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0 pointsbhupy3y ago0 comments

> And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).

Yeah that's completely untrue; the list prices that insurers pay for GPs are heavily inflated by the market distortions introduced by the Federal government. I don't know if you read any of what I've written up-thread, but I'll paste the relevant parts here for your benefit:

"First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.

To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices."

Put simply, the US healthcare industry is not subject to traditional market forces.

> The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).

It's quite clear that the reason the government is not doing this is because it would further exacerbate the staffing shortage and lead to even higher wait times. That's not a political problem, that's a hard economics problem.

> It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.

There is a key governance difference between making the decision to lift distortionary regulations once & up-front so as to unblock efficient resources allocation vs actively having to continuously adjust resource allocation. With the former, you just have to trust that the "good governance" happens once, whereas with the latter, you have to trust that "good governance" happens forever (politics notwithstanding). The Swiss chose the former, whereas the UK struggles with the latter. Domestically in the US, Medicare Advantage is a proven model — and the governance prescription here is to have the entire private insurance industry look more like Medicare Advantage.

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salawat3y ago· 1 in thread

> big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.

I'm going to call you on this point, because what you're hinting at, whether you realize it or not, is that employers need to step up their medical care spend management game, which if implemented, looks damn near dystopian. As someone that works in insuretech, the number of times I've raised concerns about revealing too much about the shape of medical spend to employers is scary to quantify, because once you start going down that road, it isn't that far to "huh, 20% of our workforce is 80% of spend" hrrrm...

We do not want to be going down the road where employers are singled out as the appropriate optimizers there.

bhupyOP3y ago

That's not what I'm suggesting at all. The point I'm making is that employers are not capable of being optimizers because they will generally be willing to spend more on medical care than individuals, and it's because they think about money very differently from individuals. Employers are generally able to swallow a premium increase of $15,000 -> $20,000 per employee per year (it just gets rolled up into total compensation). It's usually a drop in the bucket for employers, but to an individual that's actually a lot of money. It's the same reason why corporations typically cover business class (or economy plus) air travel without blinking an eye, whereas many individuals spring for basic economy depending on their willingness to pay. Showing employers the shape of their medical care spend doesn't change that equation all that much for the same reason that enterprises today are willing to spend more on SaaS licenses than individuals (or even small businesses) regardless of how precisely their QuickBooks or NetSuite instance shows them the shape of their SaaS spend. I work in insuretech too, sometimes even work directly with employer HR teams, and see this behavior all the time. We agree that employers should not be the optimizers here. It's not that they need to step up their spend management game, it's that the way they play that game will always be different from the way individuals play that game, and that's a big part of why per capita $'s spent are even able to be so inflated in the first place.

What I'm suggesting is that the proven private sector model is one where employers are simply not involved, not a part of the equation. Private insurance purchased on the individual market. That's exactly how it works in Switzerland, the Netherlands, and also how it works in Medicare Advantage (seniors directly buy their insurance plans using dollars they theoretically set aside over the course of their lifetime through Medicare FICA taxes).

The most practical way to get there, in America, would be to either enact Medicare Advantage For All, or to tweak the employer mandate to only include ICHRAs rather than group health insurance. ICHRAs are employer-sponsored funds (in lieu of employer sponsored insurance) that the employee-beneficiary uses to buy health insurance on the individual market.

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