UnitedHealth CEO Shot dead

[FireLane]

I agree, and it's also an indirect drain on businesses.

Employees dealing with health care insurers and administrators mainly have to do so during typical office hours, Mon-Fri,
9am to 5pm.  Meaning workers have to take time during the workday to try to appeal claims denials or fix snafus instead of doing their job.
I worked in cubicle-land for many years and overheard scores of conversations from co-workers who were forced to handle these things in a not so private workspace. 

Yes, that too. My wife has had several medical procedures in the past couple of years where her insurer tried to deny coverage for routine care, or billed us for things that should have been covered. She had to fight them each time, spending hours on the phone to resolve it.

I'm FIREd and she works mostly from home, so even though it was a burden on us, we had the time to spend on it. Someone with a less flexible job, like a teacher, would have a much harder time or wouldn't have been able to fight it at all.

I always wondered why private corporations didn't insist on Medicare for all for this reason alone:  it would eliminate the many hours their employees had to spend on this and let them spend that time focused on their jobs instead.

I may be cynical, but I bet big companies prefer the burdensome system we have now because it's a moat that they can deal with, but smaller competitors can't. It holds down the competition from small businesses and startups.

[Tigerpine]

I may be cynical, but I bet big companies prefer the burdensome system we have now because it's a moat that they can deal with, but smaller competitors can't. It holds down the competition from small businesses and startups.

Less so now with the ACA, but I think it also makes employees more beholden to their employers.  Everyone knows that medical care can potentially bankrupt them without proper insurance.  And where do most people of working age get medical insurance?

[Poundwise]

I'm frankly disgusted at the inequality of treatment. 100 policemen beating the bushes of Central Park!

[MustacheAndaHalf]

I'm waiting to see when they catch this guy whether the jurors on his trial will go rogue, ala O.J. Simpson's jury.

Given the public reaction to date I can honestly seeing that scenario happening.

It's an interesting moral question.

You have a person who committed a single murder (bad).  The person who was murdered though, is responsible for running the company that has killed thousands through denial of care.

If the murderer manages to change the way that the next person running the company does things and that saves just two of those thousands of lives, there's a pretty clear argument that it is morally justified (legality aside).

But there's also the scenario where the system that has been created simply guaranteed that any rich guy running an insurance company will kill people who need health care in order to save money.  In that case the murder of the CEO doesn't serve a purpose.  He'll simply be replaced with another CEO who will continue to do the same thing.  (And in that case, I'd argue that there's really no point in having a CEO as he just seems to function as an overpaid figurehead with no power or responsibility.)

I thought about this after watching "Extreme Measures" (1996) where Gene Hackman made the following point:
"If you could cure cancer by killing one person, wouldn't you have to do that?"
https://www.imdb.com/title/tt0116259/

In my view, the flaw is the missing "with 100% certainty" in that quote.  One person's death for cancer research contributes, but doesn't cure cancer.  And going back to the healthcare example, there is no certainty the next CEO's actions will save lives, compared to the prior CEO.

[LaineyAZ]

And in the ongoing issue of for-profit vs. not-for-profit health care, get ready for more of your taxes going to the for-profit insurance companies:

Apparently the U.S. is at a tipping point where more citizens turning 65 are choosing the for-profit Medicare Advantage plans vs. original government not-for-profit Medicare.  It's initially attractive because of low premiums and perks like limited dental and vision coverage, but people are finding out - surprise! - that it comes with excessive prior authorization denial rates, slow payments, and only emergency treatment while traveling, so now many doctors and health care systems are refusing Medicare Advantage patients. 
When are we going to learn that profit should not be included in any health care scheme?

[Morning Glory]

I'm frankly disgusted at the inequality of treatment. 100 policemen beating the bushes of Central Park!

+1

[Tigerpine]

And in the ongoing issue of for-profit vs. not-for-profit health care, get ready for more of your taxes going to the for-profit insurance companies:

Apparently the U.S. is at a tipping point where more citizens turning 65 are choosing the for-profit Medicare Advantage plans vs. original government not-for-profit Medicare.  It's initially attractive because of low premiums and perks like limited dental and vision coverage, but people are finding out - surprise! - that it comes with excessive prior authorization denial rates, slow payments, and only emergency treatment while traveling, so now many doctors and health care systems are refusing Medicare Advantage patients. 
When are we going to learn that profit should not be included in any health care scheme?

It's not surprising when you see some of the advertisements that target seniors and people nearing/at 65.  They are quite misleading/convincing.  People who don't have the time or inclination or even the idea to do their own research into how Medicare actually works may not even understand that they're getting private insurance.

In my family's experience, traditional Medicare plus so-called Medigap (supplemental) insurance is the gold standard.  I hope when I get to that age it's still a viable option.

[Wolfpack Mustachian]

And in the ongoing issue of for-profit vs. not-for-profit health care, get ready for more of your taxes going to the for-profit insurance companies:

Apparently the U.S. is at a tipping point where more citizens turning 65 are choosing the for-profit Medicare Advantage plans vs. original government not-for-profit Medicare.  It's initially attractive because of low premiums and perks like limited dental and vision coverage, but people are finding out - surprise! - that it comes with excessive prior authorization denial rates, slow payments, and only emergency treatment while traveling, so now many doctors and health care systems are refusing Medicare Advantage patients. 
When are we going to learn that profit should not be included in any health care scheme?

I'm lost. I thought that those were add ones not complete replacements for Medicare.

[PeteD01]

And in the ongoing issue of for-profit vs. not-for-profit health care, get ready for more of your taxes going to the for-profit insurance companies:

Apparently the U.S. is at a tipping point where more citizens turning 65 are choosing the for-profit Medicare Advantage plans vs. original government not-for-profit Medicare.  It's initially attractive because of low premiums and perks like limited dental and vision coverage, but people are finding out - surprise! - that it comes with excessive prior authorization denial rates, slow payments, and only emergency treatment while traveling, so now many doctors and health care systems are refusing Medicare Advantage patients. 
When are we going to learn that profit should not be included in any health care scheme?

I'm lost. I thought that those were add ones not complete replacements for Medicare.

No, Medicare Advantage plans are not Medicare at all but private health insurance in lieu of Medicare.
Medicare Advantage plans are some of the most predatorial health insurance products out there.
Insurance companies offering these products target one of the most vulnerable populations out there, namely the old and sick on fixed income. The victims are typically unable to deal with insurance company shenanigans and are bankrupted, go untreated or die.

Medicare Advantage Myth-Busting
March 14, 2024
Brandon Novick

This year, the majority of Americans eligible for Medicare coverage chose to enroll in private Medicare Advantage (MA) plans rather than Traditional Medicare. Insurance companies that run these MA plans spend significant sums of money to blanket seniors with marketing that highlights the supposed advantages of MA like low upfront costs, supplemental coverage, and other unique perks like subsidizing gym memberships. However, the ads leave seniors in the dark on the downsides of MA like heavily restricted networks that damage one’s choice of provider along with dangerous delays and denials of necessary care. At the same time, both the Biden Administration and many members of Congress from both parties have voiced support for the further privatization of Medicare through growing Medicare Advantage.

...

All in All, Medicare Advantage Is a Scam

Congress created Medicare Advantage with the 2003 Medicare Prescription Drug Improvement and Modernization Act (MMA). After signing the bill into law, President George W. Bush boasted how MA would lower costs, expand benefits, afford seniors more choices, and improve quality of care. However, this supposed modernization of Medicare was really a scheme to privatize, gifting billions of dollars to insurance companies while seeking to end Traditional Medicare.

In reality, MA has never saved taxpayer money. Through gaming the system of capitated payments, MA insurance companies have reaped billions in overpayments — which have also increased the amount all Medicare beneficiaries pay in Part B premiums.

Through restricting care and taxpayer subsidies, MA plans do offer a lower cost alternative to Traditional Medicare, especially for beneficiaries who cannot afford a supplemental Medigap plan. Additionally, it can offer supplemental benefit coverage unavailable under Traditional Medicare, even if the quality of such coverage is poor and provides limited financial support. However, this reality is not because of its inherent design; it is a result of the political sabotage of Traditional Medicare. Congress can cap OOP expenses and provide supplemental coverage for Traditional Medicare with the same money it overpays to MA insurance giants lining their profit margins.

The only choices MA afforded seniors has been which private plan they want to choose. The program destroys beneficiaries’ choice of doctor due to restricted networks. Additionally, there is not sufficient evidence that MA significantly improves health outcomes while health providers are increasingly dropping MA plans due to low reimbursements, further limiting the number of providers MA patients can see. At the same time, current comparisons between MA and Traditional Medicare are unfair as long as policy makers refuse to fix the cost gaps in the latter.

Within both the Medicare and entire American populations, healthcare costs are rising at the same time as health outcomes are worsening, especially in comparison to peer nations. While MA is a convenient solution for insurance companies, it neither addresses the causes of high prices nor poor health outcomes.

MA proponents consistently point to the increasing share of beneficiaries who choose MA over Traditional Medicare as evidence of success. Along with millions of dollars spent on deceptive advertising by insurance companies, this is the consequence of policymaker’s failure to update Traditional Medicare.

It’s past time Medicare beneficiaries are given a real choice. Instead of overpaying insurance giants to the tune of hundreds of billions of dollars, Congress can cap OOP expenses at $5,000 annually and provide supplemental benefits in Traditional Medicare.

https://www.cepr.net/medicare-advantage-mythbusting/

[reeshau]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

[twinstudy]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

Universal coverage means the young and healthy subsidise the premiums of the old and chronically ill. It would be like all drivers being categorised as having the same driving history. Great for someone who's had a DUI conviction. Not so good for the person without a speeding fine in 20 years.

[Morning Glory]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

Universal coverage means the young and healthy subsidise the premiums of the old and chronically ill. It would be like all drivers being categorised as having the same driving history. Great for someone who's had a DUI conviction. Not so good for the person without a speeding fine in 20 years.

Not a fair comparison.  You can choose not to drive drunk but you can't really choose not to become ill or disabled. The whole point in insurance is that you can't predict who it will happen to and when.

[reeshau]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

Universal coverage means the young and healthy subsidise the premiums of the old and chronically ill. It would be like all drivers being categorised as having the same driving history. Great for someone who's had a DUI conviction. Not so good for the person without a speeding fine in 20 years.

Not a fair comparison.  You can choose not to drive drunk but you can't really choose not to become ill or disabled. The whole point in insurance is that you can't predict who it will happen to and when.

Yes, more like people who were driving cars with airbags that would project shrapnel, vs. those who weren't.  It wasn't until long after the purchase that the fact was known.  Same with cancer, alzheimer's etc.  You can't "healthy life" your way past hereditary diseases, or environmental damage.

And, everyone gets old eventually.  Over a lifetime, whatever subsidizing occurs gets reversed.  Advocate for "young rights" at your peril.

[Financial.Velociraptor]

There is a scene in "A Christmas Carol", where Scrooge is being show the town's reaction to his death.  Basically, nobody is sad because he was a worthless piece of shit who valued profit over people.  Why is that considered a heartwarming morality tale when it is considered tacky to throw shade at this CEO?

[PeteD01]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

Universal coverage means the young and healthy subsidise the premiums of the old and chronically ill. It would be like all drivers being categorised as having the same driving history. Great for someone who's had a DUI conviction. Not so good for the person without a speeding fine in 20 years.

Kind of what the point of insurance is, isn't it?

The comparison of health insurance with car insurance risk pooling is fallacious as it rests on a false equivalency:

Car insurance is required to cover a risk that is imposed on others while exercising the privilege of operating a piece of dangerous equipment in shared public space.
Stratifying the pool of the insured into risk pools with premiums proportional to the risk brought to bear on the public makes perfect sense when it comes to car insurance.

Access to affordable health care is a nearly universal need that arises from unpredictable biologic events/injuries and is brought into being by merely existing as a human being. (And yes, there are risks imposed on others by simply living, such as infectious diseases etc., but that veers into public health, not individual health which is what concerns health insurance.)

In addition, the comparison fails on the grounds that the pool of the young and healthy is somehow comparable to people who forego driving a car and therefore do not require insurance.
It does not take much to realize that young and healthy people do carry a risk of becoming ill, whereas it is impossible for a person who does not operate a car to become involved in an at fault motor vehicle accident while driving a car.

The false equivalency fallacy might be the most common logical fallacy employed in bad faith arguments and is also rampant in meme level reasoning, but typically does not hold up on even cursory evaluation.
The false equivalency fallacy is an indicator of either malicious intent (typically a derailing effort) or weak thinking on the part of the writer/speaker.

We seem to get a lot of weak thinking and opinionating from relatively clueless Australian posters who for, some reason, are interested in American politics - is there something in the water over there or is it simply that life is so boring on the island that even discussions of US healthcare become a source of entertainment. 

[Glenstache]

Not quoting to save space...

ACA premiums are age adjusted and can be up to 3 times higher for an elderly person than a young one. Rates can also be adjusted upwards for people who smoke tobacco. So, yes, to some extent the young and healthy subsidize old and sick, but it is not quite an outright plundering of the young to finance health care for the elderly.

The insurance is a risk pool with generic adjustments based on where you fit in those populations rather than pre-existing conditions (ie, for age or smoking as a behavior rather than presence of emphazema). The pre-existing conditions clause also prevents the reverse moral hazard case in which insurers simply drop (or make prohibitively expensive) for patients likely to be expensive while basing premiums on the full risk pool.

[PeteD01]

Not quoting to save space...

ACA premiums are age adjusted and can be up to 3 times higher for an elderly person than a young one. Rates can also be adjusted upwards for people who smoke tobacco. So, yes, to some extent the young and healthy subsidize old and sick, but it is not quite an outright plundering of the young to finance health care for the elderly.

...

True, when looked at solely from the perspective of the insured and what they have to pay (when paying full fare) - but there are also the premium subsidies which amount to around 50% (an accurate number is hard to find) and those subsidies are paid from tax $$ which, in turn, end up as higher subsidies for older people thus leveling individual cost to some degree.

I'd really like to see some numbers to get a better handle on this but I think it is safe to say that, for the insured, the actual difference in premiums paid might not be that great between the young and the old. Where it does show up is in the payments to insurance companies, who receive more for older and less for younger people.

[iluvzbeach]

Not quoting to save space...

ACA premiums are age adjusted and can be up to 3 times higher for an elderly person than a young one. Rates can also be adjusted upwards for people who smoke tobacco. So, yes, to some extent the young and healthy subsidize old and sick, but it is not quite an outright plundering of the young to finance health care for the elderly.

The insurance is a risk pool with generic adjustments based on where you fit in those populations rather than pre-existing conditions (ie, for age or smoking as a behavior rather than presence of emphazema). The pre-existing conditions clause also prevents the reverse moral hazard case in which insurers simply drop (or make prohibitively expensive) for patients likely to be expensive while basing premiums on the full risk pool.

I don’t know at what age you consider someone “elderly” but in my book elderly people are on Medicare.

[GuitarStv]

There is a scene in "A Christmas Carol", where Scrooge is being show the town's reaction to his death.  Basically, nobody is sad because he was a worthless piece of shit who valued profit over people.  Why is that considered a heartwarming morality tale when it is considered tacky to throw shade at this CEO?

Because the idea of abusing wealth to hurt the lower class has been deified in our hypercapitalist society enough to distort many people's view of morality.

[Metalcat]

There is a scene in "A Christmas Carol", where Scrooge is being show the town's reaction to his death.  Basically, nobody is sad because he was a worthless piece of shit who valued profit over people.  Why is that considered a heartwarming morality tale when it is considered tacky to throw shade at this CEO?

Because the idea of abusing wealth to hurt the lower class has been deified in our hypercapitalist society enough to distort many people's view of morality.

And in reality, no one gives a fuck about Tiny Tim and the public would probably elect Scrooge to office.

[Villanelle]

There is a scene in "A Christmas Carol", where Scrooge is being show the town's reaction to his death.  Basically, nobody is sad because he was a worthless piece of shit who valued profit over people.  Why is that considered a heartwarming morality tale when it is considered tacky to throw shade at this CEO?

I mean... one is a fictional character and the other is a dead actual human being, father, and husband.  Just spitballing, but that may have something to do with it.

[NorCal]

I've spent time thinking about why I'm totally okay with this murder.  It's not my normal reaction to such things.  I'm a strong believer in the rule of law, due process, etc.

It comes down to two things.  The first is personal. 

My wife recently went through chemotherapy and I got to witness the necessity of anti-nausea medications first hand.  It took the doctors a few chemo sessions to figure out the right anti-nausea dosage.  These aren't pills.  This was a one-hour IV drip of a fluid that blocked nerve receptors in her spinal cord right before the dose of chemotherapy.  The chemo drugs are ones that will actually cause skin burns if it touches your skin, but are somehow safe to put in your veins.  My wife was incapable of leaving bed for about 3 days after each chemo session.  Dealing with this while raising two kids under 10 is the hardest thing I've done in my life.  It was harder than going to war and watching people get blown up.

If I had an insurance company throw anti-nasuea denials at me in the middle of chemo (as UHC is known to do), the thought of murder would have crossed my mind.  Not to the point of action, but it would have been considered.  A company that behaves this way has gone further than amoral profit seeking.  They have moved to the point of being actually evil.  There have been plenty of evil human beings throughout history, and having a wife and children doesn't change their fundamental human character. 

Normally we can trust the justice system to deal with bad-actors in our world.  That is the point of the justice system. 

However, in my career, I've had more than passing interactions with the health care industry.  I don't know it deeply, but I've done consulting for some health care companies.  My first exposure was a client that would be hit by the federal "surprise billing" legislation that came up a few years back.  I watched the company mobilize every financial resource to defeat that legislation.  In the end it was watered down to such a degree as to make it meaningless.

I also attended an annual dinner for our local Biotech association.  They gave awards and thanks to the PHRMA representatives that were personally responsible for killing state-level legislation designed to cut costs in the health care industry.

This is just a long way of saying that there is no due-process when it comes to the healthcare or health insurance industry.  The insurance industry has a liability shield written into law that prevents them from being sued for these decisions.  The laws are written by and for the health insurance industry.  Even when it comes to behavior that I consider to be outright evil. 

If the state is working in collusion with corporate bad actors, what options are there other than vigilante justice?  This isn't a rhetorical question.  I despise the idea of vigilante justice, but am failing to find due process that can be used to hold these companies accountable. 

[Glenstache]

@NorCal All that your family was managing over that period sounds incredibly difficult, indeed. I hope that the prognosis and outlook is positive moving forward.

I was not aware of the liability shields written into those laws. It is odd to me that decisions overriding doctors are shielded from liability, while decisions and actions of doctors are not. My SO has been called in to testify at multiple cases even in her short time of practice to date, so it's not like cases are not being brought for medical liability. I guess the doctors are so busy filling out the forms, notes, and documentation so that their work meets billing standards that they don't have the cohesion to advocate as effectively for themselves as the insurers. Make no mistake: the reason that you are weighed, height measured, and blood pressure taken at every doctor visit is because it is to meet the criteria for billing as a doctor's visit, not because it is necessarily appropriate for every appointment with a doctor.

I think the disconnect is that we (the public) want a system where we pay into a common fund and that fund is used to pay for our health care when we need it. Most years we will pay more than we get in services, but it is there when SHTF.

[NorCal]

@NorCal All that your family was managing over that period sounds incredibly difficult, indeed. I hope that the prognosis and outlook is positive moving forward.

I was not aware of the liability shields written into those laws. It is odd to me that decisions overriding doctors are shielded from liability, while decisions and actions of doctors are not. My SO has been called in to testify at multiple cases even in her short time of practice to date, so it's not like cases are not being brought for medical liability. I guess the doctors are so busy filling out the forms, notes, and documentation so that their work meets billing standards that they don't have the cohesion to advocate as effectively for themselves as the insurers. Make no mistake: the reason that you are weighed, height measured, and blood pressure taken at every doctor visit is because it is to meet the criteria for billing as a doctor's visit, not because it is necessarily appropriate for every appointment with a doctor.

I think the disconnect is that we (the public) want a system where we pay into a common fund and that fund is used to pay for our health care when we need it. Most years we will pay more than we get in services, but it is there when SHTF.

I don’t have time to search for it now, but I recall the WSJ (I think) doing a piece on this liability shield a while back.

The short version is that a big insurance company pulled a coverage denial on a litigation attorney.

This attorney dedicated multiple years of his life to recovering tens-of-thousands of dollars. He wasn’t able to recover significant damages, or even enough money for attorneys fees.  This is the best legal outcome possible.

The firearms industry has a similar liability shield in place.

[twinstudy]

It’s interesting that you can’t deny coverage for pre-existing conditions in the U.S.

Of all the morally reprehensible things that US insurers do, I feel that hypothetically increasing premiums or instituting a waiting period for pre-existing conditions would be nowhere near the top of the list. Forcing all insurers to cover for pre-existing conditions raises premiums, and leads to adverse selection. It would be like a car insurer having to assume that you’ve had your licence suspended in the past, when in fact most of us haven’t.

I have no doubt that some insurer practices are immoral and deceptive – including the use of AI to process claims. I work in litigation and sometimes I act against insurers (sometimes I act for them) and I see the gamut of conduct from good faith to bad faith. To the extent that they make bad faith decisions, they deserve criticism. If it's bad faith to a criminal standard, they deserve punishment. But the immorality lies in the deceptiveness of a decision or the failure to abide by terms. It doesn’t lie in the deprivation of resources as such.

You could before the Affordable Care Act in 2010.

Also, this was paired in the ACA with a requirement for universal coverage.  If you were young and fit (and invincible) and so skipped coverage, you were fined essentially the amount of premium.  This was exactly to keep the insured pool from reducing to the most sick, and making premiums spiral.  Republican efforts during the first Trump administration eventually led to that penalty being lowered to $0, in the hopes said death spiral would happen.  Only, it hasn't.  The ACA has continued to grow enrollment since then.

Universal coverage means the young and healthy subsidise the premiums of the old and chronically ill. It would be like all drivers being categorised as having the same driving history. Great for someone who's had a DUI conviction. Not so good for the person without a speeding fine in 20 years.

Not a fair comparison.  You can choose not to drive drunk but you can't really choose not to become ill or disabled. The whole point in insurance is that you can't predict who it will happen to and when.

I don't agree that your state of health is wholly outside your choice. Even something that is partly genetic - say lung cancer, diabetes type 2 or obesity - still has a strong lifestyle component.

It's true that you can't predict your future state of health, which is why you take out insurance in the first place. The question is whether the insurance premium itself should vary depending on risk factors. For one, failure to vary it means that adverse selection is more likely.

[twinstudy]

Kind of what the point of insurance is, isn't it?

The comparison of health insurance with car insurance risk pooling is fallacious as it rests on a false equivalency:

Car insurance is required to cover a risk that is imposed on others while exercising the privilege of operating a piece of dangerous equipment in shared public space.
Stratifying the pool of the insured into risk pools with premiums proportional to the risk brought to bear on the public makes perfect sense when it comes to car insurance.

Poor reasoning. You might be right if car insurance solely covered third-party damage. However, it (at least comprehensive insurance) also covers damage caused by your own fault to your own vehicle.

Not to mention that public funds are a public good, the same as public space.

In addition, the comparison fails on the grounds that the pool of the young and healthy is somehow comparable to people who forego driving a car and therefore do not require insurance.

It does not take much to realize that young and healthy people do carry a risk of becoming ill, whereas it is impossible for a person who does not operate a car to become involved in an at fault motor vehicle accident while driving a car.

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

It might be fair if we all were required to buy lifetime health insurance. In that sense, most of us lose out when we're young, and recoup the gains when we're old. However, that's not the case.

If everyone across society had to pay, say, $3000 per year for insurance from age 18 to age 100, I'd be fine with that. Maybe that's how it works in the US under the ACA - I don't know. In Australia, private health insurance is *mandatory* for anyone earning over $90k, whether you want it or not, and risk is community rated. So someone who is young and healthy and doesn't want to take out insurance (similar to the pedestrian in your example: someone who is happy to just privately pay for private medical care, or otherwise rely on the public system to which her taxes contribute) is nonetheless forced to take it out. And the premiums aren't adjusted for your own healthy lifestyle. Doesn't seem fair to me.

We seem to get a lot of weak thinking and opinionating from relatively clueless Australian posters who for, some reason, are interested in American politics - is there something in the water over there or is it simply that life is so boring on the island that even discussions of US healthcare become a source of entertainment.

Play the topic, not the man. Weak post.

[FireLane]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

True, but you don't know which group you're in, except in retrospect.

People who stay healthy their whole lives and die peacefully in their sleep are treated "unfairly" in that they pay for coverage they never need. People who get critically ill from disease, get badly hurt in accidents, get cancer, etc., are treated "generously" in that their care is subsidized by others and they pay less than the value of the treatment they receive. But you can't predict in advance which of those groups you're going to belong to. No one can.

That's why insurance exists, to spread out those risks. It's an application of John Rawls' veil-of-ignorance argument: because I can't choose whether I'll be sick or healthy, I'd prefer to live in a society that helps everyone who needs it, rather than a society where some live and some die based on a roll of the dice.

[twinstudy]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

True, but you don't know which group you're in, except in retrospect.

People who stay healthy their whole lives and die peacefully in their sleep are treated "unfairly" in that they pay for coverage they never need. People who get critically ill from disease, get badly hurt in accidents, get cancer, etc., are treated "generously" in that their care is subsidized by others and they pay less than the value of the treatment they receive. But you can't predict in advance which of those groups you're going to belong to. No one can.

That's why insurance exists, to spread out those risks. It's an application of John Rawls' veil-of-ignorance argument: because I can't choose whether I'll be sick or healthy, I'd prefer to live in a society that helps everyone who needs it, rather than a society where some live and some die based on a roll of the dice.

You can have some sense of which group you belong to. For example, if you have a chronic condition already, or diabetes type 2, or emphysema from smoking, you are going to (if you are rational) realise you have a higher propensity for needing future medical care than someone with no medical history whatsoever. True it is that either of them could be hit by a car tomorrow and need medical care, but that doesn't exclude the first consideration. To say that you can't know the future doesn't cover the field; neither a good driver nor a driver with 5 DUI suspensions knows the future.

As I said above, you can deal with this issue with some degree of fairness by requiring everyone to pay the same insurance premium from birth (or effectively from age 18), in which case I would argue it's fair, as it adheres to the Rawls principle. Fair is fair from birth. However, as I understand it, not everyone has to pay for ACA coverage. Certainly here in Australia, many people are exempt from insurance, including the people who need it most. The cost of insuring them then gets passed on to the rest of the community, including people who are forced to take out insurance when they (on a probabilistic view) don't want or need it.

Having forced community rating leads to adverse selection and ex-ante moral hazard in insurance scenarios. For example, if you gave me a rental car and told me that my insurance premium would be identical whether I crashed it or took good care of it, I would have a lot less incentive to drive well, even if I didn't specifically want to crash the car (and even if some random factors affect things outside my own control).

[Glenstache]

Arguing Australian insurance on aca criteria or vice versa is unnecessarily complicated. The original aca required insurance throughout and rates coyld be adjusted for adverse behaviors. The same conservativet/libertarian that would support many of your arguments also gutted the requirement for participation.

At some lwvelnit comes down to a political philosophical decision on if we are a society that benefits from mutual support or "rugged infuvifuslism". I think my previous posts indicate where i stand on these issues.

[SilentC]

I'm frankly disgusted at the inequality of treatment. 100 policemen beating the bushes of Central Park!

+1

Yep.  Pretty sure this guy is a hero and it will somehow work out ok for him.

In CO my insurer (Cigna) subcontracts to American Specialty Health to deny people coverage. So when you want to dispute a denial Cigna points the finger at ASH and then ASH doesn’t answer the phone and you just suck it up. 

[twinstudy]

Arguing Australian insurance on aca criteria or vice versa is unnecessarily complicated. The original aca required insurance throughout and rates coyld be adjusted for adverse behaviors. The same conservativet/libertarian that would support many of your arguments also gutted the requirement for participation.

Insurance throughout + rates being adjusted for adverse behaviours seems extremely fair to me.

I think people should be free to elect not to participate also, but then they have to wear the consequences, i.e., no healthcare.

[reeshau]

Arguing Australian insurance on aca criteria or vice versa is unnecessarily complicated. The original aca required insurance throughout and rates coyld be adjusted for adverse behaviors. The same conservativet/libertarian that would support many of your arguments also gutted the requirement for participation.

Insurance throughout + rates being adjusted for adverse behaviours seems extremely fair to me.

I think people should be free to elect not to participate also, but then they have to wear the consequences, i.e., no healthcare.

This brings to my mind the anti-vaxxers who begged for a Covid vaccine in the ICU.  Nope, too late--your immune system can't take it.  Thanks for playing!

But, hospitals that take public money in the US can't deny ER patients.  (Even for-profits take research money and Medicare / Medicaid patients)  And hospitals can't kick out non-payers.  (even those anti-vaxxers took up ICU beds)  So, society would have to have some "exile island" to put people who failed to prepare.  Otherwise, their chronic conditions eat up resources, as well as costing everyone since hospitals have to make up for the losses.

I doubt many individuals could raise their hand and say they could stomach it.  I can't imagine what that would be like for the healthcare workers, to give up on people.  (Yes, they already do, when the science and services fail--bad enough already)

Advocate for a direction or line, but think through a few iterations to the ultimate end.  What would work for 100M people or more, in close proximity?

Smoking is a common behavior that is accepted to ask about in different kinds of risk assessments.  In fact, so many questions are not allowed--ethnicity, for one--that smoking is used as a proxy for overall bad behaviors.  You use what you can measure.

[YttriumNitrate]

The FBI has now added to the reward money being offered for information leading to the arrest of the killer. https://www.forbes.com/sites/lindseychoo/2024/12/07/what-we-know-unitedhealthcare-ceo-brian-thompsons-shooting/

Notably, United Healthcare -- a company with with $370 billion in revenues in 2022 -- has not yet chipped in anything to up the reward. It would be sweet irony if somewhere in the bowels of that company a request for funds to pay more reward was bureaucratically denied.

[chasesfish]

Two more random comments from someone who uses the ACA and is also frustrated as hell with the system...

The ability for parents to keep dependents on their health plans until 26 was a huge wiff by politicians.   At 18 the insured should have to go into the ACA pool.   This subsidizes corporate insurance pools and universities offer their own low cost health plan to the healthiest population, making the ACA pool a higher risk / adverse selection group.


Medicare for all would be great, but politicians won't adequately fund medicare as is because payroll taxes would have to go up 2.5x.  Payroll taxes only cover around 40% of expenses today, the rest is made up surcharges and government borrowings.   Why not increase payroll taxes?  They'll be voted out of office.   Medicare for all fails for that reason.   I'd be fine paying the $1,000/mo for two people in taxes vs. health insurance, but most voters will remove whoever does this thanks to a bunch of political adds that'll say "Mr. Smith raised your taxes!!"

[cpa cat]

Medicare for all would be great, but politicians won't adequately fund medicare as is because payroll taxes would have to go up 2.5x.  Payroll taxes only cover around 40% of expenses today, the rest is made up surcharges and government borrowings.   Why not increase payroll taxes?  They'll be voted out of office.   Medicare for all fails for that reason.   I'd be fine paying the $1,000/mo for two people in taxes vs. health insurance, but most voters will remove whoever does this thanks to a bunch of political adds that'll say "Mr. Smith raised your taxes!!"

History has also shown that voters are easily swayed by the idea of health care choice. I think Medicare For All only works if you can voluntarily buy into it like any other health plan. For instance, if Medicare was listed as an option alongside ACA plans during open enrollment.

[PeteD01]

Medicare for all would be great, but politicians won't adequately fund medicare as is because payroll taxes would have to go up 2.5x.  Payroll taxes only cover around 40% of expenses today, the rest is made up surcharges and government borrowings.   Why not increase payroll taxes?  They'll be voted out of office.   Medicare for all fails for that reason.   I'd be fine paying the $1,000/mo for two people in taxes vs. health insurance, but most voters will remove whoever does this thanks to a bunch of political adds that'll say "Mr. Smith raised your taxes!!"

History has also shown that voters are easily swayed by the idea of health care choice. I think Medicare For All only works if you can voluntarily buy into it like any other health plan. For instance, if Medicare was listed as an option alongside ACA plans during open enrollment.

I think this could be easily addressed by a bunch of Medigap choices with different benefits and price points.

[FireLane]

Medicare for all would be great, but politicians won't adequately fund medicare as is because payroll taxes would have to go up 2.5x.  Payroll taxes only cover around 40% of expenses today, the rest is made up surcharges and government borrowings.   Why not increase payroll taxes?  They'll be voted out of office.   Medicare for all fails for that reason.   I'd be fine paying the $1,000/mo for two people in taxes vs. health insurance, but most voters will remove whoever does this thanks to a bunch of political adds that'll say "Mr. Smith raised your taxes!!"

History has also shown that voters are easily swayed by the idea of health care choice. I think Medicare For All only works if you can voluntarily buy into it like any other health plan. For instance, if Medicare was listed as an option alongside ACA plans during open enrollment.

I'd be all in favor of a public option, but there'd have to be a way to prevent for-profit insurers from dumping all their sickest and most expensive patients on it.

[NorCal]

I always come back to asking the question of why we pay for medical care through insurance in the first place.

Why don’t we have integrated care options available in every market?

There’s a reason I get my care through Kaiser and the VA. I pay Kaiser directly and they provide me health care. There’s no middleman. There’s no third-party-payer problem to load down the process with economic inefficiency.

In the rare cases something isn’t covered, it’s a conversation with the doctor and not an after the fact AI driven decision.

I care less about whether my insurance is corporate or government provided than whether there’s a third party between me and my doctor. 

Kaiser certainly has its flaws, but they manage to avoid all of the billing nonsense traditional insurers are bringing to the table.

[reeshau]

Medicare for all would be great, but politicians won't adequately fund medicare as is because payroll taxes would have to go up 2.5x.  Payroll taxes only cover around 40% of expenses today, the rest is made up surcharges and government borrowings.   Why not increase payroll taxes?  They'll be voted out of office.   Medicare for all fails for that reason.   I'd be fine paying the $1,000/mo for two people in taxes vs. health insurance, but most voters will remove whoever does this thanks to a bunch of political adds that'll say "Mr. Smith raised your taxes!!"

History has also shown that voters are easily swayed by the idea of health care choice. I think Medicare For All only works if you can voluntarily buy into it like any other health plan. For instance, if Medicare was listed as an option alongside ACA plans during open enrollment.

The other issue is that Medicare payments don't actually cover the cost of care.  They are still broadly accepted, because their covered group consumes a lot of healthcare--it's hard to be in business without it.  But like any underpaying group, private payers have to make up the gap.

[JLee]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

That is kind of the fundamental foundation of society.  Some of us contribute more than our 'fair share', some less -- but we all win if the system works for everyone.

[Metalcat]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

That is kind of the fundamental foundation of society.  Some of us contribute more than our 'fair share', some less -- but we all win if the system works for everyone.

Right??

People exist. Sick people exist. Are we just supposed to go die because we're inconvenient and expensive? JFC

[rocketpj]

If only there were literally dozens of examples in the world of single payer or universal health care that are both cheaper (overall) and more cost effective than the current flustercluck of a 'system' that operates in the US.  Boy, sure would be nice to see what else might work.

From the outside looking in, US Health care debates are a bizarre circus of insanity.  You spend more on health per capita than anyone, and get less actual health care with worse outcomes than almost any other developed nation.  But you get caught up in arguments about who pays a trivially disproportionate amount of the costs, yada yada yada, all completely ignoring the huge chunk of expenses that go to either side of the administration of insurance (please pay us - why - because these reasons - not good enough - etc).  Not to mention the absurdity of also having to add (massive, unaccountable) profit to the system.

It all makes sense if the world stops at your borders.  Once you are outside your borders it looks like a slow motion squid game.

[Omy]

It doesn't make sense inside the borders either.

[Metalcat]

It doesn't make sense inside the borders either.

Not have I seen many Americans in this thread saying that any of it makes sense. It's mostly the Australian poster who is advocating those positions.

[Kris]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

That is kind of the fundamental foundation of society.  Some of us contribute more than our 'fair share', some less -- but we all win if the system works for everyone.

Right??

People exist. Sick people exist. Are we just supposed to go die because we're inconvenient and expensive? JFC

Metalcat, the point is, if you’re sick, it’s your fault. Keep up.

/s

[Metalcat]

This doesn't go to the heart of the point, which is that a forced acceptance of common risk treats some people unfairly and others generously.

That is kind of the fundamental foundation of society.  Some of us contribute more than our 'fair share', some less -- but we all win if the system works for everyone.

Right??

People exist. Sick people exist. Are we just supposed to go die because we're inconvenient and expensive? JFC

Metalcat, the point is, if you’re sick, it’s your fault. Keep up.

/s

Better go die then...oh well, it's been a good run.

[FINate]

I don't agree that your state of health is wholly outside your choice. Even something that is partly genetic - say lung cancer, diabetes type 2 or obesity - still has a strong lifestyle component.

I was diagnosed with a rare aggressive cancer about 2 years ago, didn't expect to be alive and in remission today. I have zero known risk factors. I was a healthy weight, exercised 3-5x/week, balanced diet, low alcohol consumption, not a smoker, no known genetic factors, and about 20 years younger than the median age for this.

So while you can reduce personal risk factors, your health *is* ultimately wholly outside your choice. You can do everything right and still end up sick. This is often extremely unsettling when sharing my story with others because people want a sense of control. This usually means I get a lot of questions as folks try to find something to blame. Early on I found this rather peculiar and annoying, but I understand now that it's driven by their anxiety.

I will add that, in my experience, the insurance+medical system in the US is broken. Thankfully I was part of a health sharing ministry, so no pre-approvals, no denials, etc. The health sharing ministry covered all but $1500 of our massive medical bills (multiple major surgeries, chemo, months in the hospital). But the cost of healthcare and the way prices are negotiated is very opaque and bureaucratic.

One thing I haven't see mentioned on this thread: The Medical Loss Ratio (MLR) for UnitedHealthcare is 85%, which is higher than the mandated 80% and in line with its peers. This means that $0.85 of every $1 in premiums is paid to cover claims. Yet apparently UHC has a much higher denial rate. Not sure what explains this discrepancy. Maybe UHC has a sicker/older than average pool, or is this initial denials with many being reversed on appeal?

While I have no love for insurance companies and think there should be a public option, due to the reality of MLR  these are not hugely profitable businesses. There are not a lot of inefficiencies to be gained at the insurance level -- even a public option or single-payer system would have a decent amount of overhead. What needs to happen is reducing the cost of healthcare, but that's a very difficult issue.

[Glenstache]

I don't agree that your state of health is wholly outside your choice. Even something that is partly genetic - say lung cancer, diabetes type 2 or obesity - still has a strong lifestyle component.

I was diagnosed with a rare aggressive cancer about 2 years ago, didn't expect to be alive and in remission today. I have zero known risk factors. I was a healthy weight, exercised 3-5x/week, balanced diet, low alcohol consumption, not a smoker, no known genetic factors, and about 20 years younger than the median age for this.

So while you can reduce personal risk factors, your health *is* ultimately wholly outside your choice. You can do everything right and still end up sick. This is often extremely unsettling when sharing my story with others because people want a sense of control. This usually means I get a lot of questions as folks try to find something to blame. Early on I found this rather peculiar and annoying, but I understand now that it's driven by their anxiety.

I will add that, in my experience, the insurance+medical system in the US is broken. Thankfully I was part of a health sharing ministry, so no pre-approvals, no denials, etc. The health sharing ministry covered all but $1500 of our massive medical bills (multiple major surgeries, chemo, months in the hospital). But the cost of healthcare and the way prices are negotiated is very opaque and bureaucratic.

One thing I haven't see mentioned on this thread: The Medical Loss Ratio (MLR) for UnitedHealthcare is 85%, which is higher than the mandated 80% and in line with its peers. This means that $0.85 of every $1 in premiums is paid to cover claims. Yet apparently UHC has a much higher denial rate. Not sure what explains this discrepancy. Maybe UHC has a sicker/older than average pool, or is this initial denials with many being reversed on appeal?

While I have no love for insurance companies and think there should be a public option, due to the reality of MLR  these are not hugely profitable businesses. There are not a lot of inefficiencies to be gained at the insurance level -- even a public option or single-payer system would have a decent amount of overhead. What needs to happen is reducing the cost of healthcare, but that's a very difficult issue.

MLR is federally set at 85% for large groups and 80% for small groups with states able to adjust these numbers locally. If a insurer pays less than this amount in claims, then they have to issue a rebate to policy holders. The MLR cost percentage is intended to cap admin and profit costs relative to premiums taken in. The actual calculation of the MLR appears includes a lot of parsing and room for adjustments of the numerator and denominator. For example "quality improvement" costs are multiplied by 2 in the MLR calc to incentivize insurers to do more of that. I downloaded the UHC MLR filings for New Jersey 2022 and their large group MLR was calculated at 83.2% and 83.9% after some adjustments, which then became 85% after a rebate was issued. It appears that this calculation has the admin/profit capped at 15% of the premiums taken in, not claims paid out. I have many questions about how some of the details of physician review of claims etc are categorized, but I decided to stop going down that rabbit hole for the sake of sanity.

As a counterpoint, studies of the administraive overhead for Medicare are: Part A B D (1.35%), Part C (14.84%). Parts ABD are the public options while Part C is the Medicare Advantage privatized version discussed in some of the prior posts.

Additionally note that hospital internal administrative costs are lumped in with the claims paid, not the overall administrative part of the MLR calculation. So, the cost of the administrative burden of dealing with the byzantine health insurance system is also reflected there and could be reasonably expected to be streamlined in a broadly adopted single-payer system.

[FINate]

I don't agree that your state of health is wholly outside your choice. Even something that is partly genetic - say lung cancer, diabetes type 2 or obesity - still has a strong lifestyle component.

I was diagnosed with a rare aggressive cancer about 2 years ago, didn't expect to be alive and in remission today. I have zero known risk factors. I was a healthy weight, exercised 3-5x/week, balanced diet, low alcohol consumption, not a smoker, no known genetic factors, and about 20 years younger than the median age for this.

So while you can reduce personal risk factors, your health *is* ultimately wholly outside your choice. You can do everything right and still end up sick. This is often extremely unsettling when sharing my story with others because people want a sense of control. This usually means I get a lot of questions as folks try to find something to blame. Early on I found this rather peculiar and annoying, but I understand now that it's driven by their anxiety.

I will add that, in my experience, the insurance+medical system in the US is broken. Thankfully I was part of a health sharing ministry, so no pre-approvals, no denials, etc. The health sharing ministry covered all but $1500 of our massive medical bills (multiple major surgeries, chemo, months in the hospital). But the cost of healthcare and the way prices are negotiated is very opaque and bureaucratic.

One thing I haven't see mentioned on this thread: The Medical Loss Ratio (MLR) for UnitedHealthcare is 85%, which is higher than the mandated 80% and in line with its peers. This means that $0.85 of every $1 in premiums is paid to cover claims. Yet apparently UHC has a much higher denial rate. Not sure what explains this discrepancy. Maybe UHC has a sicker/older than average pool, or is this initial denials with many being reversed on appeal?

While I have no love for insurance companies and think there should be a public option, due to the reality of MLR  these are not hugely profitable businesses. There are not a lot of inefficiencies to be gained at the insurance level -- even a public option or single-payer system would have a decent amount of overhead. What needs to happen is reducing the cost of healthcare, but that's a very difficult issue.

MLR is federally set at 85% for large groups and 80% for small groups with states able to adjust these numbers locally. If a insurer pays less than this amount in claims, then they have to issue a rebate to policy holders. The MLR cost percentage is intended to cap admin and profit costs relative to premiums taken in. The actual calculation of the MLR appears includes a lot of parsing and room for adjustments of the numerator and denominator. For example "quality improvement" costs are multiplied by 2 in the MLR calc to incentivize insurers to do more of that. I downloaded the UHC MLR filings for New Jersey 2022 and their large group MLR was calculated at 83.2% and 83.9% after some adjustments, which then became 85% after a rebate was issued. It appears that this calculation has the admin/profit capped at 15% of the premiums taken in, not claims paid out. I have many questions about how some of the details of physician review of claims etc are categorized, but I decided to stop going down that rabbit hole for the sake of sanity.

As a counterpoint, studies of the administraive overhead for Medicare are: Part A B D (1.35%), Part C (14.84%). Parts ABD are the public options while Part C is the Medicare Advantage privatized version discussed in some of the prior posts.

Additionally note that hospital internal administrative costs are lumped in with the claims paid, not the overall administrative part of the MLR calculation. So, the cost of the administrative burden of dealing with the byzantine health insurance system is also reflected there and could be reasonably expected to be streamlined in a broadly adopted single-payer system.

For sure, there are savings to be had. It's just that ~15% is the upper limit. This isn't nothing, totally worth doing, but it's not at big as many seem to believe. I think the bigger benefit to a public option or single-payer is getting away from the dysfunctional adversarial triangle of patient, insurer, and health care.   

[NorCal]

I don't agree that your state of health is wholly outside your choice. Even something that is partly genetic - say lung cancer, diabetes type 2 or obesity - still has a strong lifestyle component.

I was diagnosed with a rare aggressive cancer about 2 years ago, didn't expect to be alive and in remission today. I have zero known risk factors. I was a healthy weight, exercised 3-5x/week, balanced diet, low alcohol consumption, not a smoker, no known genetic factors, and about 20 years younger than the median age for this.

So while you can reduce personal risk factors, your health *is* ultimately wholly outside your choice. You can do everything right and still end up sick. This is often extremely unsettling when sharing my story with others because people want a sense of control. This usually means I get a lot of questions as folks try to find something to blame. Early on I found this rather peculiar and annoying, but I understand now that it's driven by their anxiety.

I will add that, in my experience, the insurance+medical system in the US is broken. Thankfully I was part of a health sharing ministry, so no pre-approvals, no denials, etc. The health sharing ministry covered all but $1500 of our massive medical bills (multiple major surgeries, chemo, months in the hospital). But the cost of healthcare and the way prices are negotiated is very opaque and bureaucratic.

One thing I haven't see mentioned on this thread: The Medical Loss Ratio (MLR) for UnitedHealthcare is 85%, which is higher than the mandated 80% and in line with its peers. This means that $0.85 of every $1 in premiums is paid to cover claims. Yet apparently UHC has a much higher denial rate. Not sure what explains this discrepancy. Maybe UHC has a sicker/older than average pool, or is this initial denials with many being reversed on appeal?

While I have no love for insurance companies and think there should be a public option, due to the reality of MLR  these are not hugely profitable businesses. There are not a lot of inefficiencies to be gained at the insurance level -- even a public option or single-payer system would have a decent amount of overhead. What needs to happen is reducing the cost of healthcare, but that's a very difficult issue.

MLR is federally set at 85% for large groups and 80% for small groups with states able to adjust these numbers locally. If a insurer pays less than this amount in claims, then they have to issue a rebate to policy holders. The MLR cost percentage is intended to cap admin and profit costs relative to premiums taken in. The actual calculation of the MLR appears includes a lot of parsing and room for adjustments of the numerator and denominator. For example "quality improvement" costs are multiplied by 2 in the MLR calc to incentivize insurers to do more of that. I downloaded the UHC MLR filings for New Jersey 2022 and their large group MLR was calculated at 83.2% and 83.9% after some adjustments, which then became 85% after a rebate was issued. It appears that this calculation has the admin/profit capped at 15% of the premiums taken in, not claims paid out. I have many questions about how some of the details of physician review of claims etc are categorized, but I decided to stop going down that rabbit hole for the sake of sanity.

As a counterpoint, studies of the administraive overhead for Medicare are: Part A B D (1.35%), Part C (14.84%). Parts ABD are the public options while Part C is the Medicare Advantage privatized version discussed in some of the prior posts.

Additionally note that hospital internal administrative costs are lumped in with the claims paid, not the overall administrative part of the MLR calculation. So, the cost of the administrative burden of dealing with the byzantine health insurance system is also reflected there and could be reasonably expected to be streamlined in a broadly adopted single-payer system.

For sure, there are savings to be had. It's just that ~15% is the upper limit. This isn't nothing, totally worth doing, but it's not at big as many seem to believe. I think the bigger benefit to a public option or single-payer is getting away from the dysfunctional adversarial triangle of patient, insurer, and health care.

I agree with you on getting rid of that triangle. Or third party payer problem as I call it.

Be careful when reading about the various policies on this. Most “single payer”or “public option” proposals out there involve the government behaving as an insurance company. They don’t fundamentally change the dynamic, just replace the corporate entity with a government entity.   They don’t fundamentally solve the problems you’re getting at.