I don't think employers should even offer health insurance.
Leave it to the consumer to buy just like all other insurance. In fact the increase in wages could be used to fund a basic preventative care plan (read not full on single payer) for all Americans.
But as an employer in the U.S., you get to write off medical insurance as an expense that isn't counted as income for the employee. It's entirely tax free, and a rational employee will take it into account as part of their compensation package.
If you don't want employers to give it to employees, then we should fix the tax situation.
That is a major factor, but there is a bigger one: the product that an insurance company will agree to sell you and the product they will agree to sell your employer are not materially the same product.
The actuarial assumption is that substantially all white collar employees will get group coverage and therefore any company's 25, 100, or 500 pulls out of the pool of white collar employee health risks will be actuarially consistent with random selections from the underlying distribution. This is not true of individual insurance purchasers, because the individual purchasers can have more signal on their health risks than their insurance companies. They can, for example, purchase insurance when they know they're likely going to require treatment and decline to purchase (or shift to different coverage options) when they're likely to be healthy.
This is called "adverse selection" and it is the tradeoff in individual insurance. For a while, the US's policy was that insurance companies could underwrite individual health insurance policies in a fashion roughly similar to underwriting business liability policies, which could be caricatured as "We'll give a policy to anyone with a pulse but if you've so much as glanced in the general direction of an expensive outcome at any point, our answer is Hell No, just like substantially every other insurance company's will be."
If you let insurance companies do underwriting, health insurance is (relatively) cheap and lots of people can't buy it on the individual market at any price. If you require "guaranteed issue", health insurance is only (relatively) cheap if everyone buys it.
The US has been wrestling this tradeoff with Obamacare and subsequent proposals. There are no simple solutions to it that make everyone happy.
Shouldn't the price then basically be the same our cheaper if I was willing to lock myself into a multi year contract? I won't know my health status in say five years.
Worse yet is that the cost of these benefits creates an incentive for companies to prefer younger, unmarried, and childless employees over others. Until the ACA with the new preexisting conditions rules, it also meant that if you had a chronic condition of some kind, you were essentially stuck at the job you were at when you were diagnosed - if you switched jobs, your employer may not cover your preexisting condition, which could bankrupt you pretty quickly.
I doubt the ACA will ever fully live up to its promise because Congressional Republicans need to try and overturn it every 4 months. Even if they don't succeed, they still end up injecting uncertainty into the market, which drives up prices. And it will go on forever and ever. It'll be one of those things Republicans never, ever let go of like abortion and guns.
You nailed it. When I started my own consulting business I just about fell out of my chair when my accountant said I couldn’t write off my health coverage. I pay about $19K a year and that’s after taxes so more like $25K+.
Do you pay self-employment tax? If so you can likely deduct the cost of your medical insurance for yourself and your family. I deducted $6,157 for myself and my wife last year through my single member LLC. Line 29 on IRS form 1040 [0].
S-Corp greater than 2% ownership. This means I can sort of write it off, but only after the corporation providing the money through payroll which means paying tax on it upfront. Doing it that way could end up costing me money because payroll taxes are higher than corporate dividends.
In general I think the point is, why can corporations just straight write off premiums for their employees when self-employed types have all these special rules to follow vs just a standard deduction?
If you're an officer in an S-Corp, you're required to pay yourself a "market rate" salary for payroll tax purposes, and cannot legally use the salary/draw distinction as a tax avoidance strategy. If you're not paying yourself a salary, the IRS gets very annoyed.
If you're a sole proprietor, the tax impact should be equivalent whether you choose to take draws or salary:
> Sole proprietors and members of partnerships are free to pay themselves — or otherwise take the profits out of their businesses — whenever they’d like. Payroll withholdings do not apply, but each individual essentially pays the equivalent on his or her reported income at tax time.
Paying the health insurance through payroll would be in addition to the fair and reasonable salary. Say I set a fair and reasonable salary of $65,000, then I want the S-Corp to cover my health insurance $20,000 a year then I need to set payroll to $85,000.
Yes, I could continue to pay myself just $65,000, but the IRS could come knocking and say, "you said you paid for health insurance through S-Corp payroll, so that means you only gave yourself a $45,000 salary which is not fair and reasonable.
Depends on your corporate structure;my accountant told me that the costs may make enough of a difference to justify changing the structure. Not an accountant, and not your accountant.
You need to incorporate. You can't write it off as a 1099 contractor. You CAN write it off as an employee of an LLC.
There's a lot of other good reasons to incorporate as well. Use an S-corp election (as an LLC) and you can get out of paying the SE tax on a significant portion of your income. There are some limitations and you need to bill over a certain amount, but anybody who makes a six-figure income consulting should be doing so under an LLC, not as a 1099 contractor.
Actually, you can deduct health insurance expense as a self-employed (1099) filing a Schedule C, or as a member of an LLC, or as a member of an S corp.
You need to incorporate as an S corp and hire yourself W2. Then pay your "employees" 100% medical that way it's a cost for the company and therefore reduces the company's profit, meanwhile you're not getting taxed to pay insurance premiums.
Going from being an employee to being 1099 and SE is still getting
fucked on taxes, just in a different position.
If you're serious about freelancing, your income should be split between a W2 and a K1.
I am not a CPA. This is what I pay him to do for me.
Don't you enjoy yourself in your company? You should be able to offer full coverage if that's what you want. You just have to offer that to all of your employees, but that's probably just you.
I can't tell if you're just joking, but assuming you're serious, the rules (US tax rules, essentially) state that you have to have at least one other "real" (i.e., non-family) employee.
That's why many proposals that scrap employer provided health insurance, give the same benefit to employers via HSAs (a pre-tax health savings account ).
In effect, instead of the employer picking the employee's health insurance the employee could go to the open market, but both the employer and employee get the same tax benefits via putting money pre-tax into a HSA which can then be used to pay for health insurance.
It would require massively increasing the maximum contributions on HSAs (currently only $6,750 for a family), since HSAs weren't originally designed to pay for your health insurance, just healthcare costs. But conceptually it is the easiest way to allow consumer choice in the health insurance market.
> putting money pre-tax into a HSA which can then be used to pay for health insurance.
Surprisingly (it was to me, anyway), health insurance premiums don't qualify as a medical expense, so any funds withdrawn from an HSA for insurance premiums will be subject to taxes and penalties.
You're describing how HSAs currently work. The discussion is healthcare reform, so limitations like that would go the way of the low maximum contributions if HSAs were redesigned to be used to pay for insurance.
Right, it makes sense for the company to offer and the employee to accept, but it doesn't make sense that the deck should be additionally stacked by a tax code that makes the meal ~40% cheaper than meals the employee usually buys because they get to buy it with pre-tax dollars.
1) Company pays you 100k of which you then go spend 19k in the private insurance market to buy insurance leaving you with 81k after insurance costs.
2) Company pays for your health insurance and then pays you a salary of 81k.
They sound the same right? But they aren't! In #1 you will pay income tax based on a 100k salary. In #2 you will only pay income tax on 81k of salary. So you're better off in scenario #2.
Given the strong employee preference for #2 most employers in competitive hiring situations will tend of offer employer sponsored health care.
There are some other reasons why this happens too, but this is one of the biggest.
Ah ok, makes sense, thanks! I guess thats a less than ideal tax condition where entity X can tax write off expense E, but entity Y can't, so it makes sense for Y to pay X rather than buy directly.
Fixable by making health insurance premiums tax-deductible. Also when I was paying for an individual family plan it was nowhere near $19,000/yr. It didn't cover maternity, but that was OK because we were done having kids. But that was roughly 7 or 8 years ago.
At $20K/year, I would expect a lot more households to itemize. I'm trying (and failing) to calculate off the top of my head what kind of mortgage you'd have to have for a similar deduction. But it's gotta be pretty damn big if your interest is $1600/month.
Well, if you are required to prepare your own tax returns through an accountant then he will most certainly, itemize deduction, you'll be asking him to get your tax bill down a bit. Power of incentive is nothing to be questioned.
Yeah this would overall be good, but not short-term.
Once consumers are directly exposed to the shit show that is insurance and pre-existing conditions and zero price transparency, and they have no collective negotiation power as they do when a company purchases, they will revolt and it will force a change.
There are a few people who cannot get insurance individually thanks to pre-existing conditions. They can only get insurance via employers group plans. Short-term a few of these people go bankrupt or die, but whats a few deaths in service of a good ideology?
I agree with your other points though ("directly exposed to the shit show that is insurance"): removing employer provided health insurance would speed up the current system's collapse and push us to single payer at ludicrous speed. There would be no other option palatable.
> and push us to single payer at ludicrous speed. There would be no other option palatable.
Considering how many people are against any kind of collective payment for health and how many protections Republicans are happy to sacrifice... is it really the only option? It could just go worse with few people getting any kind of insurance. (Enough to keep the system profitable, but not necessarily helpful)
> Considering how many people are against any kind of collective payment for health
There is more support for single payer than you might have been led to believe.
"Currently, 60% say the federal government is responsible for ensuring health care coverage for all Americans, while 39% say this is not the government’s responsibility. These views are unchanged from January, but the share saying health coverage is a government responsibility remains at its highest level in nearly a decade."
"Even among those who say the federal government is not responsible for ensuring Americans have health care coverage, there is little public appetite for government withdrawing entirely from involvement in health care coverage. Among the public, 33% say that health care coverage is not the government’s responsibility, but that programs like Medicare and Medicaid should be continued; just 5% of Americans say the government should not be involved at all in providing health insurance."
I think there's a huge difference between "federal government is responsible" and specifically single payer solution. There's more ways fed gov could be involved.
yea, but any specific plan that is put forward will go through an absolutely endless relentless well-practiced vilification process and many people will end up believing that the bill is intended to the do opposite of whatever it actually does, largely only to get people to listen to radio ads.
I think if the healthcare and education cost situation gets much worse, there's going to be a big drain of people who have the means to move to more civilized societies. Or maybe thats just a personal bias because that's what I keep edging closer to in contemplation. Tech salaries are better in the US than say Europe, but if that all taken out by healthcare, while adding all sorts of bankruptcy risk and poor standards of care then there's little point gambling.
Not trying to be snarky - serious question: if you feel that way, what's stopping you? I've often contemplated what I would do if the US leans further left, and sadly, there aren't a lot of other places to go where I can have guns, freedom of speech (although in a lot of places people have been protesting against that lately, because they believe it should only apply to speech that's not horrible), and a private-business dominated economy. Looking in the other direction, there are a ton of places where you can get super-tight gun laws, a huge welfare state, and a government dominated economy ... so why not pick one and go?
Gun laws? Who said anything about gun laws. I actually think we should take a much different approach than silly bans, like maybe geographic analysis of dealer sales vs permits/ownership records to identify illegal sales.
I'm talking financial analysis and quality of life.
Not all of them. I had individual coverage from Anthem for a while, before Obamacare, and it was all fine, and yes we had some routine medical issues in our history.
What insurance companies want to avoid is people who go without insurance until they are sick, and then want everything covered. As long as you don't have gaps in coverage, pre-existing conditions are not a huge showstopper at least in my individual experience.
This is why the US system is broken. Wind the clock back 70 ish years and stop this and you'll likely end up with the same system as other developed countries like the U.K. Or Australia.
I tried to find some good data around surgery wait times by OECD countries but couldn't find much except it seems that Canada + UK + US have bad wait times compared to other OECD countries.
Does double healthcare cost = less wait times? Are there less wait times for private insured vs those using public system? Would love to see the data if you have any...
You can't pretend the US doesn't have wait lists of its own.
I'm trying to schedule an MRI and the first appointment was 2 months out (I might have been able to get an earlier appointment somewhere else, but the neurologist said I should just keep this appointment). I've been trying to schedule PT for a couple months, as well. I've called the PT office every single day for over a week waiting for my approval to come back from billing so I can schedule an initial evaluation.
Ironically, there's a program funded by my state offering in-home OT services twice a week. I don't pay anything out of pocket. It did take a month to set up, but everything that would have been covered by insurance would be in an office (but they didn't even have those options available).
When, besides emergencies, do you go in to the doctor and come out with a surgery in the same day in the US or even the same week? My only real surgery was emergency or reconstructive right after the swelling went down. All of my oral surgeries were at least 2 weeks and could easily have been a few months out. Wifes major oral surgery was months in advanced.
But aren't the prices artificially inflated to build in the supposed "discount?"
To use an analogy, it is like how vehicle manufacturers adds 10% to reach the MSRP, which is "discounted" at the dealership for every vehicle sold. It is a shell game, there is no winning when the game is rigged for the game's own existence.
If discounts were banned tomorrow on medical services, you'd see the costs drop significantly to reflect that.
I think the main driver of the inflated base price is there is no cost transparency wethere you have insurance or not. Have you ever gone to a doctor and known the costs ahead of time or shopped around for the best price?
Their primary function is risk pooling. Secondarily they ration limited resources, attempting to distribute the available resources to effect the greatest good (this is why you often have such a hard time getting them to cover things, and why everyone loves to hate them). They've also traditionally been in the business of managing moral hazard in such a way that people feel it necessary to sign up for insurance while healthy, but the government has dramatically changed that function in the last few years. There's also the basic book-keeping and shuffling money around the system ... and while all of the things I listed are somewhere in between crusted puke and a fresh horse turd in terms of their appeal, they are necessary functions that any system (even a government run one) has to perform. One huge advantage that the government has in the moral hazard department is that they can use guns and jail time to prod people into paying ... but for whatever reason the single-payer folks typically ignore that particular evil when campaigning against the private insurance companies. Personally, I feel that the government's tactic of taking someone's freedom for refusal to participate is much worse than refusing coverage, which is what the private companies do.
The insurance company's methods of establishing the pool are far less coercive and destructive than the state's. Additionally, people can opt not to participate with an insurance company (or at least they used to be able to), so they have some motivation to be efficient and provide a basically decent level of service ... this is not true of the state. So establishing that large, mandatory pool has a downside.
Sometimes innovation is about figuring out ways to make more money, not by lowering costs to attract more consumers, but by limiting choices, creating illusion of choice, denying coverage, cheating consumers. Not all corporate innovation is good thing. Certain industries the possibility for real innovation is practically non-existent, and the 'innovation' that occurs is not in the public interest.
>>Additionally, people can opt not to participate with an insurance company (or at least they used to be able to), so they have some motivation to be efficient and provide a basically decent level of service.
You have the same backwards concept of Healthcare as everyone else who is rich; it's only for me. Healthcare is for everyone, it is a right. It is not a privilege that you only get if you can afford it. Health insurance is THE PROBLEM.
If you don't have car insurance, you might be financially strained. If you don't have flood/fire insurance, you could loose your stuff. If you don't have health insurance (in this country) you could die. If you think these things are the same, there is no hope.
I agree with what your saying but I'm bothered by the use of "right" -- I wish there was a better word. The US has the bill of rights and they're all effectively about "the right to be left alone".
In the case of healthcare it is effectually a demand of the government. Because language frames the debate it would be nice to have a better word to describe this.
I disagree with him, but agree with you, healthcare is not a right. As you stated, the natural rights enumerated by our constitution make no demands on others - in fact, they are the opposite - they guarantee protection from coercion by others. Anyone who believes in healthcare as an entitlement believe, effectively, that they are entitled to demand that others serve them without compensation. While there are cases where this is necessary at the federal level, healthcare is not one of them, and it's why it's not specifically mentioned in the constitution. Generally things like healthcare are better handled at the state level (and indeed, states were beginning to try before the feds stepped in). Handling these issues at a federal level enables people in the midwest to force people on the coasts to do things they'd rather not do, and vice-versa. Eventually, this leads to the kind of strife we've been seeing lately in the form of protests regarding healthcare.
Seeing how states often want to apply their rights (denying marriage equality, outlawing abortion, etc.) I don't trust them more than the Feds.
What's interesting about the current "health care reform" taking place is that there doesn't seem to be any discussion of how to actually decrease costs other than denying coverage.
There's a fundamental problem - the medical industry has made all kinds of decisions based on the assumption of high cost - doctors take on $300,000+ student debt, hospitals have built huge new facilities, and pharma has poured billions into R&D on the assumption of high cost. Rolling it back now will be difficult and will surely screw over some group of people, whether it's the elderly, doctors, nurses, hospital administrators, or hospital owners (which, due to 401(k)s, is you and me).
The primary function of insurance companies is to make a profit and serve their investors. These are publicly traded companies and only care about making that dollar; in this case, they make money by denying people healthcare and business is booming. Aetna for example has seen a 400% jump in their stock prices in the last 5 years.[1]
You really do sound like you work for the insurance industry, claiming their functions are necessary (even though every other country manages without them). Also, government run healthcare is bad because they are going to shoot people (or threaten to) and put them in jail for not paying their medical bills? Come on.. are you serious?
>>Personally, I feel that the government's tactic of taking someone's freedom for refusal to participate is much worse than refusing coverage, which is what the private companies do.
Oh fuck right the fuck off. The government does not throw people in jail for not having health insurance or if they can not afford it. Refusing/denying coverage KILLS PEOPLE. You sound like someone who's got it made (so screw everyone else right?), and doesn't give 2 shits about anyone but themselves.
That is simply wrong. Most health "insurance" companies no longer provide much actual insurance anymore. Instead they provide claims payment and administration services for self-insured employers who bear the risk. Furthermore the ACA imposed a minimum medical loss rate. So insurers have little financial incentive to deny claims anymore.
Agreed. Many large firms do self-insure at this point, relying on the 'insurance' companies for administration. In fact, my employer does this. However, it's not a popular thing to recognize the actual value that insurance companies and the folks who work for them contribute these days (and no, I don't work for an insurance company).
> Also, government run healthcare is bad because they are going to shoot people (or threaten to) and put them in jail for not paying their medical bills? Come on.. are you serious?
Really their taxes, but yes, dead serious. If you have a decent income, stop paying taxes for a while and see what happens. They'll eventually send the cops to arrest you. Vigorously resist arrest, and you'll end up dead or injured.
> You really do sound like you work for the insurance industry, claiming their functions are necessary (even though every other country manages without them).
That argument can be made for every industry, not just healthcare. If you want to live someplace like that, the best examples in the modern world (since the USSR collapsed) are cuba and venezuela. If you haven't already, I strongly encourage you to research these countries, and I think that you'll find that the downside is much greater than the upside. Corporations are not evil and do perform a valuable function in society -- this coming from someone who works for a corporation that's been having mass layoffs for the better part of a year. The world is a brutal, competitive place. Sticking your head in the sand to ignore it doesn't make it go away, it just makes your entire country poor.
> You sound like someone who's got it made (so screw everyone else right?), and doesn't give 2 shits about anyone but themselves.
Not rich, but solidly middle class. I worked hard for everything that I have, and no, I don't believe people are entitled to confiscate my things just because they've been less fortunate. I believe that people who have been blessed like this should help people who are less fortunate (and I do - through private charities), but I don't believe that the government is the solution to this. If you do believe the government is the solution, I encourage you to voluntarily pay additional taxes, you are allowed to do this but very few people actually do.
>Aetna for example has seen a 400% jump in their stock prices in the last 5 years.
In all honesty, what would you expect? The ACA forced millions of people who didn't have health insurance to buy health insurance, and investors responded accordingly by buying the shares of companies who benefited from an influx of new customers.
That article argues that other single payer systems work better than Canada's system. But you're linking it like it is some smoking gun assassination of single payer as a concept; did you read your own article?
Both the availability and quality sucks - waitlists and infections galore across their hospitals.
That's an exaggeration.
I live in the UK and I know first-hand how it is. I've personally never had to wait more than a day, even for an operation.
There are waiting time and service problems recently, but you can thank the Tory government for purposely underfunding the service ion an attempt to drum up support for privatisation.
I mean, our current health secretary wrote a book stating that he wanted to privatise the NHS and now denies wanting to do so. It would be hilarious if it wasn't so sad.
The thing with single payer is it's just like communism.. it looks REALLY great on paper
We still have people covered for health care better than the US does. So make of that what you will.
Plus, nearly every developed country in the world has free healthcare in some form, it's just the US that refuses to spot a good thing and fix its broken-ass system.
Kinda like the metric system in that respect.
If enough rich politicians and leaders of industry label something communist, enough gullible Americans will drop their support for it even when it would clearly help them.
One thing i learned that i enjoyed sharing: employee provided healthcare started with ww2 to lure employees to a company since they couldnt increase wages.
OK, but as long as individuals buy their insurance through an exchange so that they can benefit from group purchasing. Otherwise, people who purchase as an individual won't be able to negotiate for lower prices.
Find out a medical code, call 3 different hospitals in your area and try to nail them down on a price for that billing code - the variance will be large; but given they should all have similar price structures and pay wages that are roughly the same, they shouldn't vary by much more than 5% ...
Price transparency doesn't really help when you can't factor in all the potential costs and unknowns. It certainly is of no use when there's a life threatening emergency.
A birth might be a flat $4000 but what happens if the mother has high blood pressure and needs to be on a magnesium drip? Or the baby is in distress and there's an emergency caesarean? Are you going to call around for a better rate?
The problem with our medical system is insurance. Insurance companies are always playing games to avoid paying bills and they force medical providers to play games to get paid. Vast amounts of money are wasted in billing and claims departments trying to process or deny claims.
It's gotten to the point where an insurer can fine the insured for submitting a claim with a code that requires prior authorization after seeking care from a healthcare provider. I'm not sure how pricey transparency would help with that.
This is a particularly naive understanding of markets.
To restate your argument: there are sometimes unpredictable health care events that arise for which one cannot negotiate, bargain, and price compare in advance. Therefore, price transparency doesn't work.
The problem is you wouldn't make this argument about any other sort of good (for example, an emergency or home car repair) because you know exactly how markets function in those cases.
The answer is: when there's price transparency, and consumers are incentivized to shop around and demand lower prices, prices come down. This benefits not only yourself, but also consumers who don't want to (or are unable to) perform this role themselves.
This is why you pay cheap prices at the grocery store even if you don't haggle, clip coupons, and so on. This is why "emergency" home and car repair (while it may cost more) does not cost an order of magnitude more than "non-emergency" home or car repair.
Some reasons why healthcare markets are not nearly as efficient as other well-functioning markets (like car insurance):
- Prices are extremely inelastic: You'll pay whatever you have to not die.
- Consumers have far less control over what they purchase: they are told to purchase things by doctors, who may have different incentives.
- Healthcare isn't a "commodity" that can be easily swapped out. Prescription drugs may be commodities, but doctors are not. People won't easily swap doctors, making the entire system less efficient.
- There is no "perfect information", in economics speak: people know very little about what the quality of care they are receiving.
- It's extremely expensive to bring healthcare "products" to market (e.g., new drugs, hospitals, etc.). Like building a nuclear plant, very high capital costs reduce the number of players that can enter.
I don't think emergency car repair and emergency healthcare are comparable. You can take the bus or walk. If you mess up you can junk your car or upgrade to a nicer one later in life.
I do think price transparency would help preventative care, but (even if you're thinking in the aggregate) it won't help people in an ambulance on the way to a hospital. Other comparable services, fire and police, are already socialized but have similar, horrible, stories from before they were paid for by the government.
> The problem is you wouldn't make this argument about any other sort of good
The problem with your argument is that healthcare is a service, not a good; and unlike a commodity, every human body is different. A box of Nabisco crackers is the same regardless of where shop. Even service based industries like automotive repair have limited variability with parts or process. The service provided by healthcare providers varies dramatically depending on the procedure desired and who is performing it. Simple procedures like wart removal can be performed a dozen different ways and each has a different cost.
Routine healthcare services have relatively fixed costs and insureds typically pay small deductibles for these services. Uninsured individuals can absolutely call around for quotes on exams and common procedures like wart removal.
Unplanned and Emergency healthcare services are an entirely different story and aren't comparable to any other service. The nearest I can come up with would be an emergency plumber and, like emergency healthcare services, you play through the nose for them. The primary difference is that a plumber can triage the situation by shutting off the water before discussing options and payment. Doctors don't have such luxuries.
Statistically predictable costs could be built into pricing. Basically have the hospital insure itself against low frequency medical events.
To the extent that certain complications can be managed, this creates good alignment of incentives. The hospital bears the cost of not managing the complications and thus has an incentive to manage the complications.
To the extent that certain complications can't be managed, I still find it an appealing way to distribute the low frequency costs (it builds the systemic cost of offering the procedure into the price).
Outcome based payment schemes are probably how it happens though.
I think you are spot on. I want to see a website where you can go to plug in whichever procedures you need, and you will see the the itemized costs, and whether it's covered by your insurance or not, associated with that procedure for every provider within an X mile radius from your address. It's absurd that this doesn't already exist.
Uploading this pricing data to the database would have to be mandated by the federal government.
Even then it's not like you know the pricing - is your surgeon a hospital employee? Many are not and have their own billing. Is the hospital quoting you for the anesthesiologist? Nope. Radiologist (separate from the imaging itself)? Maybe.... Evaluation of removed tissue for cancer, etc? Likely separately billed.
Getting an answer on all of those for costs is going to be very hard. You might be better off finding someone who'll give you a fixed cost that they're pretty sure will provide them a profit when everything is done.
Why not? Most medical care isn't urgent. Cancer treatment, joint replacement, heart surgery are a few examples. Most of the time you're waiting a week to do the procedure.
As I said, it doesn't work for the most expensive medical care. The most expensive medical condition is sepsis.[1] You're not gonna shop around if you have sepsis. Also in the top 10: heart attacks, pneumonia and strokes.
The only solution is for employers to stop offering healthcare. Give the equivalent in salary to employees and let the employee figure it out. When this starts to en masses healthcare will get figured really quickly, i.e. single payer
The Fortune 1,000 won’t do this because they can control employees, wages and competition. Getting a small company off the ground is so much harder because only recent grads are willing to take a job without healthcare. I’ve turned down a dozen companies because of healthcare issues.
I also find it strange that we discuss guaranteed income as a viable solution but not guaranteed healthcare.
I know lobbyists are pushing their agenda, but why is nobody talking about the economic freedom of untethering employment to heathcare? So many people are tied to less than ideal jobs or prevented from starting their own business because of insurance. You also constantly hear about companies hiring contractors or cutting hours just under the margin where they owe benefits.
It's funny that I often hear about how expensive COBRA is and how it's not a good deal. That's what your employer is paying for your insurance. (in an ideal world) that is would-be compensation of your's.
I know the actual cost of healthcare isn't pretty, but it does no one favors by hiding it and tying it to your employer with weird tax incentives.
Bernie Sanders "Medicare for All" plan makes all the sense in the world. Expand medicare for everyone. Pay the government instead of insurance premium. Medical costs go down. Doctors/hospitals might earn less, but will have guaranteed payments. Medicare, a government program, is considered the gold standard of healthcare, so this isn't the government's first rodeo.
If you think government run healthcare is the solution you should talk to any military member or veteran; people are literally killing themselves in VA parking lots because the care is so bad.
Isn't a big part of it the huge wait times because VA hospitals are overburdened by the number of vets? If they were covered by any hospital in their area rather than specific VA hospitals, presumably the care would be a lot better.
Maybe that will force the industry to increase their efficiency(hopefully not through decreased attention to patient, but through cost reduction, better negotiation power with pharma industry and all)
That's what the hospitals have been doing recently through consolidation of both hospitals and private practices. Not reducing their costs overall per se, but trying to grow as much as possible to increase buying power. I'm of the opinion that this is a bad road to go down, one with a lower degree of competition and choice compared to what we had 15 years ago.
I think you need to have incentives in place to foster innovation in healthcare somehow. Consolidating hospitals sounds like a way on monopoly, i agree, but consolidation could also happen on payer (single payer?) side, which would give some bargaining power. I think at this point US healthcare system is too complex for many of us to follow. We have different private practices, labs, hospital facilities, and all that comes with the cost of opacity. When you can't really tell how much you are going to pay to whom in advance comes with loss of power to choose (a different care-giver), which probably creates local monopolies.
No, it will cause the medical industry to do less. A big reason (though not the only reason) why the US is so expensive is because way more medical procedures are done here vs. other countries.
Above they mean system wide spending when they say cost.
Also, we are very likely doctor constrained. The patients/doctor in the US isn't hugely different than other countries, but it is difficult to estimate the impact of how a payment model causes them to direct their care. The current US model needs lots more doctors.
on a second read of the original message, maybe that's exactly what he's talking about.
More medical procedures because of less preventive care, or more procedures "to cover their ass". I heard doctors tend to be on the super cautious side to reduce liabilities, and require more testing, procedures, and what not.
The only reason it's the gold standard is because it's everywhere. Having worked in 6 hospitals since 2006, I'm not quite sure how you think expanded medicare is any sort of solution.
Health insurance companies are running out of time and they know it, this is their last ditch effort to get as much money as possible. There is no point to lower prices, why gain market share if there is no "later" when you can extract more profit? Why enter the health insurance market if you are not sure how long it will last?
About time for someone to start offering an insurance plan where all consultation is via facetime/video chat and expensive non-critical operations are done in Mexico or a ship parked in Int'l waters close to major cities on either coast. Only get an emergency room insurance for the US!
Where I'm from 90% of what a general practitioner does is give out antibiotics. I hate the over prescription of antibiotics but they could easily prescribe that over video chat. This would keep sick people at home and allow doctors to focus on people that actual need to come in to be physically examined.
There are startups popping up that offer consultation via facetime/video chat but unfortunately, they are only covering small areas or big cities at the moment. We're really behind on this in the US unfortunately.
What's weird is my insurance sent me a card for Teledoc. I was thinking, "Fantastic. I never know if I should sleep it off, go to an ER, or make an appointment." I figured it was a cost-saving measure for them.
Turns out they charge a not-insignificant fee per use. I can't remember exactly how much, but I'm not sure where that card is (with the number on it) and I don't plan on using it.
Yes! This McKinsey report is the best I've seen in terms of tracking where the dollars go vs. other countries.[1]
In summary, it's mostly going to outpatient care. The US spends only a small percentage more on in-patient care. In fact, the US spends less on durables and long-term care than most other countries.
There are simple answers Health Insurance affordability in the US. Rationing. No NOT via a single payer system where some all-knowing official decides who does and does not get care. Rather, the rationing is done by the buyer. For example, Buyer one could decide to only buy a policy which covers only generic drugs, which would exclude all patented drugs (newer and even superior), Buyer 2 could decide to buy a policy which covers generic drugs and patented drugs in one or more specialties (e.g., cardiac). The theme is let the buyer decide, not everyone wants to live the last 10 years of their life struggling to regain their youth.
Are there examples of such a system working anywhere? It sounds plausible, but the fact that it didn't arise pre-Obamacare gives me pause. It seems like the demand for it might not be prevalent enough, or the savings too small.
I'm interested in new models, but I'm tired of the US thinking it has to be special with its healthcare system and wasting a trillion dollars a year.
You fundamentally don't understand how this works. The fact that you repeated the "some bureaucrat decides who gets care" line proves it.
Your "market" approach fails the minute someone is born with preexisting conditions. Or if someone needs emergency care, but doesn't have the right plan.
With Kaiser Permanente Northern California, for a family of 4 $18k buys you a gold plan with $0 deductible, and $20k buys a platinum plan. This is on the open market. I just priced it on their website. Most plans are substantially cheaper.
HMOs are really the way to go, but unfortunately Americans stupidly prefer to pay a huge premium for more choice (or at least one very specific dimension of choice). A family member who is a long-time partner at a law firm forced her firm to purchase a plan that allowed her to keep her doctor of 20+ years. This happened during the nationwide market reconfiguration as the mandates rolled out and insurers aggressively re-architected their plans and provider networks. Now she rants and raves about how Obamacare raised the costs of healthcare, and her partners resent her for forcing the huge premiums on everybody. She's totally unwilling to consider that the problem was entirely of her own making; that her firm could be paying a fraction of their current costs for the same quality of care, just not including that one specific doctor.
HMOs aren't very common, and in many regions they seem to suck. Fortunately, Northern California Kaiser is one of the best hospital systems in the nation. If you live in the Bay Area I highly recommend it. Kaiser aggressively pursues cost-cutting measures and efficient service delivery procedures. Appointments go through a phone bank of nurses with a rotating staff doctor, so minor illnesses like a cold or flu don't require wasting your primary physician's time. For more serious but still common injuries like a broken wrist you're directed to, e.g., their sport injury unit clinic; again saving both the ER and the primary physician's time. Kaiser runs their own labs, and the volume of people their labs efficiently handle is incredible. All the doctors are employees (as opposed to independent, affiliated providers like in many for-profit hospitals), and Kaiser doctors very consistently apply uniform policies on best practices, prescriptions, etc. I think they're large enough that they run their own studies; at least that's the sense I get when I've inquired about why they choose X instead of Y.
All of this comes across to some people as impersonal, but personally I think it's amazing. I've never had an interaction (nor have any of my family members, AFAIK) that left me feeling cheated for attention, even though there's always the sense that everybody--doctors, nurses, staff--is working to keep things moving along at a brisk pace. The way they've balanced conflicting requirements is really laudable. After being with Kaiser for many years, other hospital systems seem downright chaotic.
It genuinely blows my mind that some of the top comments are pro-socialized medicine.
This is a forum populated primarily by hackers and people interested in starting or working at start-ups -- should we also have a single payer of all hackers? The notion is laughable, but it's put forth seriously when it comes to medical care. Like all problems of costs being "too high" this one is caused by artificially restricted supply (govt regulation of medical system) and skyrocketing demand (much of which is driven by the abysmal nutrition advice the US govt has doled out over the past 50 years which has only made 2/3 of the country obese and overweight).
Control economies do not work, how much more evidence do we need before people stop saying "this time is different, we just need the RIGHT people this time"?
I'm not in favor of single payer healthcare, but to say there's no evidence that it works is inaccurate. Healthcare in Canada provides the same health outcomes as ours for half the price. If that doesn't interest you because they do it with the wrong philosophy, you're an ideologue. In fact, the evidence that your proposed changes would give a 50% reduction in cost seems a lot slimmer than the case for straight-up single payer.
>Control economies do not work, how much more evidence do we need before people stop saying "this time is different, we just need the RIGHT people this time"?
The current system is just a different control economy. Companies don't really care about the cost because non-transportable health care is one lever of control that enables then to depress wages.
First, it's not socialist, healthcare is a fundamental asset in modern societies
Having different healthcare standards for different social classes is detrimental for society development
Second, public healthcare is not a single player system, is a decentralised system with many actors competing under the same rules
If you don't believe me, just take a look at what happens in Japan or Europe or in Italy (my country, generally a disaster but second after Japan for average life expectancy)
That's exactly what a hacker culture supports
US healthcare reflects US mentality that market can fix itself so instead of net neutrality you're going towards net conglomerates
Leave it to the consumer to buy just like all other insurance. In fact the increase in wages could be used to fund a basic preventative care plan (read not full on single payer) for all Americans.