Seeing my health insurance deny hospital claims that were pre-authorized has been insane. The hospital checked in advance with my insurance that several operations would be covered and the insurance approved. Now that the bill comes, the insurance company has repeatedly denied and denied their claims. Health insurance companies are horrible and parasitic to everyone involved.
I've had BCBS reject prescriptions they've already pre-approved multiple times. First time, they denied all knowledge of the REQUEST (when my doctor has their APPROVAL fax in hand). Second time they acknowledged they had approved it but had to contact their pharmacy group to put in an "override".
I've submitted a complaint with the state insurance regulator though I doubt it goes anywhere.
Anyone for a class action lawsuit on the grounds of bad faith breach of contract and medical malpractice for obstructing access to care they already admit is medically necessary (by denying something already pre-approved)? I don't even want money. I want a Consent Decree enforced by the court that strikes fear across their whole industry.
Audio record every interaction you have with insurance and tell 'em you're on a recorded line.
> medical malpractice for obstructing access to care they already admit is medically necessary
This has been tried before and failed. The insurers argument is that they are not denying care, they are just not willing to pay for it, which isn’t practicing medicine.
The big problem with health insurance is that it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy. That's a big reason why the Affordable Care Act panned out the way it did, as a partnership with the insurance companies.
That's not how the economy works though — the GDP is correlated, not causated, with economic strength. What drives the economy in the end is positive-sum value creation, not trade in itself (although without any market failures, trade tends to create value). The only reason we use GDP as a measure is because actual subjective value created is very hard to measure.
If I start an extortion business, and make you pay me money in order for me to not kidnap your family, this will increase the GDP but not economic strength. This is particularly obvious during wartime, when GDP is artificially inflated, but the actual economy tends to be doing very badly regardless.
In other words, a trade that harms one party more than it helps the other makes the economy worse — regardless of how it affects GDP.
But fiscal and debt policies are built on GDP as primary indicator. That is why recently, some states/nations privileged GDP growth over economic wellbeing (gambling is such any easy example)
Goodhart's law strikes again. It's one of those things that explains so many problems in the world once you understand it. I wish there were ways around it, but I think it's a natural thing in matters involving a lot of people.
>it accounts for 17% of the US GDP, so although it's parasitic for everyone involved, it's basically indispensable to the economy
if people weren't forced to spend it on healthcare, they would spend it elsewhere. if healthcare was free tomorrow, the GDP would be fine, just redistributed.
Also, if people get the medical attention they need on time, they’d be more productive and also be more active in the economy. The loss of productivity coming from inadequate healthcare because of insurance coverages is in the order of tens of Billions annually.
Here is an observation from someone in a country (Australia) that has mixed public and private. In my country we are continually bombarded with news stories about how bad the public system is. This was puzzling to me, because after experiencing both I think you would be mad to use a private hospital if a public one was available.
There are two dynamics at play. The private hospital's customers aren't the patients, it's the doctors. It's the doctors that chose which hospital their customers go to. Thus if the doctor makes a mistake (or the hospital for that matter), it's in the hospitals interests to suppress the news. The information you do see about them is mostly paid advertising. The masters of the public hospitals on the other hand are the politicians. The opposition picks up on each and every failure in a public hospital, and parades it to every media outlet they can find to show had bad at the government in power is. Thus most of the news you here about public hospitals is bad, often very bad, and its a near continuous stream of unflattering news.
This means the public hospitals are terrified of making mistakes because it will be publicised. There are literally posters in every public hospital ward advising you how to get 2nd opinions, who you can lodge complains with, and urging you to discuss any concerns with nursing staff. They will follow them up, and they will discipline / exclude doctors that cause trouble. They are free after all, so if the patient can't pay the doctor has no choice. The net result is the public hospitals the standard of care from the patients point of view is usually outstanding. Meanwhile, I've had a father-in-law with heart problems literally half carried out of a private hospital, the nursing assuring us he was fine. I think they needed the bed for a patient paying higher fees. My father-in-law died from the condition a couple of weeks later.
It is true that free public hospitals are under funded, and chronically overloaded. Maybe that's probably a tragedy of the commons. The result is non-life threatening treatment can take a long while if you want it for free. But, the public hospitals do take fee paying patients. Insurance companies do pay those fees. When that happens I haven't noticed any wait times. In other words the USA system is available to those who can afford it, and those who can't wait. The major difference with the USA is they don't have the "free" option. The "wait times" thing you referred to is therefore 1/2 true, 1/2 myth.
I think this is an incorrect impression caused by cherry-picking data. E.g. in the dataset linked below, while some European countries have longer waiting times for elective surgery, they have between 2x and 10x shorter waiting times than the US when it comes to seeing a primary physician. Which is arguably one of the most important metrics for getting people medical attention on time.
Furthermore, in many non-US countries you have "controversial" things like emergency contraceptives being prescription free, so people don't even need to see a doctor in the first place. Imagine how much more efficient that is.
That page says the lowest waiting times for surgeries are the USA and Switzerland, which has a mostly private healthcare system and private health insurance.
It also claims waiting times for a GP are only ten days on average in the UK which doesn't sound right given the difficulty people have even getting an appointment booked at all lately. I wonder how they compute these numbers.
One thing I don’t like about discourse around healthcare is that we automatically talk about socialized healthcare systems being bad.
Asking for more transparency and accountability in insurance companies is not unreasonable. You pay thousands of dollars every year to these conpanies only to have your medical procedure delayed because the insurance doesn’t think it’s necessary. If you can’t set up a system that requires insurance to fulfill their duty, make health insurance non mandatory and set up a public system with more accountability. Right now these companies want to have their cake and eat it too.
That's funny because I am disappointed that so many people talk as if socialized healthcare is the miracle cure for all our woes.
There are a couple things you just can't get around in any society. The Law of Supply and Demand, and that corporations serve their customers.
That second one is the number one problem we have currently in the US. We, the patients, are not the customer. We are are basically a cost of doing business for the "insurance" companies and medical providers.
Socialized medicine aims to solve this problem by removing all insurance companies and becoming the single customer for all medical providers, and then dictating how much they will pay. Due to Supply and Demand, if this single customer doesn't offer to pay enough, then the supply of medical care will go down. Again in this scenario, you and I are not the customer. If we don't like this reduction in supply, we don't have much we can do. We aren't allowed to offer to pay more to get what we want. If the government offers to pay more, the supply of medical care will go up, but where does that money come from? You and I, but again, we have almost no say in this.
And more than half of my 50s-year-old friends would be able to retire from jobs where they do the bare minimum just to maintain their health insurance.
Yeah, going single payer alone could reduce that 17% to 13%, maybe more, just through eliminating all the barriers insurers put up to providers being paid and administrative overhead.
Source? A study from KFF puts "administration" responsible for only 12% of the increase the US pays over comparable countries, or less than 1 percentage points.
> Administrative costs include spending on running governmental health programs and overhead from insurers, but exclude administrative expenditures from healthcare providers.
From what I've read, healthcare providers spend an inordinant amount of time and effort dealing with insurance companies.
Correct, it's cost both for insurers AND provider organizations. We have an entire team of humans who call insurance companies on the telephone to verify insurance benefits because most insurers make it EXTREMELY difficult to determine benefits in an automated manner because that makes it easier to bill them. They do everything they can to make it difficult for patients to get coverage and for providers to collect. We're actually working with an AI company to build a tool that uses AI and lots of data to predict with better accuracy benefit coverage. All because insurers want barriers to treatment to lower their costs.
Source is my own lived work experience. In the healthcare companies I've worked in, the size of teams to investigate benefit coverage, to bill, and then to nag insurers to actually pay us works out to roughly 15% of the total staff. This is where _providers_ are about 25% of staff. Add to those salaries the costs of the tools we have to employ to manage it all, track it, and management of all of those folks, and it bloats the cost by 20%.
We're actually working with an AI company to build a tool that uses AI and lots of data to predict with better accuracy benefit coverage. All because insurers want barriers to treatment to lower their costs.
If we went single payer, we would virtually eliminate benefits investigation teams because Medicare is honestly super easy to determine benefits of a patient unless they're on the private Medicare Advantage plans. We could eliminate the need to work with clearing houses as we'd have one payor, not hundreds of payors each with dozens of plans and single-case agreements. RCM departments would shrink because with one payor, providers wouldn't have to constantly nag payors to actually send the money.
No, Medicare and CMS are run exceptionally well with some of the least fraud and waste in the entire government. CMS is NOT an agency you want to screw with because they come down like a ton of bricks when they find fraud. People go to prison. It's not like being a DoD contractor where they milk billions from the gov't.
>The big problem with health insurance is that it accounts for 17% of the US GDP
Healthcare overall, not insurance. Insurance is just how most of it gets paid. Conflating the two is like saying credit card companies account for 50% (or whatever) of the US GDP because that's how most people pay for their stuff.
Good point. However, it's almost impossible not to conflate the two (healthcare overall and health insurance) because, unfortunately, health insurance is pretty much required for healthcare. The credit card companies would be a good measure of GDP if they were required for every purchase.
Only fools pay for healthcare with insurance. If a doctor can't convince you to pay directly, don't use his services. Find a better doctor and pay for it yourself.
If for-profit health insurance is really almost 1/5th of US GDP, something is entirely wrong.
Then again, maybe it makes sense the country that perpetuates suffering all over the globe through being global police and lately just fucking up any sense of stability is the same one where almost 1/5th of our "output" is built on top of making money off of prolonging our own peoples pain and suffering.
There was a way to solve it in a much more economically effective fashion with the Dr. Ben Carson plan. It was (and still is) the only feasible way to fix things long term.
This happened in our family a few years ago. It was a penny dropping moment when the hospital revealed to me thar they routinely record all calls with insurance companies. So they had a recording of the insurer approving the procedure. They still refused to pay nevertheless.
Obviously frustrating and shouldn’t be happening. If it was pre-authed, is it possibly a billing code mismatch? That may be correctable if you book an in-person appointment with the hospital’s financial office.
Why? I wanted to express sympathy for suffering in our system while offering practical advice. It seemed rude to just launch into advice without acknowledging it shouldn’t be necessary in the first place. What phrase would you have used?
You’d start with that office and escalate to the ombuds of both the hospital and the insurer, with your lawyer and the pre-authorization document and communication trail. I get your question is facetious but it’s still worth knowing how to navigate a broken system.
Private insurance in the US needs to be completely dismantled, and we need to go to a single payer system. Not a panacea, of course, but what we have is so broken and irredeemable, it's the worst of all worlds. The US has best-in-class (if crazy expensive) health care despite our insurance system, not because of it.
I will never forgive Lieberman for killing the public option, which would at least have force private health insurance to compedte with the government.
I'm of the opinion that either a real free market or single payer would be better than what we currently have.
The main thing everyone should agree on is that the employer healthcare mandate that ties health access to W-2 employment is responsible for this situation and should be revoked.
What comes next matters less; every system has its drawbacks but ours is the worst. It has all the drawbacks and none of the benefits of everyone else's systems
No? It's a very simple logical deduction. We know what types of systems these countries have and we know their health outcomes. They're the opposite of what they claimed in no uncertain terms.
Parent said that if your employer pays for your healthcare (which is pretty much the system in the US) or your government pays (which is the system in several other countries) you'll be less healthy than if you pay yourself. That's not what you seem to have understood from the parent comment
What percentage of the US population has their health coverage FULLY covered by their employer or the government, such that they don't financially feel the effects of their health choices, i.e. no out of pocket premiums and deductibles?
As far as I'm aware that's nearly non-existent.
Let's stop mincing words, clearly what they meant was that people who don't have to pay for their healthcare won't take care of their health.
Do you really think this description applies to the US where people are afraid to go to the GP and even to the ER for financial reasons?
Haha! This little conversation between is getting ridiculous but sure. Let's keep going. Original comment said with my interpretations in brackets:
"If your employer [probably referring to the United States System?] or the government [probably refers to the European socialized medicine systems?] pays for your healthcare, you'll be unhealthy. If you pay, you'll be healthy."
At first you seemed too think our friend was saying that under socialized medicine people are less healthy than in the US. I pointed out that's not what was said. Now you seem to agree that our friend was saying that you'll be healthier if you pay for healthcare yourself (neither the US or the European model). I agree with that interpretation.
You now want to argue that the assertion is false. Note that the original poster has not responded once and is very likely blissfully unaware that this discussion is taking place. I am, but I didn't chime in to argue that point. I just wanted to clarify what I thought the original poster was saying. It is an interesting debate (more interesting than whether the current US system or the Euro system is better), but honestly, since it was this difficult just to come to the understanding of what was really up for debate, I'm kinda tired and not interested in continuing.
I'd like their to be a single payer for my healthcare but I'd like that single payer to be me and not the government and not an insurance company. Just like I am the single payer for all my food and my housing why can't we have a world where I pay for my healthcare too?
This would work very well for medicine/procedures which are known to work very well, to both doctors and consumers. This includes medicine which is already OTC (pain relievers), but also probably anything they can do at an urgent care: x-rays for broken bones or sprains, throat cultures, antibiotics (drug resistance is complex for this but people generally know they work).
Where costs will inevitably get complicated are:
1. emergency medicine, where the purchaser is in severe pain or possibly unconscious.
2. conditions without cures, or possibly even well-established treatments, and there is thus active experimentation and disagreement
Both of these are unpredictably expensive to an extraordinary degree, and the second category is sometimes rare enough that economies of scale don’t come into play for individual conditions.
I think government coverage of emergency medicine, aka ERs for severe injuries, is relatively uncontroversial due to its nature of treating unconscious patients.
However, that other category is very large in modern medicine. It includes all chronic conditions without cures, for which many options are available and improved techniques are constantly sought - and it includes complicated conditions where treatment has risks involved, which is basically a huge range of surgeries.
The problem in these areas is that the consumer does not have adequate understanding of the efficacy of what they’re buying, yet they’re driven to buy it strongly by pain and suffering. They are likely to want to do whatever a doctor or hospital tells them to do.
What is needed here is a consumer advocate with medical knowledge to keep prices consistent. In the US, this is provided by a mixture of regulation, medical malpractice lawsuits, and insurance companies.
Insurance companies are now failing in that role, but removing them entirely without any sort of replacement is going to leave the courts as the major vehicle to manage the costs - that isn’t a system renowned for efficiency.
Because unlike food and housing health is something that can hit people very unevenly. Imagine walking down the road with a copy of yourself, everything in your life is equal, you earn the same, eat the same, same genetics, etc. All of a sudden a car hits your copy and leaves him with a broken leg. The car sped off and the driver is never caught. Now through no fault of his own your copy has potentially huge medical bills whilst you do not. The concept of insurance and government paid healthcare is simply to distribute these costs. Everyone pays a little, but when you need healthcare you get it. Of course the current US system is quite broken so you end up paying a lot and still not getting healthcare when you need it. The government has a lot more tools to regulate prices of healthcare and no runaway capitalist drive to make money which makes them far more apt at providing such basic services as healthcare.
We shouldn’t even have to pay for essential services like healthcare. If it’s a matter of life or death, the state should be taking care of its citizens.
Because there is a non-zero chance that at some point you'll need a medical procedure that is, even at non-inflated cost price, more expensive than your net worth in order to survive; and society considers it unethical to let you die in that case. With the same reasoning you're not actually the single payer for your food, and food stamps exist.
Just like you're single-payer for your emergency fire services, your police services, your road maintenance, your food supply health inspection service, OH WAIT. =)
Health care is yet another of those services where society as a whole does better if everyone's needs as a whole are considered and taken care of together. It is definitely frustrating for those who have more and wish to pay more to get better care, but heck, it's still a better deal in that case. There are all kinds of diseases that have been eradicated (or are on the way out) due to a broad social program to first discover and then distribute the cure. Paying for the very best leprosy care yourself pales in comparison to never catching it.
I haven’t seen any measure where the US is the best concerning healthcare. I usually see it in the teens for outcomes and generally other measures are worse. It’s just bad.
However we basically have 1 solution, and its not legal. And naturally, its the solution in this article.
To be completely fair, just from the people who I know who have terminal uncovered diseases, I'm surprised more "direct action" hasn't been done. Desperate people with no good options can and do take the terrible options.
The by far best system I've witnessed was the Swiss healthcare system, which is NOT a single-payer system.
Some features: (1) health insurance is obligatory for all residents (2) must be private, cannot be purchased/sponsored by company (3) minimum coverage is specified by law (4) health insurers are private companies, often (mostly? always?) non-profit (5) they cannot reject applicants, and can only discriminate (by price) on: (a) age, (b) residence (i.e. more expensive city/area => more expensive health insurance) (6) all procedures are paid - 10% copay is mandatory (up to a certain yearly amount) (7) health insurers make extra money on better health insurance ("private coverage") offering better service, more experienced doctors, private hospital rooms, extra coverage (e.g. for mental health, abroad etc.) etc. - those can discriminate on much more features, including existing health conditions sex (e.g. for young women it's more expensive, because of pregnancy)
In 2016, Switzerland’s healthcare expenditure, as a percentage of GDP, was the highest in Europe. The country spent 12.3% of its GDP on healthcare.
Swiss hospitals also accumulated losses amounting to CHF1 billion ($1.13 billion) in 2023. Most hospital costs are covered by the gov't though whereas in the US hospitals are private corporations.
A single payer system is politically impossible :/. But there are ways to get the system without overturning it completely. But they all come down to cutting or eliminating insurance profits in some way, I think.
For example, prohibjt insurances from making profits at all - earnings must go into savings, future rates need to go down when savings are getting built up beyond a safety buffer.
Another idea: a government mandated catalog of services that have to be covered, including fixed costs (maybe plus a small effort scaling factor based on provable additional needs for a patient). If a doctor claims medical necessity, the insurance is automatically required to pay that fixed amount - no rejection possible. If the claim is fraudulent, they can sue the doctor later.
Why? US healthcare costs have nearly nothing to do with insurance and everything with doctor and hospital payments.
I think the best way to improve US healthcare is to off all the righteous idiots. Just kidding!
The 2nd best way is outlaw health insurance of any kind except maybe genuinely catastrophic, like lump sum cancer insurance or emergency room coveragr. Don't provide any public option. Once everything is out of pocket the outrageous provider prices will be forced to come down either economically or politically (my preferred option is easy immigration and the recognition of medical degrees from OECD countries)
The costs just get worse as our understanding of disease prevention and chronic illness grows. The costs of neglecting early intervention are ultimately borne by society through programs like Medicare, as individuals age with significantly poorer health than they would have if they had received earlier treatment.
It's much cheaper to repair a roof that has a small leak than it is to clean out and rebuild a house rotted with mold.
I had to look up what “single player payer system” means since I thought it meant something like “each individual pays for themselves”, the opposite of a social safety net.
I was completely wrong. Single payer means there is a single (gov) entity paying health care for everyone. 1000% this is what we need.
Everyone needs to care about their health. When we need healthcare it’s so often for things out of our control, like cancer. Putting the burden on the individual is cruel.
Capitalism as applied to human health is fundamentally inhumane (literally, profit valued over human life). I’d be interested to heard arguments otherwise.
Of course, a universal healthcare system should take notes from capitalist markets to be efficient, but have the primary goal of maximizing human well-being
Caner isn't out of your control, it's usually caused by being fat and eating bad food. It's sometimes caused by genetics but that's a minority of cancers.
What class is US healthcare best in? It’s probably among the best in quality you can get as a rich individual, but as a system it’s deeply flawed in many factors. US doesn’t even make it into the list of best 50 countries by life expectancy or maternal mortality ratio. Which is batshit crazy for such a rich country.
What is the life expectancy and maternal mortality ratio for lean white people in New York and Massachusetts? I'll bet that it's better than most European countries.
In Netherlands we have a free market for health insurance, however there are regulations and pretty much all essential care is included. Also the insurance company is not allowed to reject any person. Furthermore, every person is required to get health insurance. So healthy people pay for the old.
"Single payer" really just means "no choice, and no competition". I wouldn't really expect things to get better under such a system, and worse it would put a much larger percentage of our freedom on the chopping block.
Just look at the all the stuff they pulled over COVID. It would usher in a terrible era where everything you do is free for someone else to say no to, because "we all pay for that".
I give it 10 years under such a system until we have a similar supreme Court ruling to the one we got for interstate trade. Except this time blowing out their scope of power to anything and everything, with no more limits
It's not the same as the current setup, as it would provide justification for control over every aspect of your life.
Like skydiving? Too bad, it costs us in heath care dollars, so we have to ban it. Competitive sports? Can't justify the cost. Oh and of COURSE you can't have free choice in your diet and libations. People make unhealthy choices and it costs all of us, so your choices will be made for you.
It won't go all the way there day one, probably won't go there fully in the end, but the effect will be real. Just look at how every aspect of our freedom was restricted over COVID, with the justification that your choices "impact other people".
It will put overly cautious or even just overly controlling public health individuals as having control they never should be allowed to have
Medicare has been providing single payer healthcare to Americans 65 and older for nearly 60 years without running into the pitfalls you are worried about. Why do you think a single payer system for younger people would not be able to also avoid those issues?
Our "insurance" sucks because of all the government involvement. Putting government completely in control would solve some problems, but I personally would like to see how things go if we do the opposite and take government out of it completely.
When people say things like this I feel sad that we seem to have no idea what insurance really is, or that people are free to organize help for others and that many many good people would freely choose to do so.
It's an obvious outcome though. Cheaper insurance can be had by excluding anyone with a chronic or serious condition. Healthy people will flock to it. Their rates will drop. The rates for the non-healthy will thus go up, and effectively be unaffordable for most; the same reason you cannot get home insurance in a fire prone area. It's not that it is expensive -- you literally cannot get it (unless Government backs it, e.g. same as our current insurance). The destitute in health will indeed get some charity. But unless people willingly donate to the same level they are paying for insurance today, it will be strictly less.
Yes, "insurance" as such has lost its meaning. Its healthcare coverage. Everyone knows that, we just keep calling it "insurance".
Insurance is supposed to be for rare and expensive occurances. Fires (in most places), windstorms, car accidents, etc. It's essentially a bank account that a large number of people put money into and only a few people ever withdraw from. So yes, you are correct that it doesn't work to have fire insurance in fire prone areas, or to cover medical care for people that are chronically sick. It's not that insurance companies are evil, it just doesn't fit the insurance model. A different solution is needed. One that we could come up with if we had some freedom to experiment with.
Health insurance today is really a collective bargaining organization. You join the UHC club and UHC negotiatates rates with medical providers on club members behalf. Except it doesn't even work very well in that model because it's not run like a club with members having any input really. You also can't easily leave one club if you are unhappy and join another club, and your employer and the government are paying more of the money into the club than you are.
> A different solution is needed. One that we could come up with if we had some freedom to experiment with.
I believe if you propose such a practical experiment HN would be happy to discuss, poke holes, etc. However, most people are fine to look at other countries that have already implemented universal health care well, at a fraction of US prices and say, lets do that. The average American on private insurance already pays more than what such a system would cost. Allowing a private option on top would resolve issues with anyone worried about reduced quality / lack of choice.
We have done so in the form of government. The whole promote the general welfare bit. The free rider problem is not an issue with publicly funded healthcare.
Government forcing us all to do something a certain way is not people freely organizing. Sorry to break it to you. Please see my other comment in this thread for more of my thoughts on that.
It is to the extent possible for 330 million people. There are no instances in world history in which people freely organizing as you put it adequately solved the issues of hunger, education, healthcare, etc. for civilizations with more than 5 million people.
People, in the form of their elected officials, can freely decide to impose a publicly funded solution. You’d be free to refuse care in such a system, or to leave. All societies have rules that some people don’t like.
In all seriousness, if those are the only choices then it's not people freely organizing. And this forced "free" organization is NOT the only way to solve these problems, and in fact it isn't really a solution to these problems at all.
Acknowledging what governments do makes me a communist? All societies impose rules on its citizens. Some socieities have imposed a publicly funded healthcare solution. Some of them have done so successfully. Leave the country if you don’t like living somewhere that imposes rules on you.
If you can't tell the difference between which kinds of rules governments impose then I'm sorry I can't help you. I'm not going to leave this country because it still grants citizens the most freedom of any country. I'd like for that to continue to be the case.
and private industry has a prime directive to attain profit goals at predefined amounts, regardless of who is healthy or sick, so the more expensive of the two will fall by the wayside.
what has me pensive is, i think you already know this
"profit goals at predefined amounts" ? What are these pre defined amounts? Who sets the amounts? I'm really not sure you know what you are talking about at all.
Private industry has no prime directive. There is no supreme leader telling them what to do. That's kinda the whole point. Some choose to pursue maximum short term profit at the expense of all else, and some choose to give every penny they earn to the poor and needy, with a whole spectrum in between. Most people in our society are good people, unless they are constantly told they are not, constantly told that they should be afraid of everyone else, or are given too much power over others.
Look, our society functions at all because most people are good people. Not everyone is good, so good people who are scared of bad people have given government power over all people. The problem is, power corrupts good people.
Government gives power to insurance (and to other healthcare related companies, and really to a myriad of other players in other industries) primarily by:
- introducing regulations that make competing with incumbents nearly impossible
- giving tax breaks to favored corporations and behaviors
Why does government do this? Again, because the good people in government have been corrupted by power. The people they give power to help them stay powerful by giving them campaign contributions and other favors. It's a vicious cycle.
I'm not sure how to answer your last question, "what actions do you think companies might take to benefit customers if not for government involvement?" when every corporation does things to benefit it's customers. That's why any and every corporation exists, to benefit it's customers. Customers are anyone that benefits the company. Apple makes great products that benefit their customers without the government telling them to do it. In industries like healthcare in the U.S. right now, we are not the people who are primarily benefitting the corporations. The way things are bought and paid for right now I don't think we benefit health "insurance" companies at all!
> “That's why any and every corporation exists, to benefit it's customers.”
That is an incredibly optimistic belief you have about the purpose of corporations. In reality, corporations only have the responsibility to benefit their shareholders.
Making sure your customers are happy and keep giving you business is certainly one route. And I think most companies at least start out this way.
Though it’s funny you use Apple as an example, since they’ve been widely criticized in recent years due to the parasitic App Store practices enabled by their stranglehold over the smartphone industry.
Government does get corrupted by money, but that money ultimately comes from rich corporations. Eliminating government involvement could just make corporations abuse their power in other ways.
And I would reply that your view is incredibly pessimistic.
Making your customers happy is the only route they have. When governments or other third parties get involved then you and I might no longer be the customer, but I can assure you that the corporation is still serving their customers.
That's the number one problem with our current situation in the US with healthcare. You are not your doctor's customer. You are like, 3 layers away from being his or her customer.
No, it’s not the only route they have at all. There is a long history of companies screwing over their own customers to make money. I can’t honestly believe that you aren’t aware of this.
Just look at how Wells Fargo a while back was opening up accounts and charging fees to customers who never authorized it.
Or Purdue Pharma that gave kickbacks to doctors to prescribe opioids and misled the public about how addictive they were.
Or payday loan companies that suck people into vicious cycles of debt. Or the numerous companies that profit from gambling addiction.
Or the big banks that gave out dubious mortgages and lied about risks to investors, which precipitated in a global housing meltdown and recession in 2007.
Or how cigarette companies lied about the dangers of smoking, leading to countless deaths.
Companies will lie, cheat, and scam their way to profits if they have to. Not all of them, and not all of the time, but the endless quest for more money is always corrupting.
Sigh. Sorry that I didn't specify "long-term route." Some of those examples are of companies making moves that made them money in the short term but hurt them in the long run. In a free market, customers can easily stop giving money to corporations that do that. I might point out that in a couple of those scenarios heavy government regulations and/or protections made that difficult for people to do. I would also point out that those examples are a small percentage of companies overall because again, most people are good people. Things will never be perfect, but we don't list off the examples of successful companies giving customers what they want because there are so many.
Also, you have to understand that public corporations get cash from people buying their products and services and from investors. The investors are therefore just as much their customers as you and I are. Often it feels like investors preferences are given far more deference than your and my preferences. In a free market, we can pay attention to that and make choices accordingly.
Finally, your opioid example is very pertinent to the original topic. You and I were not Purdue Pharmas customers in that scenario. The doctors and insurance companies were. We are just a weird cost of doing business caught in the middle.
Theoretically customers can give their money to some other company, but we have seen massive consolidation across most industries over the course of decades. Many important markets are dominated by only a few large companies.
The free market works when there is actual competition. If we want a healthy free market, then we need vigorous antitrust action to block mergers and break up companies that get too big.
I also would recommend that government should stop making regulations and tax breaks that favor one company over another. I think that would be even more effective than just antitrust enforcement.
Here's just one idea. Currently the vast majority of us get healthcare through our employers because government heavily incentives that. Because of that, we really aren't the customers of health insurance companies, our employers are. That's ludicrous. It gives far too much power to our employers.
Remove the requirement to spend 80% of premiums on care. Right now there's no incentive for providers to keep their costs low, which hurts people both with and without insurance.
They can negotiate any price they want at any point. That means pre-deductible price can stay high, but afterwards the provider pay is low and the insurer profits are high. The accounting has enough slack in the way billing's done that it can be achieved in many ways. That change has no benefit at all for the insured (unless you assume the insurer cares about them...)
One of the most interesting things about this whole situation is that nobody is trying to even pretend that the current system is fair or effective. The tone in media and from corporate PR, business leaders, and politicians is either silence or some version of "hey stop talking about that / well it's not MY fault." Everyone knows the system is unfair, parasitic, and literally murderous, but no one in power is willing to take responsibility of any kind or show real leadership in bringing change.
Nah nobody knows that, it is a lie. The reason healthcare in the US is expensive is primarily providers. As reported by e.g. Vox.
In fact us out of pocket spending is low compared to OECD, and overhead while relatively high is not huge. It's that the doctors and hospitals in the US are paid much more.
It's not just denials. This is anecdotal but my company moved from Aetna to UHC starting in January, and there are already dozens of threads in our internal slack about drug co-pays jumping 10-100x, despite the UHC rep's assurances that the plans were equivalent with what we had before.
Suing (or threatening to sue) everyone and anything that speaks poorly about the company is an interesting PR response, isn't it? I'm used to companies just ignoring the issue and hoping it goes away.
It's an extremely common response. I think you're used to remembering stories as "companies just ignore the issue and hope it goes away", summarizing away all the day-by-day coverage of letters they sent telling people to stop being mean, and that's probably how most people will remember this story in a few years too.
I had a baby. Months later, UH retroactively denied all birth and baby care claims. They claimed I had other insurance, which I don’t. Now I get to prove a negative. So fun.
Maybe there should be a government mediated system for "DMCA", denied medical claim arguements, where anyone could send in a DMCA against a health insurance company and automatically involve the formal legal court system at no cost to themselves. Normally I would not want to involve government but in situations relating to life and death I think it is justified (like other things govs regulate involving life/death).
Yeah, you’ve come to mostly the same conclusion as Mark Cuban(whole thread [0]). He agrees that you need some sort of watchdog to prevent fraud/waste/mistake but that insurance companies don’t work because their for-profit nature perverts their incentives. I don’t know if a government-based watchdog is the solution but I think you’re on the right track.
Insurance contracts are not allowed to be cancelled in lieu of the fulfillment of the liabilities created by the insurance contracts. That's literally fraud and laws were made in the late 1800's and early 1900's to deal with insurance companies that ran this scam for life and fire insurance.
The answer is to eliminate health insurance entirely.
Note that this is compared to 6% the previous year, the decrease partly due [1] to a security failure where they got ransomwared and may also have leaked people's info [2]. In absolute amounts, that's 22 billion in 2023 down to 14 billion in 2024.
The company also holds assets worth ~300 billion, an increase of 26 billion compared to 2023. [3]
The problem with this statement is that a lot of the reason healthcare costs so much is that insurance companies have a legally mandated max profit percentage, so they make deals with hospitals to make services more expensive in order for them to be able to take a higher amount of profit.
How is the absolute amount relevant aside from being able to use shocking words like "BILLIONS" or whatever? 3.6% is 3.6%. It might work out to billions, but if it's split across hundreds/tens of millions of customers that's nothing. I doubt anyone is going to be placated if UNH provided 3.6% more healthcare to its customers.
Because then you can start to ask questions about whether the absolute amount has been inflated to create and absolute amount of wealth for the executives and investors.
Do you really need a health insurance company's revenue/profits in absolute amounts to "start to ask questions" about the state of the US healthcare system? The fact that the US spends twice as much as its peers on healthcare should be enough justification.
Moreover, it's unclear how you make any meaningful conclusion from the UNH's absolute financial numbers. UNH makes $32.3 in profit on $400.3 billion of revenue. Medicare on the other hand spent 1 trillion (!). It's unclear how anyone can look at those numbers and conclude whether they're too high, too low, or whether "the absolute amount has been inflated".
It’s not that the absolute figures are all you need to know — you might want to look at how many more people Medicare serves for instance. It’s that without them you’ve got nothing to go on.
I’m also inclined to agree it’s. as we spend more than peer nations, but there are also arguments to be made why we aren’t directly comparable. Differences in our demographics and lifestyle, etc. that affect the healthcare we consume.
Their margin isn't the only opportunity. There's also their administrative costs, and the administrative costs they induce in everyone else (medical, software, legal, whatever) who has to deal with the complexity UHC adds.
>What percent of denials do you think would not happen, if everyone worked for the company for free?
Wrong question. The correct question is - what percentage of denials would not happen, if exec pay and market cap is allowed to be cut by 75% while keeping the revenue the same.
Based on some quick napkin math from their 10-K for FY 2023, they could afford to spend about 7% more in claims (107% of their current payouts, that is).
If you cut exec comp to $0 and profits to $0, it's more like 9.7%.
No, it's not 9.7% more claims, it's spending 9.7% more on claims.
And that means very little without an understanding of the total cost of claims denied. How many claims would still be denied?
Do denied claims even follow the same cost distribution of allowed claims? Maybe I'm wrong, but I imagine very expensive claims are denied more commonly than very inexpensive claims.
I think it's pretty clear that even if that extra 9.7% was paid out, there would still be a huge list of denied claims, and the psychos that celebrate Mangione would still be calling for murdering people in the healthcare industry, if they're basing their calls for murder on the fact that claims get denied commonly.
The US healthcare system is fundamentally broken by absurd costs all around. It is not really broken because a tiny fraction of workers make large bonuses. That doesn't help, but it is not the root of the issue in the slightest.
I’d be remiss if I didn’t also mention that 98% of that 9.7% (so 9.5 of the 9.7) comes from slashing profits to $0. Exec comp alone is just a rounding error by comparison.
Is this GPT? Point 2 makes no sense at all, since you mentioned percentages. Point 1 - do they cover more high risk patients, or is it just a hypothetical? Same for point 3 - do they? Point 5 doesn't matter for rejection rate.
This is what you get when profit is prioritised over every other factor. i'm not sure why anyone finds this surprising. Social democrats recognise the role of government is to put in place regulations that temper this kind of behaviour. under Trumps 'slash and burn' approach to regulation expect things to get worse on every field
Gee, I wonder if there's a law famously referred to by Obama's name, that improved the appeals process for denials? Maybe the internet even has information on this that you could search for? [0]
Yes, obviously Obama tried to improve this, and Trump at most ignored it, and will probably make it worse within the next few weeks.
So it's plenty worse under Obama and Biden. They're both the same ffs. Your tribe has more things in common with the other tribe than it has differences.
>If stuff like voluntary plastic surgery wasn't covered, what the hell kind of medical fraud would there be?
Off the top of my head: going to a doctor, conspiring with him to make an insurance claim that you had some sort of procedure done even though none was actually done, and splitting the claim check? Not saying this happens, but it's not hard to think of frauds you could perform even if "voluntary plastic surgery wasn't covered".
Or there's things like doctors ordering dozens of tests to identify a particular cold virus even though it wouldn't change the treatment or patient outcome, and oh, it just so happens the doctor owns the lab. (A real example)
Or a doctor prescribing a monthly massage to a patient. Or approving a questionable disability claim. etc. etc.
There's no reason for the doctor to involve any patients, other than to write their names down. These are fraud factories submitting thousands of templated claims per year.
>There's no reason for the doctor to involve any patients, other than to write their names down.
...until the patient looks at his health insurance account and notices a charge that he doesn't recognize, or the insurance company decides to do a random audit of a claim.
Right, it's true that insurance companies investigating and denying claims is a major constraint on claims fraud. That's why Medicare and Medicaid still deny a lot of claims (although not so many as UHC) despite being publicly run.
You can peruse Medicare fraud prosecutions for all kinds of scenarios. See for example https://www.justice.gov/archives/opa/pr/doctor-sentenced-54m.... If you convince a confused elderly person that they need some device, and submit paperwork falsely certifying you agree they need it, that's not trivial to detect.
That’s what a claim denial is. If you dig into the details of a viral claim denial story of your choice, you’ll almost always find the same dispute: the insurance company thinks the doctor prescribed an expensive treatment when a simpler treatment would have worked just as well.
I don’t mean to overstate the argument. Claim denials are a terrible way to resolve disputes like this, because they inflict quite a lot of pain and stress on the helpless patient who did nothing to cause it and can’t meaningfully help resolve it. But it’s important to understand why simply telling insurance companies to stop denying claims, despite its intuitive appeal, isn’t a real option.
This is what’s frustrating with the current political situation. Since we are already wielding the sledgehammer, why not take it to this system, which would actually solve some real problems for every day people?
And they wonder why so many people are supporting Luigi. I could never condone murder, but I understand and deeply sympathetic. United is the comcast of health insurance
It’s disappointing we don’t get any further investigation into this he said/she said argument.
The cynic in me is inclined to believe the company is denying it to the press without regard to the truth, because they can. No one will hold them accountable, so there’s only upside to lying publicly. (We’re currently seeing this strategy play out in national politics as well.)
It recently occurred to me that the crazy expense of the US Healthcare system (most expensive in the world, while also being terrible quality) might be by design: it keeps you desperately tied to your jobs. Just another threat enforcing that weird modern serfdom the Americans are so fond of, along with their unsolved homelessness and massive prison industry.
Wouldn't it be nice if we could just keep collecting premiums and get paid salaries for doing nothing productive for society?
Honestly, it's like that Bilbo meme where he's thinking about keeping the Ring.
I'm sure every neoliberal capitalist dreams of just entrenching themselves in some kind of regulatory-protected business model paradise, so that they can keep "running the business" for hundreds of years, but that's not a good thing to aspire to if you have even a shred of human decency or ethics.
It's clear that health insurance companies are awful, but I wish people weren't so quick to let medical providers off the hook. It takes two to tango, and health insurance companies have found medical providers are eager to protect the status quo.
Under our system, companies are highly incentivized to spend lavishly on employee health insurance plans since those dollars are not counted as taxable income on the employee's tax returns. By law, at least 80% of those tax advantaged insurance premiums must be passed on to medical providers [0].
Healthcare providers further benefit from having insurance companies act as a cut-out between consumers and them. Consumers have minimal price sensitivity since their care has already been paid for by their employer in the form of health insurance premiums. Under single-payer, providers would be unable to play insurance companies off one another in price negotiations.
So it's little wonder that the American Medical Association has been opposed to government-backed health initiatives throughout the 20th century [1]. Both the AMA and the American Hospital Association have joined with the pharmaceutical and health insurance industry to oppose Medicare for All [2,3,4].
Doctors have also lobbied to limit competition that could drive down their compensation. They have lobbied for caps on the numbers of doctors trained in the US and on Medicare reimbursements for resident physicians. A testament to the success of these limits is that in 2022, a quarter of US physicians were trained abroad [5]. The AMA has opposed expanding the scope of practice for nurse practitioners [6]. Resident physicians are subjected to grueling long hours in what amounts to an institutionalized hazing ritual, with residents working up to 28-hour-long shifts and 80-hour weeks under applicable duty hour regulations. Even these generous limits are routinely evaded by false reporting [7]. The Association of American Medical Colleges projects a shortage of up to 86,000 physicians by 2036 [8].
Meanwhile, despite most hospitals being nonprofit institutions and enjoying the concomitant tax benefits, they increasingly behave like rapacious capitalists. The Guardian reports [9]:
> Since the 1990s, hospital systems across the US – for and not-for-profit alike – have relentlessly chased after market power, executing nearly 2,000 mergers with little pushback from overwhelmed federal antitrust regulators and indifferent state authorities. Research from the American Medical Association found that by 2013, 97% of healthcare markets in the US had little competition and were highly consolidated under Department of Justice antitrust guidelines. By 2021, that figure had risen to 99%.
A 2023 Health Affairs study reported "substantial growth in nonprofit hospital operating profits and cash reserves" between 2012 and 2019 "but no corresponding increase in charity care" [10]. Direct-to-consumer advertising for health services ballooned from $542 million to $2.9 billion between 1997 and 2016 [11].
Stories have emerged of hospital staff steering patients toward unnecessary procedures and testing [9]; of exhorbitant charges, like $629 to put a bandaid on a finger [12]; and of fraudulent billing practices like upcoding [9]. ProPublica describes the case of Dr. Thomas C. Weiner, an oncologist at a Montana nonprofit hospital who was found to be routinely giving his patients unnecessary treatments. In one case, a patient died after 11 years of cancer therapy from treatment complications despite a biopsy in his medical record showing he never had cancer. An autopsy has confirmed the biopsy [13]. Over those 11 years, Dr. Weiner was paid over $20.1 million, billing up to 70 patient contacts a day [14].
Just last week, my wife had an otolaryngologist push to perform a closed reduction to straighten her broken nose despite a CT scan in her record showing that the fracture was not displaced. This was the third medical appointment she completed (ER, primary care, specialist) for an injury for which the ultimate treatment was OTC pain medication and ice.
Insurance executives make easy targets, and they earn their bad rap, but it would be a mistake to ignore the other players in the medical industry. Everyone is at the feast, and we're on the menu.
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