal coverage of citizens.
They rename themselves as the National Health Service.
I see what's going on here.
It's another example of externalization of costs.
Doctors have no incentive to fight the denial of insurance. They should, but it's not important yet. If they have to sue you eventually for the billed cost, they will; or at least they'll sell the debt to a collection agency at some number of cents on the dollar.
The Insurance company most definitely doesn't have an incentive. Once you're denied, they're off the hook. They kick it back to the provider, and ultimately to you through some debt collection agency.
The only person that has an incentive is you. And now you're stuck with the cost; either in dollars or time, but what's the difference really? It's going to cost you either way.
Maybe Holden Karau's approach is good and valid, but should it be converted to a paying service we're just back at square one where it's either time or money. Maybe there'll be a discount which makes it cheaper net/net, but who knows?
The little person here is the patient. All the others, doctors and insurers, are the big persons. The little person absorbs the cost, whether they want to or not.
Single payer or not but I think everybody should agree that dealing with health insurance needs to be easier and more predictable. When I read the stories of how people won against them, it's always mind boggling to see the giant effort they had to put into it.
Hospitals and insurances should be fined if they have a high ratio of claims that get rejected first and reversed after appeal. Patients simply shouldn't have to go through this. The whole system is set up to profit from wearing down patients by attrition.
Most of the time it's not too bad to appeal a claim for smaller amounts. People go through the hoops for the larger denials because they are so motivated.
I got a $150k bill for emergency care for my daughter once; it wasn't too bad because they denied it as "uncovered elective procedure" which was trivial to show it wasn't, but it was still a tense month for me waiting. The punchline, of course, is that the insurance company and the provider agreed upon $30k.
Doctors' offices can't tell you what a procedure will cost ahead of time, and the amount they bill you afterwards is completely fictitious (because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways).
“Most of the time” in my case, it has been bad. Because it wasn’t one big bill. It was dozens of bills for $200-500. Each submission could fail in unpredictable ways. “Lost” claims forms, database “errors”, “incomplete information”, etc. And trying to deal with this burden while being sick, was too much for me. I scraped back a few dollars, but had to give up and move forward with my life.
Too often, we throw our hands up and declare legislation impossible "because companies will just get around it in ways, X, Y, and Z". The solution is to write better laws that also remove X, Y, and Z as options. And also X0, X1, Y0, Y1, Y2, Z0, Z1, Z2, Z3, and Z4. The world is complex and regulation can be complex, too. You'll never fix things by giving up and saying "We can't write the perfect law--oh well, let's just let companies do whatever they want!"
Most of the time the "we oughta do" ideas are so simple that they wouldn't work as a law "it should be illegal to charge too high prices!" so it's sort of a non-solution as it factually wouldn't work in the real world.
Real talk, the US spends more on socialized medicine per capita than all of Europe, nobody should get reelected, no foreign aid rendered nor bombs dropped until we receive what has been long paid for.
They want you to focus on the former sort of "solution" than the one I provide and that's why you probably are first hearing of mine now.
Funnily enough, as far as I have been able to figure, this is basically the unifying element of all developed-country healthcare systems outside the US, which have a lot of variety but all seem to do this, one way or another.
Some do it with comprehensive direct price controls that are pretty much exactly “it’s illegal to charge too-high prices” (Japan), some through state monopsony (Great Britain), some through limited price controls but the very-credible threat of adding more if providers get too greedy (Singapore), and many through some combo of the above, but the effect always boils down to price controls.
You misunderstand. In nations with socialized medicine (and this includes the US) there is really only one primary buyer of healthcare products and services.
If that buyer decides your price is too high, you sell around 0 units.
You can often receive these treatments if you wish to pay privately. Only the very wealthy do this, a small market.
Drug companies in the US prefer to sell units at the prices that the buyers in those nations are allowing them VS not selling them at all. That's why they do it. Then turn around and say they can't do the same in the US as it would bankrupt them.
The difference is in the US, Medicaid is quite happy to pay prices that are multiples of what other nations are paying. They sort of pretend this is all some sort of accident or due to some complexity that you wouldn't understand but it's just theft.
If your point is that the US government is tantalizingly close to being able to throw its weight around and drop healthcare prices a bunch with only minimal changes in policy and law, due in large part to its very-high spending on healthcare, but is just choosing not to, I agree.
[edit] apologies if I’ve misunderstood, though—the above is not intended as one of those “rephrase your point into something you definitely weren’t saying” sarcastic things people do sometimes, I’m really trying to follow along.
If you look at the investment portfolios of politicians you'll quickly understand why there is no interest in using Medicare to reduce prices. Watch a single commercial break during the nightly news to understand why they will never cover it, drug companies are half their advertisers (more worrying a quarter of them sell bombs)
Reimports of drugs produced in the United States back from Canada are prohibited for safety reasons. You know because those Canadians are famous for tampering with drugs for unclear reason and benefit. It's all a farce.
The concept of spirit of the law vs letter of the law infuriates me to no end.
I think the letter of the law should stipulate the spirit of the law (almost a TL;DR right at the beginning) so that jurists can later take that into account when deciding if the law was broken.
The US obsession with literality in recent times is very sui generis (and even then you have a lot of people criticizing it for not taking further, e.g. the fish is a tangible asset SCOTUS case). In Portugal, the law specifies how it should be interpreted (1966 civil code, art. 9)
1. Interpretation should not be limited to the letter of the law but should reconstruct the legislative intent from the texts, taking into account the unity of the legal system, the circumstances in which the law was drafted, and the specific conditions of the time when it is applied.
2. However, the interpreter cannot consider a legislative intent that does not have at least a minimal verbal correspondence in the letter of the law, even if it is imperfectly expressed.
3. In determining the meaning and scope of the law, the interpreter will presume that the legislator has adopted the most appropriate solutions and has expressed their intent in suitable terms.
It doesn't help make the meaning of the text more determinate, but it may shift where the battle is fought.
US Tax law is the only place where I can think of that the spirit is the most important part of the law. There isn't much of a hard and fast definition of a home based business, but if the vibe is "this is a hobby and I'm using the business only to claim deductions, not turn a profit someday" you can be in violation.
I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions. The way I see the problem, it takes way too long for us to legislate anything. By the time something passes different levels of approval, whoever has any skin in the game might figure out a way around it.
That happens a lot with finding loopholes in housing related legislations. If there is a proposal that would hurt investors, they lobby against it for a while, buying time to figure out an alternative method, and by the time it passes, they don’t really care because they’ve circumvented it anyways.
I see why it would also suck if we fast tracked most of the legislations though.
> I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions.
That happens anyway though, as much of law in Common Law systems is only settled by precedents, jurisprudence, etc. Even the US's Constitution interpretation is up to the courts when questions arise, that's the courts' job anyhow.
At least working with the spirit of the law allows ways to prevent loopholes in a way that the letter of the law process only allows if new legislation is passed to cover those loopholes.
> Even the US's Constitution interpretation is up to the courts when questions arise, that's the courts' job anyhow.
Judicial review of the constitutionality of laws is itself an invention of the courts, in fact. (And probably a good idea, but it’s something the courts had to decide they had, not a role or power plain in the law). So that specific thing being their job is… something they decided was their job, which is kinda funny.
Most laws have preambles and records of the debates to help with their intent.
The theory of strict construction is a protection in our legal system. Otherwise you'll end up with a system similar to the insurance you're complaining about - generalized rules, you won't know the outcome going into it, and they can find ways to make the rules for the desired outcome. (This stuff happens in the legal system today, it would just get immensely worse)
I agree that it’s very frustrating, but law is a language game between opposing parties. There is always going to be willful misinterpretation, because, well, sometimes people want incompatible things. If you add a spirit of the law TLDR, you’ll need a spirit of the spirit of the law, and so on.
As I've gotten older, I've found that I've lost a lot of belief in the law at all. Despite being rather clever, we are still primates who live in primate societies. Some of us are greedy psychopaths and some of us are generous empaths. If you put the greedy psychopaths in power, it will have deleterious effects on society regardless of whatever scribbles you have on paper.
"Invest" here doesn't necessarily mean monetary investment, they could for instance choose to degrade their arbitration and appeals process further, understaff it, or push regulatory boundaries in that direction. And that would possibly save them money, at least in the short term.
And to the extent that costs do go up for appeals processes, there's no guarantee that the resulting setup has margins that incentivize doing right by customers at all.
That could be solved by proper regulation. As far as I can tell they are already making the process as miserable as possible. I don’t think it would get worse.
This is what I was thinking reading TFA. Doesn't it become an AI arms race, where insurance companies use AI to deny claims, and customers use AI to fight the denial ad infinitum?
The problem with fighting claims is that it's an asymmetric game. You, the patient, must MAKE time outside of your regular life, to argue on the phone with someone who is currently AT his full time job, and who feeds his family with YOUR premiums. It's a dirty game.
Disputing charges, small claims court or simply never paying bills is the better option because the good faith channels are rigged.
I help folks in r/sterilization who have obtained permanent birth control navigate and appeal their insurance. ACA compliant plans require this be covered at 100% as preventive care, so it’s building a workflow to check the boxes in the Rube Goldberg system to get to the outcome (full coverage per statue) insurance is constantly trying to avoid.
This project is helpful and is going into the case management workflow right away. Fight slop with well crafted, guardrailed slop.
@toomuchtodo - you probably won't see this, but I'm very interested in this cause. If you happen to want an extra brain to help out, email is in my profile
Because it is the most aggressive way at almost no cost to empower someone’s reproductive rights in an adversarial socioeconomic system, while each avoided unwanted child is a net positive. Cost benefit ratio is enormous. ~40% of annual pregnancies (both US and international) are unintended, $330k cost 0-18 (2023 dollars), limited to no support for parents, etc.
If you want kids, Godspeed. If you don’t, I am building systems to radically empower that outcome. “Build something people want.” or something like that. Essentially a suffering reduction flywheel.
Sure, honestly I have no problem with people wanting to sterilize themselves, although I do somewhat support the idea that what you want at a younger age isn't necessarily what you want at a later point in your life, so sterilization should be handled at least somewhat seriously.
That said, I do take umbrage with people using suspicious statistics in unusual ways to push an agenda. If your cause is just, there is no need to use misleading statistics to inflate its importance. I argue this for causes I support as well as those I don't support.
My wife and I have struggled greatly with infertility. But nobody wants to help when you can’t conceive. Certainly not the ACA.
I suspect there’s often an anti-natal bias at work: unwanted children have a very low negative value (like toxic waste), while wanted children are a luxury good.
You mentioned a cost-benefit ratio. How does this calculate the pain of not being able to have more desired children?
Several states require insurance cover IVF and there are always children available for adoption.
People who want kids are not my TAM, I cannot speak to their unmet desires. We all must grieve that which we want but cannot have. Life is inherently unfair. I can speak to the burden of unwanted children though.
I am sorry to hear of your struggle and wish you well.
The idea is to automate the tasks for the filing process.
> She began helping friends file appeals, too, then asked herself a question that’s typical for engineers: Could she figure out a way to automate the process?
> After a year of tinkering, she just launched her answer: Fight Health Insurance[0], an open-source platform that takes advantage of large language models to help users generate health insurance appeals with AI.
And then health insurance companies downsize their legal departments, replacing them with AI too.
Next thing you know the entire system is just a bunch of large language models shooting email at one another and it becomes even more unwieldy and irritating to engage with.
The equilibrium would still converge on the letter of the policies and law, which is the goal of the endeavor.
What will happen to insurance companies (and policies) once they can no longer rely on flippant violations to pad their profits depends on other factors.
I think it's a very generous assumption on your part that increased infiltration of AI into this process will benefit consumers more than the corporations. It would make AI fundamentally different from... I mean, every previous technological innovation in the history of corporate structures, and previous to them, the robber-baron empires?
And I mean, it could be, the history has yet to be written for AI in terms of it's long-term effects on industries, but I think as I said it's very generous on your part to preemptively assume that it will benefit the customers.
This is the dynamic that every corporation and government entity leverages. I feel like a frog noticing the water is starting to get hot as I see everything: water, power, trash, internet, groceries, registration fees, etc. getting more and more expensive and I just for sanity have to pay each one and forget it.
Just this morning I was thinking how every single streaming service pushed out a version with ads and a more expensive ad-free version recently. It just comes to ~$20/mo to upgrade them all, but how much more can they pile on before people just have nothing left?
I'm back to just pirating everything, except for (many) games
It's like Gaben said, piracy is a service problem, not entirely a cost problem. The same 20 euro subscription would've gotten be 100x more movies and shows a few years ago, whereas now it's split to a million random services. Sometimes one season of a show is on 1 service, while the next one is on a different one. You also can't get 4K anywhere, every service has shit quality.
So why bother paying, when radarr lets me get 4k content of anything I'd ever want to watch, completely for free?
Absolutely I was shocked to see almost all movies on that Amazon streaming service are 4€ to watch onces. Why pay for the service when most movies are not included and need additional purchases.
I would like to see some data actually about each streaming service content availability in a chart by country with over time changes.
I really feel like amazon does themselves a disservice by mixing paid for content in with the 'free with prime' content. By not clearly differentiating which is which, I'm sure they make money from people just happy to have the content and willing to pay for it, but it pushes a lot of other people away from the service altogether, although maybe they are ok with that, since those people will still pay for prime for the free shipping.
I don't even necessarily mind the cost of streaming services. I would happily pay 100 bucks to get it all ad-free.
What I DO mind is how shitty it all is. I don't want to search through 8 apps just to find what I want. I don't want to open something called Super Freebie Movie to watch season one and then go to Amazon Prime Video for season two. I don't want to have some that inexplicably only play at low quality and there's no settings to turn the quality up.
I mean, the apps suck ass. We need a common interface for this, like we had with TV. If we're gonna be breaking up the content into a million different places I should damn well be able to see it all with 1 interface, 1 website, that's fast, reliable, and easy to use.
Large companies consolidate industries and have the asymmetric advantage of more resources than individuals. They can leverage AI and other economic models to extract more and more from individuals. As we saw recently with Justice Department case against RealPage, the large companies can collude without officially colluding through better information access.
The end result is that there is less slack in the economic system. There are fewer and fewer opportunities for individuals to leverage inefficiencies. It means there is less room to be human. Less room to make mistakes.
I think about this a lot. It's certainly not sustainable for streaming companies to consistently increase end-user pricing. I understand why they are doing it, but there will only be an increasing number of individuals unwilling to watch X amount of ads or pay X amount a month.
I haven't noticed Kodi or nfs-ganesha pushing out a version with ads? There are many markets that have been captured by duopolies and turned into inescapable extraction gauntlets, but when you've got some actual market power you've got to exercise it!
Yes, the asymmetry is how it is designed, but generative AI can turn the tables there. You should be able to sic an AI on the company and go back to watching your (AI generated) shows on netflix.
I have a queasy feeling that's not going to be how this actually pans out.
It's clear the people adopting the AI systems are the big co's -- we've been battling half-assed phone navigation agents for a decade now, and more recently chatbots (often with humorous results -- see the "No Backsies" car dealership chatbot). AI always favors the one with more resources.
When you have AI's battling AI's, rather than making progress, I suspect it'll actually result in confusion, more delays as tighter roadblocks pop up, and probably some humorous events like the infamous Dominos-vs-Papa-Johns prank call https://www.youtube.com/watch?v=ALnPVybD9X8 but darker because it'll be about cancer treatments instead of pizza prices.
The only winners will be data center operators, and the losers will be everyone without access to the AI tools. In an arms race, everyone loses in the long view.
How does this make sense? The insurance company has an overwhelming asymmetric advantage in regards to the data that is used to make such claim decisions and would be used to train such AI agents. Unless of course you are referring to legal proceedings specifically and not the data that would be used in the case.
You overestimate the ability of an insurance company to make use of AI - it will take them years of meetings, internal political maneuvering, technical failures, etc. Individuals can basically start using chatgpt today.
They already can reject your appeal based on BS like you didn't fax a form correctly (or more likely, you did but they claim they didn't get it), or they require a peer consult with your doctor and chose a time he wasn't available (on purpose).
And don't forget they already use tech to speed up denials - Cigna had one doctor "review" and sign off on 60,000 a month via automation. That's under a minute a case, assuming he worked 24/7. It takes longer than that just to fax in your form. So you submit an appeal via AI, they spend 20 seconds rejecting it, with their tech stack from a few years ago. If they invest in AI it's only getting worse for individuals unless there are new regulations that put the burden of proof on the corps instead of on patients and doctors.
The presented idea tangentially touches on what IMO is the main issue with the current system.: The objectives of customer and company are unaligned. Insurance companies fight tooth and nail to avoid paying once incidents happen. And people have to do the same but as you say it's a David vs golliath scenario.
I've always wondered why don't we have companies that "equalize" that fight, with some kind of subscription or other revenue model that aligns with the consumer. They could also have armies of lawyers fighting on the side of the claimer.
Nah, at that point big companies will use their position to impose a "must be communication from a real customer" policy, and they'll implement a terrible "bot detector"... where a high false-positive rate will be a feature to them, not a bug.
In other words "suspicious bot activity detected, start over" and "account suspended for security reasons" will become new crappy barriers to claims and appeals.
But the asymmetry still exists. Which means your AI has to fight a much better trained AI that the company developed because it would rather spend 10 billion on AI than pay out 11 billion in claims, and now you're still screwed.
I feel like AI would and has been an edge companies would field better than the average citizen. Even now calling a companies phone line seems to be this weird rigmarole of infuriatingly trying to tell a virtual agent your purpose.
Massive untracked cost of our healthcare system, too. We’re already more expensive per-capita than anywhere else, by a long shot, plus we impose huge costs on patients and their families in time & stress spent fighting the system. Any good-faith accounting of that would put our costs way in to “WTF is wrong with us that we’re not rushing to fix this immediately by any means necessary?!” territory.
There are other hidden costs, too, like government employees who have to deal with private insurance issues for purposes of sorting out benefits and child support and all kinds of things, but aren’t primarily involved with healthcare so I’m sure those hours aren’t counted among costs of our healthcare system. Not sure about the hours (and hours, and hours) HR at entities public and private lose to dicking around with insurers and brokers and HSA providers and such. Doubt that’s counted, but it’s real and significant. Healthcare providers waste lots of money on similar things from their side, but I expect those figures make it in to even fairly naïve system cost estimates.
If some people stop paying bills, will healthcare prices go up, or down?
Prices is a purposeful word choice. I don’t mean costs, or your costs. I mean agnostic to who is paying - whether it’s a compulsory non tax payment via insurance and hence the price the insurer sees, or the price you pay for insurance, or the price that CMS pays for an appointment, whatever.
Disputing charges, small claims court or simply never paying bills is the better option because the good faith channels are rigged.
Yes to the first two, but the latter is a good way to get your credit score destroyed for a few years, and plenty of insurance companies are willing to send unpaid bills to collections agencies which are very aggressive about collecting.
> Yes to the first two, but the latter is a good way to get your credit score destroyed for a few years
Not necessarily or at all - in California there are a bunch of laws about what healthcare debt can even be reported on your credit score. I routinely let things fall into collections and maintain a very high credit score because I ironically gain more negotiation power occasionally with the debt collector than whatever service I was charged for - often this happens as a result of over-billing. Dispute it enough times and they can just disappear. The credit hit is/should be minor. They use "credit" as an intimidation tool to coerce people into paying bills they don't actually owe.
Classic example - I get a procedure. Doctor submits a claim that is pre-authorized (I don't know the exact term). You receive procedure, insurer later denies claim. The doctor then passes the bill to you. Later, the doctor and insurer may come to an agreement, and the doctor is paid - but sometimes/often this is never communicated back to the patient, effectively "double billing." In these cases the only sane way to navigate it is by simply allowing it to fall to collections.
Since the vast majority of Americans are on health insurance plans provided to them by their employers as part of their compensation, fighting insurance claim denials is morally equivalent to fixing payroll or expense report errors.
A lot of insurance plans are employer-paid, meaning that the money comes out of their bank account, not the insurance company's bank account. The insurance company just takes a fee to administer the claims and keep as few bills from hitting your employer's bank account.
I remember Google denying coverage after a surgical procedure that they approved during the prior authorization period, and then running out the clock on my appeal. That's on them, no evil insurance company to blame, just my employer. And, the market decided... I don't work there anymore.
Does Google actually administer the insurance plan? Usually the way it works is that they hire some traditional insurance company to administer is and then they just payout. Administering the plan themselves is very risky and has tons of compliance burden (because then Google would be a health insurance company). This means that the company doesn't have any direct control over claims, though they have substantial control over the general policy itself.
No, they had an administrator. I filed the appeal through HR, though, which was the recommended process at the time. Probably not the right process in retrospect, especially because I accepted the appeal denial at face value and just paid out of my own pocket.
There's currently a proposal that medical debt not be taken into account on credit reports. [1]
Personally, I just don't trust companies to not put that sort of thing in a credit report. Do we actually audit for that sort of thing? And what if they do? Assuming anyone finds out, they get to drag the punishment out over the span of years, and if they do get punished, it's probably only a fraction of the money that they earned by reducing risk.
Debt holders can (and will) sue to collect, win, and take the money by court order. Depending on the state they will take the debt, then take the amount it cost to collect the debt.
Do people live in some kind of alternate reality USA where poor people who can't pay extortionate medical bills don't have their checking and savings accounts wiped out by private equity firms pretending to be healthcare providers?
In my state over the past ten years 14,000 civil suits have been filed to collect medical debt. Up until last year it was legal for debt holders to place liens on debtor's houses, often their only remaining asset after being wiped out by an illness. It was only made illegal after a particularly aggressive private equity-backed firm cosplaying as a healthcare provider started relentlessly pursuing their debts, putting liens on elderly people's homes, and then aggressively pursuing judgements on the liens, and-- get this-- SNIPING THE HOME DURING THE LIEN SALES.
A person cancer would not show up to court due to being a person with cancer, the private equity firm pretending to be a healthcare provider would get a default judgement, and then immediately start hammering on the courts to get dispositions and final judgements in order to add the person with cancer's house to their real estate portfolio.
The state legislature made it illegal to garnish the wages of someone living below the poverty level at the same time because medical debt collectors were specifically targeting patients who could barely pay their mortgage due to not working due to being sick by garnishing what wages they were able to earn, if any, to the point that the debtor went into foreclosure (in order to facilitate the confiscation of their home).
Please try, for just a few hundred milliseconds, to imagine losing your paid-off (or almost paid off) house, a scant few years before retirement age, because you got cancer.
There are a large number of other industries where SOP is to make life difficult for customers in hopes that they give up on asserting their legal rights. Among other ones I can think of: insurance, debt collection, customer service disputes, privacy opt-outs, warranty work, property management, labor law.
It seems like these industries are ripe for AI-based startups whose job is basically to be an asshole to corporations on behalf of customers, the same way that corporations are assholes back. If anything, at least consumers will be able to say "Have your AIs talk to my AI."
You correctly identify a problem then suggest a complicated technical solution. The simple solution is to make these practices illegal by passing laws.
The point is that laws are useless without enforcement. There's a wide body of civil law that depends upon the plaintiff to assert their rights. The government isn't going to go monitoring every private transaction to ensure it conforms to every applicable law. We don't want them to do that - in general the government should stay out of private transactions, that's what makes them private. And the law usually requires multiple attempts and back-and-forths to ensure that everyone has had a chance to rectify the situation before it goes to the court system. Again, this is a good thing.
But one side of the transaction is much more able to put up with convoluted processes and paper trails than the other. A corporation can amortize the cost of the paper trail across many customer interactions and build systems to handle it automatically. It can hire employees to do nothing but sit on the phone, and build delays into business processes that will make most customers give up.
These sort of LLM startups just give the same economies of scale to customers seeking redress. Yes, it'd be easier if the whole process didn't exist - there's an old joke about LLMs generating e-mails to sound longer and more impressive than they need to be, and then another LLM summarizing the e-mail back into one sentence that isn't really what the original person meant. But the problem is that each incentive along the way makes the company better off if they get the customer to go away, while each incentive for the customer makes them better off if they don't go away, and so you get an arms race between them.
Already illegal yes but in a way that favors the insurance company. For example, if the insurance co claims your appeal needs a peer to peer (your dr talks to their Dr) they currently get to decide on when the talk happens. If your dr can't meet at the exact time slot they want, you lose by default. We could rewrite the law to make the patients actual doctor win by default rather than the insurance doctor who rejects literally thousands of claims per week and hasn't even read the patients history.
The other problem is that the government is in on the joke. OSHA in my liberal state is about two people. Civil right claims are capped at 300 kUSD for a large employer. The existing laws are plainly insufficient to claim the rights that the citizens supposedly have. The present state of affairs really undermines government legitimacy.
I think it can be dangerous to view "government" as a monolithic entity in cases like this.
So many of our consumer-protection laws are written by a tremendously adversarial system: one side does its level best to get solid, genuinely-effective protections in place, and the other side won't let them happen at all until they're hamstrung almost beyond their ability to function.
It'd not wrong to view "the government" as something that is run by a small group whose interests are not congruent with the majority of the population, and experience shows this.
>You correctly identify a problem then suggest a complicated technical solution.
That's one of the hardest things for STEM types to learn, not everything can or needs to be solved with a complicated technical solution. You see it with HR and interpersonal type things all the time, where some minor communicator could solve the issue, but people start suggesting overly involved technical processes instead.
It's difficult to simply make the legal system do this. You have to back it up with investigatory teeth, and the victim still has to file an understandable complaint to start the wheels turning. The legal system also has to be sufficiently "documented" so that people will file the right complaints. The net result is the same as the current system, basically.
As an example, insurance covering trans care is required by state law in my state. Is it any easier to be trans in New York than other states? Yes. But you still get very familiar with your insurance claims process and the documentation hurdles. ("We need a letter from your therapist, not your doctor." This exists nowhere in WPATH8, but it does delay the money going out of their bank account while a therapist copy-pastes the form letter. One week to wait for your appointment. One week for them to turn it around. 2 weeks of interest earned by the insurance company. And that's the best case for the patient that already has the necessary support network.)
> You have to back it up with investigatory teeth, and the victim still has to file an understandable complaint to start the wheels turning. The legal system also has to be sufficiently "documented" so that people will file the right complaints.
Correct, this is how it works in many other countries.
> [Some stuff about health insurance documentation being complicated]
Almost every developed country except the US has settled on some model of a single-payer system with universal coverage. This whole thing with private insurance companies and documentation requirements doesn't have to be a thing.
Honestly, those systems don't look too good for trans people. The NHS requires you to wait years to go on $40/month hormone replacement therapy. The government passed a law banning prescription of puberty blockers for kids that are undecided on which gender they'd like to be as adults, forcing them to go through the wrong puberty or work around the system. Saw a post on Reddit yesterday that was "I support my daughter but we can't keep her on GnRH analogues anymore because it's illegal here." The consensus was to fly to Spain once a month and pay cash for the injection, or skip puberty blockers and start estrogen early.
This is not amazing. The single-payer model is unfortunately too political, and somehow being trans is a hot button political issue right now. It really, really sucks for these kids.
Meanwhile in the US, there is a lot of hate, but a lot of insurance companies do cover the necessary care. They even pay for flights/hotels in other states when care isn't available in your state because of political issues. We all like to hate insurance, but seeing those things commonly available in private insurance policies is ... refreshing. You are still going to have to file appeals, but it's better than "the government doesn't believe in trans people so fuck you".
Good to hear that the UK's ban on this abusive pharmaceutical intervention is working as intended.
Those parents should be investigated by social services for this abuse. Destroying a crucial stage in your child's developmental process to adulthood is awful, deleterious, terrible parenting which shouldn't be enabled by anyone and needs to be urgently prevented.
Forcing people to "transition" into the opposite gender that they identify with is also abusive when simple medical procedures are available that let you defer that situation until later. Like, would it really be a huge deal if you had a high voice and no facial hair until 18? If after much consideration you identify as a man, then you go off the puberty blockers and transition into one. If you identify as a woman, you start HRT and just go through puberty once.
It's quite a stretch to call this abuse, and I know you know it, because you created a brand new throwaway account to make your comment.
It's important to note that nationalised healthcare doesn't preclude you from paying for services privately. Unlike with insurance-based systems, you just find out the prices up front, and if you like the price and can afford it, then you pay it. Plenty of people in the UK pay for cosmetic surgery and the like.
> The government passed a law banning prescription of puberty blockers for kids
This is completely independent of how health care is paid for. It might happen that a similar law is passed in the US, and the same would apply over there, private health insurance or not.
Because money laundering, wage theft, tax evasion, and labor violations never happen, right?
Law being on the books does not resolve the central asymmetry here. Again, their full time job is bleeding you. You getting your rights asserted comes at the expense of your time.
Hell, when was the last time you got to negotiate a EULA with $BigCorp's legal group? Odds are, never.
Health insurance is such a weird thing. It shouldn't exist. You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.
And insurance doesn't want to pay out, that is their business, which actually goes against the whole idea of healthcare. You need to spend money now to prevent higher cost later.
(on the other hand, car insurance weirdly doesn't penalize you for buying cheap tires, even though the difference between 4 cheap tires and 4 Michelin tires is less than the cost of a deductible for you when miss out on those 10 ft of breaking distance).
I'm about to switch healthcare plans and I'm already mentally preparing (i.e. stressing out) to file appeals for some medications I need that they will deny-by-default.
> Health insurance is such a weird thing. It shouldn't exist. You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.
I knew this in theory, but never really thought much about it.
I need a flu shot, so the company that makes the flu shot needs to be compensated (paid), and the nurse that knows how to inject it into my arm needs to be compensated, and that's it. The manufacturer and nurses provided a sufficient infrastructure to administer flu shots.
But in America, I also have to pay a bunch of insurance companies. I used to make 6 figures as a programmer in the insurance industry. I knew my salary ultimately came from the high medical bills everyone pays, and while I didn't blame myself personally for a nation wide problem, I would have been happy to see my job and my company rendered obsolete and all of us move onto more useful jobs.
I want to see a political cartoon where someone gets a flu shot and then does their patriotic duty, opens their wallet, and starts handing out money to half the nation. In the end, there's even a few bucks left for the nurse.
I exaggerate a bit. In truth I think about 20% of US workers are involved with the healthcare industry and the surrounding insurance and other supporting industries (if I remember correctly). I really do have to pay all those people every time I have a medical bill.
Fixing healthcare costs will require a lot of people losing their job, and that wont be popular.
> Fixing healthcare costs will require a lot of people losing their job, and that wont be popular.
And going to a 'single payer' model would also reduce jobs. And the whole "they want to get rid of your insurance and raise your taxes!".
Well, the taxes would be raised, but almost certainly to a smaller extent than the price of the insurance policy you pay for. A middle of the road health insurance policy for me right now is around $1k/month. Whether I pay for it, or an employer offsets some of it - it's beside the point. That's $12k/year that is effectively a 'health tax', it's just not called a 'tax'. Somehow, weirdly, we use the term 'benefit', without with I may more easily and quickly die or languish in pain. Some benefit ;)
But yes... if my taxes go up by $10k year, but I don't have to pay for a health insurance policy... I'm still ahead. If I pay for it all, and the employer is out of the loop, it'll feel 'wrong' to many employed folks, but the employer will have more money - they should either pay people more, or hire more people (who used to work in private insurance companies).
> Somehow, weirdly, we use the term 'benefit', without with I may more easily and quickly die or languish in pain. Some benefit ;)
Not dying or languishing in pain sounds like a pretty awesome benefit. And indeed, that’s the problem with health care: when one needs it, one will pay almost anything to the provider.
Prices are a communication: they signal customers how to ration goods, and producers how to produce them. The higher the price, the fewer the customers but the more the producers; the lower the prices, the more the customers but the fewer the producers. In a free economy, it is possible to say that the work output of one FAANG engineer is economically worth that of 5 New York City garbagemen or 10 Podunk, Idaho janitors or 35 burger-flippers.
How many rolls of toilet paper is one vial of insulin worth? Infinitely more, to someone who doesn’t need insulin. Some fraction, for someone who does. Some really small fraction, for someone who needs it right now. It doesn’t make any sense for all three of those people to pay the same price, for either the toilet paper or the insulin.
In a single-payer system, how much does the single payer pay? How much do the producers of health care (e.g., physicians, surgeons, nurses, medical researchers, pharmaceutical factories) get paid? It ends up being based on the whims of the people setting those prices (a wage is just a labour price), not on any fundamental voice of the market — and thus it is either too high, or too low, and there is no feedback mechanism to constrain it. And that means society will produce either too little or too much health care, which means it will produce too much or too little of other things.
Oh yeah, re benefit. I should have put it in "quotes" or something more to indicate the sarcasm. Gee.. what a great benefit the company provides me - thank you so much(!).
> not on any fundamental voice of the market
...
> And that means society will produce either too little or too much health care
Are we producing 'too little' or 'too much' in the US right now? How would one tell?
> It doesn’t make any sense for all three of those people to pay the same price,
It doesn't many ANY sense at all? I produce an item and can make ... say, a 20% profit on it by selling at a standard price with my customer base. I could possibly make more with some form of dynamic pricing, but... to say my current approach doesn't make ANY sense seems a bit much, no?
I know that you put ‘benefit’ in quotes to indicate sarcasm. My earnest point is that you shouldn’t be sarcastic: not dying or being a pain is a real and genuine benefit. You should seriously be thankful for that benefit!
> Are we producing 'too little' or 'too much' in the US right now? How would one tell?
Probably both, in different circumstances. Not being able to tell is the key thing: without the constant negotiation of prices, there is no way to tell how much is too much or too little.
That’s why command economies fail so badly: they do things like multiply the average monthly usage of toilet paper by the population, and then issue it uniformly to everyone monthly, not realising that some people have digestive issues and use more than average, while others live remotely and need to get a season’s supply at once.
> It doesn't many ANY sense at all? I produce an item and can make ... say, a 20% profit on it by selling at a standard price with my customer base.
I don’t think so. The value of a thing to a customer, or across all customers, is not determined by its production cost. Prices have to increase as demand goes up, and have to decrease as demand goes down. That’s what keeps the guy who doesn’t need insulin from stockpiling ‘too much’ of it just in case (because the price is higher than the marginal utility he would have for it), and ensures that there is some insulin available in some store for the guy who will die without it (because the price there is high enough that some remains unsold; he may not like that high price but he is glad to have the insulin).
I don't think we should be organizing our society in such a way that "staying alive" is considered a "benefit" that is largely at the whim of employers who can revoke that "benefit" at any point.
The corporate world has bugged me for years with the "get a good job with good benefits!" then people somehow thinking they "deserve" those "benefits" from an employer. The employer relationship has amplified the brokenness of the insurance systems in place (however useful they may have originally been).
I've got a similar bugbear with the word "scholarship" as a shorthand for "money" when... there's usually nothing "scholarly" about it. Yes, it's typically used for attending a university with nominally scholastic aspects to it, but "getting a scholarship" because... you hit a baseball X number of times, or what not... the language bugs me more than anything (as with "benefits").
> I don't think we should be organizing our society in such a way that "staying alive" is considered a "benefit" that is largely at the whim of employers who can revoke that "benefit" at any point.
One’s employer literally pays one the money one uses to feed, clothe and shelter oneself. And — in the U.S. — often the money one uses to insure oneself against certain risks.
Employers don’t do it out of the goodness of their hearts, of course: they want one’s labour. In exactly the same sense, one doesn’t labour out of the goodness of one’s heart: one wants that money, insurance and other benefits. Likewise, the farmers who grow food, the truckers who transport it, the grocers who stock it, the tailors, the weavers, the cotton growers, the builders, the electricians, the plumbers: everyone trades what he has for what he wants more, and in every single one of those trades everyone gets better off. Your employer is richer with your work than if it just kept your salary and benefits, while at the exact same time your are richer with your salary and benefits than if you kept your work. Likewise for all the other participants in the economy.
Your proposal appears to be single-payer health insurance. If you pay doctors more than you should, your proposed economy will get more doctors and less other things than it should; if you pay them not enough, you will get a shortage of doctors and too many other things. You don’t know how much is fair to pay a doctor (neither do I). We don’t know how much is a fair price for a painkiller. None of us knows how much a heart operation should cost. None of us can make the right call for someone else when a procedure is worthwhile or not.
It's a "health tax" that's administered entirely by a private entity that you can't get rid of except by quitting your job or by spending thousands of dollars extra per month out of pocket.
I think if it's politically untenable to go single-payer then every employer must instead be required to give you a stipend every month to buy your own insurance. Then make it illegal for a company to offer insurance for their own employees. If everyone saw what it really cost and what they were really getting there would be a lot more impetus for changes.
Honestly at this point I'd be happy if employers would include on the paystub, the amount the company is actually paying for health insurance for the employee. So many people go around saying oh they have a job with great health insurance that's only $100/month.
> Fixing healthcare costs will require a lot of people losing their job, and that wont be popular.
Agreed, but I also don't think it _has_ to be this way. First and foremost, a switch to single payer would mean that a lot of the infrastructure that's currently in medical insurance industry would need to shift towards being government employees. While there'd be massive administrative savings with single payer, there wouldn't be zero administration at all.
I'd also posture that the US would never go full single payer, and that there'd be supplemental plans similar to the German model (and Medicare, to be fair), so while private insurers would still exist, the administrative burden would significantly lower.
In the end, you'd still end up with a lot of people losing their job, but it wouldn't be a complete wipe out of the industry. Certain areas would get hit harder than others with the insurance brokers likely getting cut out big time.
> In truth I think about 20% of US workers are involved with the healthcare industry and the surrounding insurance and other supporting industries
That seems pretty high to me. I wonder what made you come up with those numbers.
To participate in an American healthcare treatment you need to interact with a private for-profit company which will shut down if it doesn't on average attain significant profitability; Let's say 30% goes to shareholders, taxes, receptionists, keeping the lights on.
But they don't deal with everything. They have to interact with upstream providers! And they have to pay somebody to negotiate with them. So another 30%, and add 5% just to pay somebody to bargain the price with the Flu Shot Distributor.
But the flu shot distributor has to interact with yet more upstream providers - the flu shot packager, who interacts with the flu shot pharmaceutical company, and the syringe company. Everybody adds their overhead and then their premium; "Price signals" become exponentially complex and more a matter of the mood of the negotiation than anything else.
This is all an externality of a non-vertically-integrated capitalist system, which is somehow, somewhy, supposed to be regulated by your desire to get a flu shot relative to your ability to pay; It is not at all optimal in the market system for everybody to get a flu shot, that defeats the fundamental mechanism of the supply-demand curve.
The weirdest thing about health insurance in the US is how tied it is to employment, Obamacare helped a little with this. The second weirdest thing is that insurance companies can't offer more tightly defined plans for, say, young people who never go to the doctor except for critical/emergency care vs me who goes a couple times a year for various things. Obamacare did not help with this, at all.
> The second weirdest thing is that insurance companies can't offer more tightly defined plans for, say, young people who never go to the doctor except for critical/emergency care vs me who goes a couple times a year for various things.
That's not weird; it's essential for the system to work, because you can rapidly move from "never go to the doctor" into "seven figures of healthcare spend" without much warning.
This was a consequence of WW II labor shortages and the government froze wages. So companies used benefits like health care instead. It should have been outlawed after the war. It is very anti-worker and many people won't change jobs for no reason other than healthcare. It has also created an issue where the health "insurance" companies don't have to compete like they do in car insurance, etc.
It is entirely correct that the young have to pay for the old. It's not robbing from the young who "don't need" it. It's the young paying for their own selves who absolutely will need it.
Setting aside the reality of the system which will happily collect premiums for 40 years and then use any slightest technicality to avoid paying in the end, ie like changing jobs or providers and it's like you were born on the day of that switch and haven't been paying in your whole life. That is a seperate issue from the simple concept that the young somehow "don't need" to be contributing to the health care pool because they "don't need" to dip from it.
In this, there are no individuals and it's not some elective luxury like how much you want to blow on toys.
Merely in the US, we have been treating it like it was, except even worse, because when I buy a fancy over the top steak, I know the price ahead of time and get no surprises after the fact either. I don't just get hit with $500 steak bills with no warning or choice or recourse and thank god my boss takes $12k out of my salary so that I only have to pay a $50 deductible and fill out 3 forms correctly for that $500 steak I didn't ask for...
You get a high deductible catastrophe plan, and bolt on a Direct Primary Care provider for simple things. The DPC is a doctor who you pay a small retainer (My guy is $70/mo) and the main reason that the cost is so low is that he does not need to staff a billing department due to simply not integrating with insurance at all. I keep $10K in an HSA to cover my deductible if I need to.
DPC doctors also keep a much smaller patient roster so it is pretty easy to book time with him and he isn't being pressured by some middle manager to keep every interaction at 10 minutes or less. Once you see how this all works it's easy to become singlepayer-pilled because wow the whole medical scene could pay providers better, offer higher quality services, and have competitive pricing if we could just get around to deleting the billing department and insurance company.
Unfortunately the high-deductible catastrophic care plans are a lot less attractive ever since Obamacare. I agree about your advice as the least bad choice (afaik) when you don't have coverage you like through work.
Well the entire public policy point of insurance is to have the people who pay in but don't really use it subsidize the people who end up needing it. This dynamic is why the ACA had an individual mandate, which addressed the incentive of young healthy people to not want to pay in.
It would be sensible if we were talking about one society-wide pool (ie single payer), since those younger people would end up being subsidized as they developed health conditions. But as it stands having many pools run by independent companies is fraught with perverse incentives, since an "insurance" company is quite happy to have you as a customer when you're paying in, but much less happy when they're paying out.
Age impacts health insurance costs, but health insurance is specifically excluded for considering existing conditions because people can’t get long term coverage.
If someone gets a chronic condition while covered the company isn’t paying out a lifetime benefit, so they soon need to renegotiate rates while sick even though they had insurance while they got sick.
One the second point, they essentially offer this with high deductible plans. Essentially, these plans really only make sense if you only expect to have emergency care (like young people).
These things don't make sense even for young people because at a young age people tend not to have savings, and a medical emergency can totally wipe out your finances. Remember what they told you about burial insurance: it's a scam, except for young people who don't have savings
Insurance isn't weird. We have been trading risk for thousands of years, and modern insurance companies have existed for hundreds of years.
What's weird about health insurance in the US is that it's often tied to an employer, and you can't freely switch between insurance providers on a whim. It's a way worse experience than insuring a car, which can be done on a phone in a few minutes.
It's weird you use your insurance to get a routine shot or exam. I don't use my car insurance to put gas in my car, or get the brake pads changed. I use it when someone does thousands of dollars of damage to my car.
It's not weird if you consider that paying for preventive care tends to be profitable for the insurance companies, because it's cheaper than paying for the problems that arise if you skip preventive care.
Auto insurance doesn't pay for your gas because they don't have to pay a claim if you run out of gas.
> It's not weird if you consider that paying for preventive care tends to be profitable for the insurance companies, because it's cheaper than paying for the problems that arise if you skip preventive care.
This is often repeated, but it's simply not true. Preventive care is better for patients in the long run, but at a population scale it is more expensive than foregoing it.
And that is before you account for the fact that patient churn is quite high (especially since most plans are linked to employment). An intervention that cost money today and may increase costs within the next few years (due to followup care) is much more expensive for insurers if the savings will only be realized in 10+ years, when the patient has moved on to another job and so is no longer on their plan.
Very few medical interventions save money in the short- and medium-term at a population level. That's reflected in the fact that health insurers didn't cover most preventive care until required to by law (the ACA), and even then they routinely simply ignore this provision of the law. If it were profitable for them to follow the law, why would they go out of their way to break it?
A lot of the preventative care isn't necessarily something insurance companies WANT to cover - it's stuff they have to cover.
Take, for example, PrEP for HIV prevention. Costs about 5,000 dollars a month - insurance is forced to cover it. Sure, you could say HIV is very expensive, but few people at risk of HIV actually get it. If it were up to insurance companies, they'd rather just pay for HIV treatment or even better - just drop customers with HIV. The ACA prevents the latter, and the former was the case for 15 years since Truvada was introduced. Of course, now that's changed too, and they have to pay for Truvada.
> Take, for example, PrEP for HIV prevention. Costs about 5,000 dollars a month - insurance is forced to cover it. Sure, you could say HIV is very expensive, but few people at risk of HIV actually get it. If it were up to insurance companies, they'd rather just pay for HIV treatment or even better - just drop customers with HIV. The ACA prevents the latter, and the former was the case for 15 years since Truvada was introduced. Of course, now that's changed too, and they have to pay for Truvada.
Except, many (most?) insurers straight up ignore this requirement and charge people for PrEP, even though it's illegal. The ACA is very clear that preventive care is required to be covered in full with no cost-sharing or out-of-pocket cost to the patient, even if the deductible has not been met.
If the type of fuel or the type of brake pads you put on had a direct impact on your likelihood of getting in a giant accident in the future they would regulate that and require you to buy from insurance-approved brake companies.
In effect this is how home appliances are regulated. You have companies like ETL Intertek and Underwriters Laboratories performing fire and electrical safety testing of home appliances, originally on behalf of homeowner's insurance companies(See the definition of "Underwriter"). It's effectively self-regulating because the Intertek or UL stamp implies a certain degree of care. And based on some lease provisions I've seen the insurance companies for buildings do require use of certified equipment as a condition of coverage in many cases.
If you don't put gas into your car, it does not run. The chances of the car incurring thousands of dollars of damage is negligible. The insurance company will pay for the routine shot or exam since they both help to avoid medical complications that would drive up the cost of care.
Granted, the comparison is imperfect. Medical insurance won't pay for a healthy diet (another way to reduce health problems) and replacing the brakes on a car would reduce the chances of an accident causing thousands of dollars of damages ... but we are human, and sometimes it is a miracle that we even take half measures.
Oil changes seem like a perfect analog for flu shots in the comparison. I think it's a reasonable and good question why health care is so thoroughly intertwined with insurance.
It's weird that you can't see the prices for those things and that the insurance companies pay a different price than individuals. That's evidence there isn't a functioning market for most medical services in the US.
But it's not weird that the insurance company wants you to get a flu shot or exam, since those things prevent them from paying out more money later.
In reality there is some cross over point, where the flu shot isn't worth it for younger people, and is for older people. If you are young/healthy, get the flu and totally recover with a few Tylenol, and no insurance claims, then it clearly wasn't worth a $10 vaccine to prevent. That's the analysis for the insurance company. Depending on how you value your time, and time spent sick, your individual analysis may be different.
Health insurance is new, because until the 1920s/30s the salary loss from sickness was more expensive than medical care, so that's what was insured against.
But no sooner was demand for health insurance created than it was pushed into groups. In America, there's never been a time where non-group insurance was the norm.
The reasons is clear: healthy people would not get coverage, but sick people would.
> Health insurance is such a weird thing. It shouldn't exist. You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.
Yes. The problem here is that (in the US) the "insurance" part is combined with the "price negotiating power of an association with lots of members" part.
I think it is well known that the non-insurance "list price" for a procedure is many times higher than the actual price that should be paid. Witness the comment here about the $150k bill for a procedure that was settled for $30k once insurance admitted they had to pay.
This is one of the reasons that you really can't be paying for medical expenses without the weight of the insurance company behind you - your bills will not be (what I consider to be) fair at all.
>You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.
Insurance makes it free to get a flu shot because it makes everyone healthier and lowers their expenses. Similar to how you get a discount on car for installing a theft prevention device.
Insurance isn't just about insuring for exceptional events either. It results in a better allocation of resources. By incentivizing reducing risk to reduce premiums. Insurance is also a huge boon to providers who would otherwise need to spend much more time pursuing non payment, or entirely deny services to financially risky patients. And then this goes back to the outcomes for society at large.
> Health insurance is such a weird thing. It shouldn't exist. You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.
I treat it more like a subscription. I pay a little over $100 a month for health insurance. A doctor visit would cost around $10-20 out of pocket, so it wouldn't be worth it. However, the insurance also costs with 50% discount on medicine, which ends up right about $80 a month (in discount), so it pays itself back more or less.
> I pay a little over $100 a month for health insurance.
Sorry friend, your total comp likely something like $800~$1400 lighter per month due to health insurance. The fact is that your company is paying the vast majority of your actual premium and you just never see that money as coming out of your paycheck.
I work as a contractor. My company is one country, my legal entity that receives SWIFT transfers, invoiced every week, is in a second country, and I live and pay medical insurance in a third country.
The problem with this analysis is (at least) two fold:
1. health care is a mixture of the predictable and the utterly unpredictable. It is vaccines, regular exams, and minor trauma care. But it is also cancer, severe trauma, rare diseases.
2. insurance in its purest form is not a business but a way of pooling resources and distributing risk. Even in some countries with socialized health insurance, it is still called "insurance" for that very reason. We could get rid of every for-profit health insurance company in the USA tomorrow, and we'd still want something that is in every way just like "insurance" and would likely still be called that.
> Even in some countries with socialized health insurance, it is still called "insurance"
To add another data-point: In the US, the real name for the law behind "Social Security" is "Old-Age, Survivors, and Disability Insurance".
That said, it is frequently mis-characterized in our political discourse, with people making apples-to-oranges comparisons to investment accounts. I blame that on bank lobbyists' attempts to take the money for themselves. Anyway, if one views it as "old and unable to support yourself" insurance, many of its "weird quirks" make perfect sense.
This isn't strictly true. We insure against the unexceptional as well. With regards to your specific example, I think refunding the flu shot is perfectly reasonable and an elegant solution to solving the social problem of getting people to be healthy. We all pay higher premiums but only those that actually do the preventative stuff get any benefit. Put another way, if health care plans were $1/month cheaper and the cost of the flu vaccine was $12, I'm pretty sure we'd see our already lackluster yearly vaccination rate plummet.
On the other hand, imagine if you had to go through your car insurance every time you had your oil changed or your tires rotated (going for an annual wellness check). Or worse, every time you had to fill up your gas tank (picking up a regular prescription).
Ideally this sort of routine "maintenance" work would be affordable and accessible to anyone, but we have layers of middlemen in the way because the entire healthcare industry in this country is designed to run everything through insurance.
And then you have phenomena like a restaurant being closed for deep cleaning because an outbreak of Hepatitis A was traced back to it - a sick employee dragged himself to work instead of being at home curing their disease.
So you go and take personal responsibility for your liver and take the Hep A shot yourself. One wishes the government supported life, liberty and happiness of its people and offered labour protection, sick leave and healthcare to its weakest citizens.
Vaccinations are a few hundred per shot, and the part-time worker hasn't got insurance or the spare cash.
You are correct but not taking it far enough. Vaccines are (often) cheap and preventative for diseases that are not cheap to treat. I bet there are many cases where taking the vaccine should not just be refundable, but actually discount your rate.
I really think that health insurance is this. Your premiums cover the yearly risk of getting cancer plus a constant amount for preventative care; a couple vaccines (get your HPV vaccine if you haven't!) and a physical exam.
I'm looking at my EOBs for this year, and all insurance has done by their own documentation is negotiate discounts for care I've received. I think they have paid $0 of their own money. Meanwhile, I'm still paying premiums, but I don't know for what!
> Health insurance is such a weird thing. It shouldn't exist.
Half-disagree: "Health insurance" is a big group that includes a whole ton of things, and only a subset of those don't make much sense.
There are plenty of other maladies/treatments which should be insurable because not everyone will get/need them but everyone has a risk that can be understood mathematically.
> Yet we use insurance for our yearly flu-shot, hardly exceptional.
In isolation, no, but "unusually extreme case of the flu" is something that can be insured because it is a rare stochastic problem.
So out of enlightened self-interest, the regular boring preventative measure gets insured as a way to reduce the odds of the exceptional case occurring and needing a payout.
I get your point but Michelin is a global company, that manufacturers in over 60 countries. Maybe leave the "Chinese" part out and go with just "cheap tires".
I used to work at the Vehicle Engineering Lab at the Technion in Israel. China is the only place where large volume of tires are manufactured and distributed to worldwide retailers, which documents their tires using the DOT standard yet consistently fails all DOT tests when tested. As the DOT requires tires to be tested only after a certain number of failures, the DOT standard is meaningless when the factory can change owners and name on a whim. That consistently happens only in China.
i'd love to fight my insurance, but it's so unnecessarily confusing.
instead of describing the process in plain language, everything is wrapped in so many layers of legalese that even the 'happy path' becomes impentrable.
i particularly hate the 'EOB' which they tell you 'this isn't a bill' but then they make it look as much like a bill as possible and don't really tell you what its for other than to show off that insurance is... around
I think the real answer here is to have bad behavior cost rather than trying to legislate it.
A company owes you something and doesn't promptly pay. If you prevail in the end and the original problem wasn't on your end what they owe gets a multiplier and then a high interest rate.
Several years ago I got totaled. The woman came up with a few bits of nonsense that clearly didn't match up with reality but the woman from the insurance company saw right through that and knew there was no possible way I contributed to it. Then they ghosted me until I filed a complaint with the insurance regulator.
Make that say 50% or 100% higher, then maybe a couple percent of interest from the date that they should have paid. This would make such tactics not in their interest because failure doesn't mean just doing what they should have anyway.
I've considered several times what a difference it would be if legal work by individuals was considered a billable expense in the event of the individuals winning. I think it would level the playing field at lease somewhat with regard to the inherent advantage any corporation has via having a legal division full of lawyers over a regular Joe trying to get justice.
But yeah, if some farmer has to sue John Deere to be able to fix his tractor or whatever, that's going to take a ton of his valuable time to deal with. Why shouldn't he be compensated in the event he was correct?
Uh,
Fines are part of regulation. Fines are what makes regulations stick. Regulation is based on legislation. Of course, it's bad to have Legislation that tries to enforce things that regulators already have the tools to enforce (but aren't using). But broadly, if you want a hammer big enough that a profit-seeking corporation will avoid any tap with it, you want legislation. The usual schemes that imply companies will face costs without regulation being in effect (basically "let the market decide") won't work with individual consumers versus health providers or insurance companies.
What I'm trying to do is remove the need for complex regulations about what is correct behavior and the complexities of proving it. Rather, remove the concept of fault--if in the end they pay it is assumed they are wrong and it costs them money.
Health insurance and this anti health insurance product reminds me of the “time share” industry and time share exit companies. However, unlike the exit companies. This is actually useful.
Hope it ends up working out, and makes it sustainable. Although one thing about insurance companies is that they have made the rules of this game.
Some sources indicate there is some legal requirement or right granted to patients for these internal reviews. But I can’t find the exact law.
If this service takes off, I wouldn’t be surprised if the language of this law changes over the years to make it more difficult to file patient appeals (or make it outright impossible).
I fully expect a disruptive startup to leverage large context LLMs to offer a service which understands policies and automatically (as much as possible) appeals any and all insurance company shenanigans with all means available. (Need a large context window to get all the legal and policy texts into there.)
Also, not living in US, I wouldn't be surprised to learn that:
- any attempts to implement this will be met with weapons-grade lobbying on all levels to make it illegal
- it was attempted and litigated to hell and back and hence forced to shut down
- this business model is illegal already, neither lobbying nor litigation necessary
> “Part of that is an unreasonable willingness to take things too far,” Karau said.
How many people lack that? And how many companies have the resources to take things even further? I wish there was another way to get this outcome. Baby steps, I guess; and this platform in particular sounds like a good step.
I have to say the worst health insurance company, that I consistently hear complaints about, is Aetna. Multiple parents have shared how difficult it was to get them to cover their labor and delivery costs even though it was clearly a part of their coverage. All of them had to spend hours on repeated phone calls over several months to get them to cover it. Once a claim is denied initially, Aetna’s appeals and reviews each take 30-60 business days for each step, and they usually have wait times of 1-2 hours. Exhausted mothers who should be enjoying their precious time with newborns are instead drowning under stress from being on the hook for five figure sums, and Aetna knows that they cannot be on the phone for hours. I suspect it’s all a purposeful strategy to frustrate people and prevent them from collecting on their claims.
In my opinion, if an insurance company ends up paying a claim that was denied, they should be forced to compensate the person for all the time spent, including wait times on hold, at 5x the equivalent hourly wage that person would have earned.
First, insurance and everything else (including your job) should be strictly decoupled.
Second, health-insurance and life-insurance companies should imho be required to be cooperatives. That makes it so that incentives are aligned.
That the instance company is denying certain claims (both wrongly and rightly) is perfectly fine. In fact, that is good. It's part of the core business to protect against abuse. The balance is important here and will reflect in the premiums.
Those two things should already fix most major issues in insurance in a working market with competition.
https://fighthealthinsurance.com/scan
Specifically laying out what and how everything is stored. Hahah. Probably overwhelming to a non-dev, but Kudos either way!