So then if it's supposedly more efficient, why do I waste multiple hours dealing with insurance bullshit literally every few months?
Start a new job at a startup, need to go to trainings to understand the health care options and choose one, get new cards and website logins, update my info at every provider
New dentist is having difficulty getting my routine care billed to insurance and calls me every week asking for my insurance information again.
Wifes doctor didn't do something correctly when I updated insurance so now I need to call and deal with this big medical bill that I shouldn't have gotten.
Startup got acquired so I get another training for the new insurance options. And get new cards and logins and update with all providers again
Planning to get a surgical operation but nobody can tell me how much it will cost, doctor says "probably whatever your deductible is" except I have a high deductible plan so is it really going to cost me $2500?
Etc cetera. There's no end to the nuisance. If I could choose to just pay more in taxes (hell I'll pay way more than my current premiums) and never deal with insurance again, I would do it in a heartbeat.
The Reno specialist made her a follow-up appointment in June. The Carson City specialist saw her in 4 days.
Etc, etc.
We're our own LLC, and we got our own group health plan, as a function of being self-employed and having experienced the employment-related gaps in health insurance coverage.
None of this is interesting, but it's stupid and risky. This system has to be changed.
Oh you went to an in-network hospital, but this one doctor walked into the room for five minutes and she was out-of-network, so now your bill is 10x higher than it otherwise would be, etc. etc. It's ridiculous.
That's why I think full free market healthcare simply won't work. It's far too much at odds with people that need medical care, made worse if you need timely medical care.
Insurance companies want to contract with the healthcare providers with the highest quality outcomes that don't have overprescription, relapses, and readmissions.
Search terms: "narrow networks"
2) Make insurance company that reimburses 1$ per visit
3) Profit
There are multiple reasons why this doesn't work for healthcare even in theory.
- Emergency care can't be substituted without massive cost. Providers compete on distance not on price.
- Emergency care can't be denied (or at least we don't want this) on the basis of price.
- Health is not insurable like cars, etc. You can't predict in advance when you are going to get in a car wreck so you better buy insurance when you get the car. If you could, the price of the insurance would be the price of the car, and therefore worthless. But you could just wait until you feel sick to get health insurance. This is why the ACA has to be paired with the individual mandate to work properly.
Just yesterday I sent in the paperwork to roll over my HSA from one bank to another-- the punchline is, my insurance provider didn't change and my insurance login was the same (Premera ConnectYourCare), but it looked like the 15k in my HSA account inexplicably disappeared. Needless to say, this was concerning.
A few phone calls later, and I come to find out that my 15k with Bank_0 was available on the backend, but since Bank_1 was preferred by my new employer, Premera shows Bank_1 on the frontend. Keep in mind, all interactions with your HSA bank account are abstracted away from you. So you must track down your Bank_0 and Bank_1 account numbers (I used my tax paperwork) and mail in honest to god physical signed forms authorizing the rollover.
Then I come to find out that I should have done this anyway-- HSA accounts are laden with monthly account fees, paper billing fees and investment fees that my previous employer wasn't paying anymore, and these aren't covered by my current employer. HSA bank accounts are one hell of a moneymaking venture for the big banks-- 0 risk because employers send yearly contributions into the account; high likelihood that people will forget to roll it over and the account will drain via fees.
HSAs have the hugely hidden cost of managing this separate account+tax entity, and I did not know this when I signed up for one. I'm not even sure that my hours of labor on it are worth the tax savings.
I am either the luckiest person alive, or maybe there is additional benefits not obviously well represented here to working for a stable, revenue producing organization, but I don't seem to encounter what seems to be the well-represented insurance pains documented here (probably a little bit of both, in my guess).
The procedure was in December. After the procedure she received a 6-figure bill, which she then had to follow up with hours of phone calls back and forth to the insurance company, hospital, and doctor's office. They sent her a revised bill for somewhere around $8,000, and then another revised bill for around $4,000.
The insurance company says it's because the doctor coded the procedure incorrectly. The doctor says the hospital coded it incorrectly. She has had to file an appeal with the insurance company, and the only reason it looks like it will work out is because the insurance company records all phone calls and was able to get records of her original calls before the procedure asking if it would be fully covered. She has still been told to expect that they will deny her first appeal and she'll have to appeal a second time in order to get it covered. This has been causing her immense stress for the past 4 months as she does not have enough money to pay even the $4,000 bill out of pocket.
My experience is that your experience actually is extremely uncommon in America today. Most people who have to interact with the health care system beyond annual checkups have to deal with something like this.
For example, I recently got prescribed a medical device, but was then told that if I didn't have a follow up appointment between certain dates I'd be billed out of pocket for the device.
The prescribing physician, of course, has no open appointments until a couple months after the given follow up interval, despite knowing the potential issue and prescheduling the followup.
And of course the device provider, the physician, and the insurance company all tell me completely different things about the situation.
The current "solution" is "just see your primary care instead," not sure how it'll go.
On top of that insurance frustrates my wife so before we were married when she was on PhD student insurance I generally managed that too, plus her transition to my insurance after marriage.
So I'm definitely out-of-norm on this. If anything I like to think that means I'm more qualified to call out how bullshit the world of insurance is, atleast in terms of end-user UX, but obviously that's just my opinion.
I've worked for employers of varied sizes and profitability (self-employed, small nonprofit, very large health system [including its own insurance plans], midsize for-profit), and I haven't noticed a consistent pattern that would differentiate them in terms of health plan stability. In all cases, the goal is to minimize cost while providing an acceptable level of coverage.
Of course, job hopping and employer-provided coverage are a painful combination. My family had to reach our deductible twice last year, which wasn't fun (the increased salary and other benefits of the new job made it worth it).
I'd love to see health coverage detached from employment. If traditional Medicare-for-all isn't feasible, then let's go with Medicare-Advantage-for-all instead.
No matter what an individual’s stance is with respect to another individual’s professional history in terms of frequent changes or gaps, I don’t think that has to correspond to level of healthcare that the latter individual is able to obtain.
Imagine there's a single, private, insurance company, A.
Wouldn't the natural interest of A be to maximize health costs (i.e. make paying for health coverage expensive, as thus their insurance more desirable and more expensive in return)?
And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition (so, having us end up with an even larger company)?
And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?
And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?
All those seem inevitable (and profitable) in a market economy. How would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?
A, an insurance company, is the one fighting to get the cost down from B, the healthcare provider.
> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition
Monopolization is more dangerous from the healthcare provider side, though it happens both ways. Basically, insurances compete against each other at state levels, while hospitals only fight the nearest hospital, maybe.
> And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?
You can see that health insurnace companies are not really profitable. They have lower margins than auto-insurance.
> And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?
Noone has more interest than to implement national health insurnace than politicans. It's the biggest political boon plus almost unlimited spending they could get. If something like M4A passed, the state would grow in the order of 10% of GDP.
> ow would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?
By keeping at bay provision costs vs quality. In Healthcare there is something called the Iron Triangle: Access vs Quality vs Cost. If you unleash access, you need to lower quality or increase cost.
Sure, but as an insurer they don't have any control over health care costs. They could bid prices up, I suppose, but that eats into their profits; such a strategy would cost them more than they could possibly gain.
> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition ... ?
The smaller companies would have to agree to that. Some of them could be co-ops or other organizations structured to represent their members and not interested in being bought out by a company which doesn't share the same principles.
> ... wouldn't it make sense for them to collude and keep prices and profits high?
Cartels are notoriously unstable. Every member has an incentive to cheat on the cartel to gain market share. And then you have the aforementioned co-ops and others who wouldn't be interested in joining the cartel.
> ... isn't it their natural interest to spend on buying politicians ... ?
And here we come to the real issue. Not that companies are interested in buying politicians—that's only to be expected, under the circumstances—but rather that (a) there exist politicians with the power to forcibly interfere in the market without being branded as criminals, and that (b) these politicians are willing to be bought and to support laws actively harmful to their nominal constituents.
In order to have a private market for either health care or health insurance you must first get the politicians out of the market.
It's friction costs for splitting up the decision-making process into multiple entities. For any bill, the insurance company pays $X, the patient pays $Y, and the provider has $Z in costs. The $X that the insurance company pays is what they optimize for, not $Y and certainly not $Z. This has the side effect of somewhat optimizing $Z, since $Y is limited by how much money people have and if $Z is consistently bigger than $X + $Y, the healthcare provider loses money and goes out of business.
Honestly, the way to go is to treat the entire process as interaction with hostile bureaucracy. Document everything, and look like you'll generate a regulatory incident if you don't get what you're legally entitled to. Otherwise the insurance company will happily reduce their costs by offloading it onto you or the healthcare provider through pulling bullshit stunts.
The insurance companies profit massively from the confusion they have created.
The market is doing its job perfectly well maximizing the value defined by government constraints and influence (since govt is the largest payor).
But I tell you one thing that really affects why insurance sucks: that you get sweet tax exemptions if you get it through an employer, and to be an insurance that works through an employer you need to overcome massive regulatory hurdles.
Welcome to the world of regulatory capture.
One of the fallacies in play is buying insurance is put in one category. Whereas paying taxes for insurance is another. The first is 'good' because it's 'free market' and the second is 'bad' because it's the government taking your money's.
Well, I'm in favor of socialized healthcare and generally receptive to increased taxation, so that's definitely not the implication I was going for. But it is true that there doesn't need to be a categorical consideration at all. A more sound statement would be "I as a consumer am willing to pay dollars equal to twice my current premiums to get healthcare coverage while avoiding hassles while receiving routine healthcare"
In truth I'm not making a blanket argument for any government-run healthcare system because alleviating my pain points necessarily depends on said system being efficient and well implemented. But I KNOW that the free market isn't suddenly going to start improving on these pain points without introduction of regulations to manage issues like competing doctor networks, confusing healthcare coding and opaque pricing, etc, and I have no trust that the free market types in congress have any interest in regulations of any kind, so I personally err on the side of socialized healthcare on this one.
If you have a high deductible, you already chose to pay less. Revealed preferences and all that.
In reality, it's less efficient.
Nope. Employer-provided insurance plans often have blackout dates.
If you quit your job on June 2, and start your new job on June 3, your new job's health insurance might not actually take effect for up to 30, 60, or even 90 days after your start date.
To cover that gap period, you either have to switch to a new plan with your old employer (commonly called COBRA) at ridiculous high rates nobody can afford, or you have to get temporary blackout insurance coverage (which cover nothing at all, and are almost identical to having no insurance).
This need is so common, that most insurance companies have special advertising just for it (like https://www.priorityhealth.com/individual-family-health-insu... for example).
In America, to switch jobs once, requires three concurrent interactions with three different health insurance plans, simultaneously. (Your old employer plan, your intermediate temporary plan/COBRA, and your new employer's plan). For obvious reasons, this is incredibly error prone, risky, and fraught with stress.
> Is the argument that switching insurance plans is stressful?
Yes! Literally every single interaction with every single health insurance provider is painful and stressful and complicated and intentionally obfuscated, for absolutely no valid reason whatsoever.
This doesn’t even cover pre-existing conditions. So, if you are on medication for high blood pressure, or have diabetes, or are just one of the 55 percent of Americans who take prescription drugs... you are out of luck.
That these plans are even legal is a monumental failure of the American system.
Lets say you payed for insurance, but were healthy for the 90s. So ~10-years of paying insurance. Around 2005, you are diagnosed with Diabetes, so your insurance pays for your care.
Around 2007, the recession happens and you lose your job. You immediately find a new job, but you need to get new insurance. Diabetes is now a "pre-existing condition", so your insurance no longer covers your condition.
Its important to recognize that changing health-plans is a regular event, that shouldn't punish people with chronic conditions. Diabetes is lifelong, once you get it, you live with it for the rest of your life. Insurance companies don't want to pay for that kind of issue. With all talk about "Repeal and Replace", its important to recognize the tradeoff.
As long as "pre-existing conditions" are banned in the USA, I don't think its a big deal to lose employer sponsored health care (at least, compared to pre-Obamacare). We should build a world where it is easy to lose (and regain) health coverage... compared to the pre-Obamacare world where it was a big risk to lose coverage. Hopefully laws of the future make it easier to switch health care plans without problems.
If insurance is optional, then only people that know they are sick or will get sick will dominate the insurance, making it more expensive, and pushing the healthy-low risk out.
Its a well known economics problem that has no silver bullet.
What is crazy to me is that insurance is involved in paying primary care doctors. That is a terrible application of health insurance, and have full faith on high deductible plans bringing sanity back into this.
Also your coverage may completely change for better or worse. The worst case scenario is just as disastrous as losing insurance entirely.
This is particularly bad for people with chronic/ongoing medical needs.
Unless they lose their jobs. Or change to a job that doesn't offer coverage/start a new business. Or have their hours cut to be <40 hrs/wk and are no longer eligible. . .
>Switching plans is hardly comparable to the transition to a Medicare-for-all program.
Why? It would be a one-time switch. Switching costs would be exactly the same as the switching costs you pay every time you change jobs, except you only pay it one time in your life and you don't have to shop around in some silly healthcare exchange or open enrollment process where you get to weigh which absurdly high premium you want to pay despite deductibles being so high that barely any of your routine health costs will be compensated.
And then there is the joy of making sure all your care providers are covered by your new plan. AND hoping your providers don't drop your plan because of insurance company negotiations.
And switching insurance plans at almost any time can be very costly, even if you go straight to a new one, as all your deductibles and out-of-pocket limits get reset. And then you have to hit them again when the plan year starts again, almost certainly sooner than a year later.
I really am considering leaving if they switch a 4th time.
The big stressor is having to pay two deductibles in one year. That said, from an individual perspective I don't see what would be different. Before you had an (Aetna|Cigna|BCBS|UHC) card, now you have a M4A card.
I think it’s clear the article is promoting universal coverage, and simply highlight how ridiculous it is that healthcare is a benefit of employment by highlighting nearly 1/3 of employment based plans are discontinued within 12 months.
I’m not sure how you can conclude switching private insurance plans is hardly comparable to a transition to Medicare-for-all, when millions of people make the jump from private insurance to Medicare every year and you don’t hear much complaining from that group. Not to mention a 1 time transition compared to nearly 33% of the workforce going through this annually.
It absolutely is stressful, because every single time you have to carefuly inspect the documentation to figure out what conditions and care (if any) you're "allowed" to have without going bankrupt.
In my case, my employer was bought and sold 3 times. All three cases involved a sudden and abrupt termination of my insurance.
It was "okay" when I was single, but once I carried my wife, and then my entire family, it became a huge problem.
Throughout my tenure at my job, I had major surgery and two children. Sudden insurance changes immediately before or during any of those events would be a huge problem. (Fortunately, the timing worked out.)
The broad overview of TUPE is that employees whose actual job doesn't change shouldn't have to put up with any negative consequences at all for the fact that at some higher level their employer changed. e.g. the office building switches from Ace Cleaning Corp. to Best Cleaning Limited, but it's still Jenny and Achmed actually doing the cleaning, just in blue overalls instead of yellow now. It makes no sense to be allowed to tell Jenny now she's only getting minimum wage because Best Cleaning Limited doesn't pay as much as Ace Cleaning Corp, she's doing the same job so she should continue to get the same pay.
But I don't mean just obvious stuff like they can't cut your pay, it's everything - your seniority is preserved, shift priorities, rules for how much paid leave you get, or how pensions are paid - if it was part of the job, then it moves with the job. If employment-based health insurance was a big thing here, that would undoubtedly be covered.
None of that money translates to the new plan, I'm back to paying deductibles for everything.
I personally would prefer a market based approach to fixing the issues with obtaining medical care, but Congress can't do anything because there's just too much money and influence involved.
Just that it's in addition to the single payer system, which means the private one is cheap because the competition is 'free'.
As a % of GDP, Italy spends a lot less than the US in health care, and people live long and productive lives.
I mention Italy because 1) I lived there and 2) it's not some perfectly run place where everything works. It's not, and yet the health care is still better, overall, than in the US.
government entities can get subsumed by politics and bureaucracy, while private markets can get distorted by poor regulations and anti-competitive practices. if bureaucrats can get thrown out for not being competitive with the private companies, and private companies can go out of business for not being efficient and serving customers well, we might get decent service-oriented entities in the market.
many goods that don't fit the simple paradigm of commerce (e.g., housing) can benefit from such a model.
Eek. This is also called crowding out. It means expensive but efficient health services can't survive. It might be a decent compromise but I would call it a success.
There's plenty of substitutes, and there are plenty of things that have little to no substitutes and don't have these issues (food, clothing..housing does have some of the same issues).
Healthcare is a mess because it is the most regulated market there is.
Instead they've invested in lobbying to keep the status quo.
Wouldn't expanding Medicare to all also require an act of Congress? Bernie will have the influence of the White House, which is important, but it doesn't change the fact that Congress is still the body that would need to fix this.
I've always felt like the Affordable Care Act was a bandaid almost designed to point out the breaking points in the existing system, and force something like Medicare for All, to come along and "fix" the situation permanently.
They'll never fix it. As long as there is a mentality that the poor are poor because they make bad life choices and thus should receive as little support as possible as a punishment, nothing will change because any change that would give everyone basic healthcare would also mean helping the poor.
It's pretty clear the Bernie's organization, as well as the loose independent collective of progressive organizations around similar national and local causes who have also sprung up, will continue full bore to change congress as well as keep pressure on congress to make, well, progress.
In addition, each insurance plan has slightly different doctors that sign on, so when there are changes, you might wind up needing to use different doctors or worse, health systems.
It'd be much better for me, personally, to require providers to all accept some US Public Single Payer plan (or whatever you call it) as part of opening a practice and seeing patients.
(I don't speak in any sense for my employer, who is in the health care space: this is just an engineer's personal musings)
I joined a startup once, but it was in Europe, so these issues weren't even on my radar or the company's radar. With government healthcare and government unemployment insurance, it's a no-brainer. The only risk is to your lifetime earning potential. Stay at a solid job with a solid salary, or take a shot at the startup lottery. Your health or your family or your home are just never on the line by taking that risk.
The amount of time and worry you have to spend on healthcare for yourself and your family in the US is absolutely off the charts, and this cost is completely hidden! Time that companies have to spend on acquiring healthcare insurance for their employees is wasted time. Time that employees have to spend on researching the insurance options their company is offering them is wasted time. Time that you spend dealing with healthcare providers to ensure that you're covered by your insurance is wasted time.
In Europe the time spent on this is, for the most part, 0. Companies don't spend time on this. Employees don't spend time on this. But noone in the US seems to regard this waste, this cost, as something fixable. Noone seems to think of the competitive edge this gives EU companies, or want to have the same competitive edge. Why? Why are US companies and US employees just completely resigned to the thought that healthcare just is a massive necessary headache for everyone?
I mean, workers created them in the first place, so I'm all for "stealing" them back.
But I also wouldn't mind single-payer healthcare in the meantime.
American politics is geared towards appealing to the extremes. Social programs are "socialist" and get connected to the Soviet Union, cuba and Venezuela. If you say something that's even slight politically incorrect you are immediately labeled as a "racist" that should be removed from your job and all public discussion. There is no interest in discussing problems and finding solutions. It's all about anger.
The US doesn't seem to have subscribed to strongly-cenralised economic policy for nearly 70 years. And yet the employer-feudal healthcare system continues.
Preponderance of evidence suggests that dominant economic, financial, and power structures prefer it that way.
The origin story is an interesting footnote, no more.
Before, the possibility of sane choose-my-health-insurance-like-I-choose-my-car-insurance was at least on the table.
It also means that every job offer has to be examined not only for salary and culture, which are usually pretty easy to see; but also benefits cost. I've had offers that were an over 20% raise which would have all been eaten by insurance costs. I've looked at my "benefits cost breakdown" at similar companies only to see that one is paying $90k for me and one is only paying $70k, on similar salaries of around $60k.
These insurance costs are not something usually shared outside the company, and they are hard to get until the last stages of your job offer.
The first step should be disallowing this negotiation. That should massively lower the on-paper prices, or let insurance companies at least make the tough decisions about what procedures are actually worth it, which is supposed to be one of their functions anyway. If that isn't their function, I'm not sure what their function is.
That being said the sentiment was never a good one, and we do need to move on from it.
I'm totally on board with Medicare-for-All but we don't need smoke and mirrors and misleading statistics.
Whatever the merits of the more general arguments for or against, it seems like we should at least not put a finger on the scale.
[1] https://www.vox.com/health-care/2019/2/12/18215430/single-pa...
Now I’m working remotely and am in a new state (Florida) and not sure I’ll stay here long enough to switch everything to this state. I needed to get a fever checked out and ended up paying out of pocket because I was told over the phone that they accepted my out of state insurance, but when I got there in person, they didn’t.
What a mess.
1. when something happened and i needed physical therapy it turned out my copay was like 6k so i just DIY my own therapy..
2. when changing jobs i had a month gap, so i bought COBRA and 3 things went wrong.
a. it cost $1300 for a month of coverage (even with a 2k deductible)
b. since my last day was before a weekend, they actually covered my only until that same day next month, so i still had a gap of coverage (might be my employer but still sucks people have to be faced with this bs)
c. when i did go to a routine physical healthcare provider still denied the claim and i was sent a full bill. after hours of calling it turned out they initially rejected it, but then accepted months later and i was left with _*some*_ expenses ?!
If I leave a job or get laid off, usually I’ll get a similar job that has similar insurance. Now maybe you could argue that there’s a big risk of an insurance gap or that something like COBRA is unfairly priced, etc., but that would have more to do with unemployment insurance and virtually nothing to do with the basic structure of health insurance.
When I “churn” in the insurance market, it is almost always going to be a super short-term switch from Insurance A to Insurance B (both via employers) where A and B are incredibly similar.
That seems perfectly consistent with saying that people love employer-provided insurance quality. The employers have to offer the same high quality insurance everywhere, or else people won’t switch. As a result, they do provide the same high quality insurance everywhere, to ensure insurance is not a sticking point that creates job movement friction.
Of course there are outliers offering bad insurance and classes of labor like Wal-Mart retail staff that get screwed by deliberately bad corporate actors, and I’m sure anybody reading this with a personalized anecdote will angrily try to refute me.
But in the aggregate, these are exceptions, and most people like their insurance for the most part and find that almost all possible employers (for them) offer such a nearly fungible set of insurance plans that they can churn jobs without significantly worrying that the insurance they like will be very different at company A vs company B.
There could be many arguments for nationalized healthcare, but this article seems pretty much wrong from its main thesis. People “keep” the private insurance they like all the time, because “churning” the coverage is not at all similar to giving up the coverage or making concessions or compromises for the next plan of insurance you accept from an employer.