The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage.
Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house.
If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.
People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did something extremely important to mitigate it.
I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or not.
I personally am in favor of just expanding medicare or medicade so that everyone can use them to get minimal health care if they need it. I mean, sure, if you have money, you probably still want private insurance on top of that, just like retirees today, but we've got a reasonable system for giving everyone over 65 a minimal level of care, and healthcare for younger people is a lot cheaper than healthcare for old people, so it seems like a big rich country like ours should be able to cover that bill.
but I don't think that is politically possible. I think this last election was in some ways a referendum on the ACA, and I would interpret the results as saying that many, if not most Americans think that you should only get healthcare if you can pay for it. Which seems weird to me, because as you point out, if you make anything like average money, healthcare for a family for three or four is impossible to pay for without a subsidy.
>I'm seriously considering returning to wage employment for health care benefits.
In the days before the ACA, I'd just get a full time job every time COBRA and CAL-COBRA ran out, because I couldn't get a plan at all without. I mean, I was happy paying $6K/year just for me, and that's what I'd pay under COBRA or CAL-COBRA but, once that ran out, nobody would sell to me. Maybe I wasn't asking the right people, but it wasn't like they came back with high numbers, they just said they couldn't cover me. It was weird, because while I did have a chronic condition or two, none of them were particularly dangerous or unusual.
It’s been nice to see that a well designed system can help people take care of people so humanely.
My mom pays half of what I pay and she gets family insurance while I get a single person insurance. Her pool is a large grocery store company.
And once you get a condition, you will get NO insurance without the ACA.
And we will all get a condition--it's called age.
Health care being tied to employment is anti-startup and anti-small business, full stop. In countries with single payer (or similar) systems you can change jobs without any impact to your coverage, you can start a business knowing your family's health and financial future won't be affected.
Center and center-right Democrats are pretty happy with the ACA as it was intended, although often not as it actually turns out in many states. Unsurprisingly, a lot of them take big contributions from insurers and pharmaceutical companies.
I think if single payer becomes widely accepted within the party, you probably will see the "helping entrepreneurs" angle as a big part of the messaging -- individual candidates do bring it up.
Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers
This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket
There's a lot of bad stuff happening on all sides, and it isn't clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare
The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this
We should also better fund Medicare and Medicaid. Taxes should be apparent.
Medicaid is like an ATM machine for providers in many states. There is usually little or no correlation between outcome and payment, and poor fraud controls. That’s why you always hear about providers in NYC and Miami who “visit” 900 patients a day. Additionally, you have the institutional racism aspect of Medicaid where services are unavailable in some red states.
IMO, the biggest issues in healthcare are for profit institutions and insurers and the trade guild practices associated with Doctors.
Single payer or regional systems supported by taxes are the way to go. Medicaid should be an institution that is replaced by something better.
now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA
before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher
the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys
i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat
[0] https://www.sec.gov/Archives/edgar/data/860730/0001193125180...
[1] https://www.sec.gov/Archives/edgar/data/1108109/000095012310...
Private, for profit insurance is almost certainly always evil. Their margins are dictated by how much they can delay or avoid coverage. That pretty much defines evil.
Medicare is why hospitals exist, period. Private insurers make it as difficult as possible to stay in a hospital, because they are more expensive and usually result in worse outcomes.
Reimbursement rates are being squeezed because there is a glut of hospital beds. As a result, hospitals, designed to operate with higher overheads, are losing money.
There’s a whole web of bullshit where the lack of universal coverage and rational allocation of resources results in strange behaviors.
this is not true. check out the annual financial reports for the UC hospital system as an example [0]. the majority of revenue comes from commercial payers. looking at data from HCA (largest public hospital company in US) tells similar story [1]. this is despite the fact that medicare patients are more costly overall
the bigger issue, however, are the margins. in 2010, UCSF, UC Davis and UCI had 3.5% profit margin for medicare, -27% margin for medicaid, and 21.8% margin for commercial. for UCLA they had -30% profit for medicare, -36% for medicaid, and 34% margin for commercial. private insurance literally subsidizes public insurance here. without private insurance, those hospitals die [2]
looking at other hospitals id imagine it is similar, though dont have data offhand
as to the reimbursement rates being squeezed bc of glut of beds, i dont think that is true and have seen data in the past to refute it, though i dont have the sources offhand.
[0] http://regents.universityofcalifornia.edu/regmeet/nov13/a4at...
[1] https://www.sec.gov/Archives/edgar/data/860730/0001193125180...
I would love to see (and am hoping to build) solutions that give more power back to doctors and patients, and focus on patient experience and outcomes.
I know that a lot of consumers want to take their health decisions into their own hands, and I support that, but i think most people want help from an informed professional who is on their side (ie not controlled by a hospital or insurance company with competing interests)
US healthcare (and education as well) are massively bloated with an abundance of low value-add administrators. These bubbles need to burst.
A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked.
About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year.
I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered.
[1] https://www.vox.com/policy-and-politics/2018/1/29/16906558/a...
What does the policy has to do with Obamacare? Completely unfair denials obviously happened before the ACA (see: this article), and the idea that Anthem is doing this to stave off bankruptcy is laughable (just see their financials since the ACA was enacted).
Unfortunately, in capitalist economies, when you use the law to put the hurt on companies, they will pass that hurt onto unsuspecting consumers. The money will come from somewhere, and it's not coming out of executives' pockets. Perhaps this is why Nancy Pelosi urged lawmakers and the public not to read Affordable Care Act before it was passed it into law [1]. Had everyone read it, they would have known that problems like this would eventually arise.
It's getting to the point where I'm genuinely thinking there is some bad faith activity going on.
Anthem pulled out of my state altogether for 2018, so I also had to switch providers at the beginning of the year (this claim was from late 2017). I think that's another reason they are giving me issues with this claim - they simply don't care because they no longer have to deal with my state's insurance regulator. The new insurance provider (which was the only choice I had in my area, regardless of price) so far appears to be even worse and more expensive. Something has to be done about all of this. I don't pretend to have the answer, but the ACA was apparently not it.
The richest don't even understand what health insurance is as a concept. I mean, just look at what our own President Billionaire has to say: "Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker of the House: "The whole idea of Obamacare is...the people who are healthy pay for the...sick. It's not working, & that's why it's in a death spiral" [2]. That's literally the entire point of health insurance. This is what we're dealing with here.
[1] https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pa... [2] https://www.washingtonpost.com/news/politics/wp/2017/03/09/e...
This is the whole point of health insurance! What a stupid idiot (I am overly nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever read).
Surely you can see how that is different from (say) fire or auto insurance, where no one would expect to pay the same to insure two houses, only one of which is actually burning at the moment.
Remember with Obamacare about how there was a huge push to get young people to sign up for it, because without healthy young people paying too high premiums, the system would fall over with the costs of the elderly? Maybe that is why young people didn't want to sign up for the ACA, and they needed to enforce 'penalties' for not having health care.
If young people were actually charged a fair market rate for their health insurance, they would sign up in droves because it would be dirt cheap. But when you make them pay far more than is reasonable, because old people need health insurance too, then that is how you get a system where no one wants to sign up for it until they are legally forced to.
The ACA in this sense completely subverted the point of insurance. So, maybe the right doesn't understand insurance, but neither does the left.
Even though I don't like the ACA, I give Obama a lot of credit for trying. There is no political benefit to doing so.
As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I'm open to suggestions/solutions.
I started a company with my brother that is attempting to drastically lower costs for primary care. (https://scalpel.com) We build software that allows physicians to set up their own direct primary care clinics. Our beta clinic in South Carolina charges $49 / month for unlimited visits and charges people at cost for things like labs and procedures. So instead of dealing with a labyrinthine medical system people are just working directly with a doctor. We really only care about making money off our memberships which we charge what we believe is a reasonable amount.
I often wonder why health insurance companies don't use a similar tactic.
Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)
Also Germany suffers from an ageing population which is why there aren't that many experienced professionals of any kind.
A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required.
So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc,
The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market.
I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially.
The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private.
It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them.
The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole.
To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels.
The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.
