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Comment by helen___keller | Hacker News Reader

The point of health insurance is to pay into a risk pool as a collective so that the small percentage of people who end up needing the largest percentage of health care, nobody dies or goes into monumental debt. This can be done via taxes but insurance is a private market solution which should in theory make it more efficient for the sake of maximizing profit.

So then if it's supposedly more efficient, why do I waste multiple hours dealing with insurance bullshit literally every few months?

Start a new job at a startup, need to go to trainings to understand the health care options and choose one, get new cards and website logins, update my info at every provider

New dentist is having difficulty getting my routine care billed to insurance and calls me every week asking for my insurance information again.

Wifes doctor didn't do something correctly when I updated insurance so now I need to call and deal with this big medical bill that I shouldn't have gotten.

Startup got acquired so I get another training for the new insurance options. And get new cards and logins and update with all providers again

Planning to get a surgical operation but nobody can tell me how much it will cost, doctor says "probably whatever your deductible is" except I have a high deductible plan so is it really going to cost me $2500?

Etc cetera. There's no end to the nuisance. If I could choose to just pay more in taxes (hell I'll pay way more than my current premiums) and never deal with insurance again, I would do it in a heartbeat.

View on HN

We have a high-deductible health plan and live in Reno. When my gf recently had the need for a CAT scan, the first choice was here in Reno, and it was priced at over $800. She cancelled her appointment, called over in Carson City (20 minutes south of Reno), and got one done, by someone in our network, for $400. The doctor's office who referred her said, "$800? Really!?"

The Reno specialist made her a follow-up appointment in June. The Carson City specialist saw her in 4 days.

Etc, etc.

We're our own LLC, and we got our own group health plan, as a function of being self-employed and having experienced the employment-related gaps in health insurance coverage.

None of this is interesting, but it's stupid and risky. This system has to be changed.

That actually sounds like the high deductible plan is functioning as it should though. Causing consumers to price-shop and avoid price-gouging providers.

Sure, in the case of a scan that isn't urgent. If you were in a car accident and have a piece of metal embedded in your kidney are you in a level, clear-minded state to price shop about which emergency room won't gouge you?

Health care is an inelastic good, we need it. So this is a market (much like having a military) that really benefits from the government stepping in and making things sane.

Not that I disagree, but the majority of health care expenses are not time-critical emergencies. I saw a statistic somewhere where it's around 15%?

IMO the biggest problem is that you're not really qualified to judge medical practitioners. How am I supposed to know if what they're recommending is actually necessary? The market price of an MRI? How do I know they're not skipping care I should have to offer a lower price? Or if they're offering unnecessary procedures?

The reality is you need an M.D. to make a reasonable evaluation. This is why at an HMO we have primary care physicians. Or in any other country, GPs. They decide if you need specialized care. However, how am I supposed to pick one of them? It's Russian nesting doctors.

It's probably the most complicated thing we have to deal with in our non-professional lives.

Actually that raises an additional interesting point... if the market price is varying from doctor to doctor it could be for many factors - how am I supposed to judge the relative quality of an MRI that would be read by two different specialists. If the quality is different then how can I be informed as to the efficacy and truth of that difference?

With a bank, Bank of America has terrible service - so I just don't use them, with a doctor though... what if I'm paying a premium price but receiving substandard care, given how complex human bodies are most illnesses compound over time and only in very select circumstances could you get a doctor to come in post defacto look at an X-Ray and say "This doctor was terrible, that's totally a tumor" maybe the real issue is that a tingling in your finger tips when you sit down that you asked your doctor about went unnoticed and twelve years later your heart gave out over totally preventable causes.

Same way you evaluate developers. Say you are a manager at a company who needs to hire somebody to develop an application for you. You aren't technical. You have no idea if you need the thing the consultant is saying you need. So you check completed works, existing client testimonials, educational history, recommendations from coworkers or friends, etc.

Just wait until you get a reference request on your last colonoscopy :P

Seriously though in general managers have worked in and around technical people before, and their role in the process is to evaluate qualitatively. Are they a good communicator? Do they seem like awful people? They use feedback from the engineers to estimate if they're good engineers. I don't have a deep bench of M.D.s to lean on to figure this stuff out.

> Or in any other country, GPs. They decide if you need specialized care. However, how am I supposed to pick one of them? It's Russian nesting doctors.

Same way you would pick anything else? I shopped around for my GP and changed several.

Some factors were: years of experience, user feedback, spoken languages, any red flags for the whole practice, how they respond to my concerns and questions in conversation, etc.

The majority in terms of cost or volume? Also is this figure including oncology treatments - those drugs can run 1k/pill and while some are potentially cures many more are just pushing eventual death a bit further off. These drugs would quite possibly skew any statistic that isn't designed precisely to account for them.

Also I think it's not really fair to take full lifetime costs into consideration at once. As you get older you'll be looking at those much more expensive treatments and covered by expensive insurance but the insurance tends to be of a higher quality when it comes to reducing sudden costs - I am more concerned about younger people who generally have terrible insurance and may get hit with 4 months of 20k physio due to a sudden injury but generally have low "normal" costs.

That’s what an advanced directive is for. We just need to extend it beyond CPR/no CPR and heroic measures vs no heroic measures, etc. Kinda how like insurance companies negotiate prices for everything in advance of you showing up.

Let users watch a series of videos and choose what kind of risk and benefit they tolerate/want and how much they’re willing to spend.

It’s morbid, but we do such assessments constantly. Do I come to a complete stop and waste a few seconds and ml of gas, or roll through it and be really careful about it?

Seriously?

The difference in your "every day" scenarios is recoverability. Your actual health put at risk means you die, unrecoverably.

Then there is always people not being able to spend. So they just die?

A poll on that policy would be instructive.

The every day scenarios can result in permanent effects. Not everyone going through a stop sign is in a protective cage.

Obviously the advanced directive solution is largely irrelevant in a 100% coverage/public system. The insurer then makes those decisions for you. But for as long as you have a system with uninsured, there’s value in having decisions made in advance as a “just in case”.

Real value is health care as human right. That we do not do it, and worse, can't even get a basic like water right is an embarrassment at the least, and rock solid cause for reform all day long.

In simpler times, a city able to provide clean water was a city of note. Worthy destination. This has been true for ages.

Flint fucked for how long now?

Our national priorities are insane! Bat shit wrong and health care, food, water, housing are all right at the top of reform agendas for damn good reason.

We can do better, and we need to.

The uninsured are uninsured because they are unable to spend. Put whatever the fuck anyone wants on that paper and it does not matter one lick.

Might as well write, "yeah, let me die, k?"

Frankly, there is zero value in the idea, and a lot of harm potential in the norms being changed for the worse: "but they consented..."

Anyone who wants to make a directive can do so today. Expecting people to do it because our system is fucked makes zero sense.

It is long past time we get our priorities in order so conversations like this are laughable, not morbid.

So now not only do I have to spend several days on the phone each year with my insurance company, on top of figuring out which plan I want every new job, but I also need to watch a bunch of videos about kidney-replacement options for when I get in a car accident? And what heart attack care is available? And how many $1000 Ti screws they should put in my leg when I shatter it rock climbing? And somehow the collective time-wasting is going to be somehow cheaper for all of us?

I always wonder if you libertarians are doing a bit, because it sure seems like it.

You get some agent to do the heavy lifting in agreement with your parameters.

It’s a solution to the problem of “I continued to choose to live in an environment without health insurance, how do I handle the situation of not being in a position to negotiate?”

The agent I choose it the government, which I am proposing becomes the common agent of all Americans and advocates for all of us - since the expertise to act as a rational agent in this setting is unavailable to most citizens.

This extreme libretarianism stuff is pure BS, health care services in an emergency cannot exist as a free market.

Oh, I agree. But most Americans actively vote against that system.

As for those uninsured that just broke their ____ and are not in a position to start calling around, having pre-negotiated rates for the best pricing against all hospitals within a reasonable time’s transport would save a pile of cash. There’s no shortage of hospitals or excess capacity in the US.

If you're in that dire an emergency you're going to max out your in-network limits anyway, so it doesn't really matter which emergency room you get taken to, you pay the same.

My in network max is around $13k, my out of network is $99,999,999.

EPO / HMO?

My card says PCP.

What if the cheaper place is cheaper cause it's not as capable? How am I supposed to know? In what other scenario are we similarly encouraged to act on price alone? Price transparency is meaningless with quality transparency.

And quality transparency isn't that much help either - if you have cancer are you really going to shop around if chemo treatment drug group A is more effective then drug group B? A patient cant even begin to be able to shop around for something like that.

... and assessing quality in this space is way outside of what a normal consumer is capable of anyway.

The UK has periodically had a back and forth on whether the outcome ratio numbers which are collected for internal statistical measures should be published.

ie should we make it easy to get a number that says 4.6 for Mr Able, 5.2 for Ms Awesome and 3.8 for Mr Good?

At one extreme the reality may be that Mr Good isn't good and his numbers are low because he's a bad surgeon, he makes a lot of mistakes, his technique is not what it should be, he's using an approach that's outdated... that's a real problem, and maybe "patient choice" is a fix where colleagues may be reluctant to say "Fire Mr Good" because he's a good guy, he's not _terrible_ at his job, but yeah they would not themselves choose to be treated by him.

At the other extreme the reality may be that Mr Good is the only guy who'll take patients that Ms Awesome thinks are too high risk. She thinks it's better to say "No", he thinks if they seek medicine he should do his part. Maybe they're obese, or they won't stop smoking, or they won't stop doing the sport that's wrecking their body. And Ms Awesome is right that Mr Good's patients are higher risk, but that's not because he's doing a bad job, he's playing what was dealt.

Also don't forget that Mr. Good might have tougher customers because he's Mr. Good and his prices are low or because he's willing to take on the hardest jobs that are unlikely to leave customers satisfied no matter how good they turn out. If you're the guy that everyone goes to because nobody else is willing to try and fix what you will your success/failure ratio will by abysmal.

Measuring quality is also incredibly difficult, patient input is practically worthless.

Every time patients are asked to rate the quality of the care, they consistently rate simple feel-good care like massages, chiropractice, or just therapy as very good, but saved-your-lfe-operations get rated very badly, because the experience and recovery is often miserable. You live, but you don't feel good, so you rate the quality of the care after how you feel, even though you ought to rate it Five-star, A++++, would transplant a failed heart again!

So the rational person abandons subjective ratings and look at objective ratings, what's the medical outcome for a provider? Sure, that's better, but the quality of the outcome is incredibly dependent on the quality of the patients! It's a well-known fact that a positive attitude helps immensely with recovery, how do you measure that? How do you integrate that with an outcome measurement?

Price is the best mechanism for organically assessing quality at scale.

I'll be sure to let the ambulance driver know after a car accident they should shop around :\ Maybe an Ayn Rand medicalert bracelet would help. Allergy: Socialism.

That's why the out of pocket maximum exists. (I think?)

if I understand correctly, the out of pocket maximum might only apply to in network providers. I think if you end up getting a non-covered procedure or get service from an out of network provider, you can be on the hook for way more than the out of pocket maximum. if so, it would be hard to ensure that this doesn't happen in an emergency.

That was fixed long ago by ACA. Emergency services are treated as in-network regardless of whether they were actually in-network.

Well yes, but you make it sound so easy. You'll have to go multiple rounds with the insurance and aca reps in many cases to get it approved after the fact.

Yes, and that is the biggest issue. Hospitals and insurance companies playing hot potato with each other while the hospital tries to pin whatever the insurance company doesn't pay for on the consumer. We need more punitive regulatory action for such situations.

The out of pocket maximum can be a lie, too. I have an 'out of pocket maximum' on my ACA insurance plan, but there are medical services that are exempt.

Last year, I paid $4000 more than my $6500 out of pocket maximum, because I had a heart procedure and the heart rehab following the procedure was an exception to the out of pocket maximum, a fact I discovered only after incurring the costs. You see, if you clearly follow the asterisk and the footnote references in the policy, then it's very clear that these expenses would not have been covered.

In our area, its becoming popular for the hospital (the only one in our area) to be in network, but the doctors who work in that hospital are NOT in our network.

#BAM!

Funny! Pointed too.

Getting the best dealz runs in basic conflict with needing to stay alive.

This is why markets do not work well for primary care. They can work well higher up the chain where life basics are not really in play.

That's not the purpose of deductibles though... it's to put people's skin in the game - if you use insurance, you also pay for it, so it's not free for you.

On the other hand, if a provider is charging too much, they shouldn't be included in the plan in the first place, as they're simply a bad option.

No... the grandparent had it right. "Skin in the game" is just a colloquial restatement of the earlier point. The purpose isn't to make people needlessly suffer more by having to pay!

The principle idea is that because they have to pay some, they'll be more sensitive to pricing and more willing to shop for an affordable provider, which is exactly the efficiency argument.

And in this particular case I agree, even. Though the fact that this has to be done by individuals (who are sick!) sort of makes a hash of the moral notions of "the market" being the solution here. We're buying efficiency at the cost of individual grief, and that has value too.

People in poor health are not consumers and getting medical help is not shopping.

If private insurance is going to work, then every healthcare provider has to accept payment from every insurance. This clusterfuck we have where you have in-network providers with one price and out-of-network providers with a different price just has to stop.

Oh you went to an in-network hospital, but this one doctor walked into the room for five minutes and she was out-of-network, so now your bill is 10x higher than it otherwise would be, etc. etc. It's ridiculous.

I've always wanted to add a clause to those consent forms stating that my consent is conditional to the provider being in-network for the insurance information I provided the hospital. It is their responsibility to make that determination before they start treatment. If they provide treatment and find that they're not in network, then they forgo the right to bill for that service.

They won't let you have the procedure if you attempt to alter the agreement. I've tried!

When you go to the hospital, you just need to wear a Darth Vader mask and rasp "pray I don't alter it any further."

A great alternative strategy is to structure your finances so that it's impossible for creditors to seize your assets - that way, your practical liability is limited to the up-front costs. Which, by being up-front, you can actually reason about and make informed decisions on.

This is less difficult than it sounds. Move to Texas, and keep all your assets in retirement accounts, home equity in your primary residence, and possibly annuities if you've made too much money for that all to hold everything. Note that this should be done before possibly incurring debts.

> A great alternative strategy is to structure your finances so that it's impossible for creditors to seize your assets

It is absolute insanity that this is even a thing to consider.

The funniest thing about it is that if you do this, you are effectively socializing your personal losses and letting everyone else insured through your provider bear the cost for your healthcare. If that's not an argument for actually socializing healthcare costs for everyone, I don't know what is.

If I could cap my downside risk from medical events through insurance, I would do that instead. And this is not a replacement for insurance, since many medical providers will refuse to provide non-emergency care if they didn't expect that they could bill my insurance for services rendered.

But, unfortunately, it's currently impossible to set a maximum price you could wind up owing due to receiving medical care. Any provider you go to could end up incurring out-of-network charges and wind up balance billing you. The only fix is to cap the actual damage of creditor judgements in general.

> But, unfortunately, it's currently impossible to set a maximum price you could wind up owing due to receiving medical care.

Of course, because demand for healthcare is infinite, so you could wind up costing the insurance company an infinite amount of money. And if their expenses are uncapped, they're not going to cap how much you can pay them.

And if they cap their expenses on your behalf, it's not really insurance, it's just a shitty payment plan.

I misspoke a little: it's impossible to set a maximum price that the 95th percentile household can afford. A single medical event can bankrupt households but not the state of California.

I wouldn't describe that strategy as great. Having a desired effect, sure, but the tradeoffs are pretty nasty. And doesn't it create potential situations where you require a lawyer? And what if the laws in Texas change, what then?

Wouldn't it be easier instead for healthcare billing not to contain so many gotchas?

>And doesn't it create potential situations where you require a lawyer?

Sure, but improving your BATNA helps your negotiations even if you don't need to exercise it. The bill gets handled with opening a dispute and sending a "give me documentation for an implied regulatory complaint" letter. If things devolve into a lawsuit or threat thereof, I tell them my financial situation and what they can expect from a lawsuit and offer to settle for a nominal amount.

>Wouldn't it be easier instead for healthcare billing not to contain so many gotchas?

Well yeah, but I can't change the healthcare billing system, while I can change how my finances are structured.

What’s special about Texas? And how can you put everything in retirement account?? 401k is 19k/year and IRA is 5k? What do you do with the rest of your money? Do you setup and LLC or trust? Can you elaborate?

>What’s special about Texas?

Debt collection follows a combination of state and federal law, and Texas state law is unusually favorable to debtors. Specific important pieces:

1. Your primary residence is protected from forced sale to satisfy general creditors, up to 10 acres (urban) or 100 acres (rural).

2. Garnishment of wages is limited to certain special circumstances, such as nonpayment of taxes or child support.

3. IRAs have unlimited protection from creditors (other states have a cap).

>And how can you put everything in retirement account?? 401k is 19k/year and IRA is 5k? What do you do with the rest of your money?

Home equity is a very significant part of this. If you borrow $300k to buy a $400k home, the $100k you have tied up in your house is protected from creditors. If you have an extra $50k you want to save, you pay down your mortgage more aggressively and creditors can no longer come after it.

Oh, also, from reading into things, it looks like if you buy a 2 to 4 unit house, then even the non-owner-occupied units remain protected. So you can extend things somewhat that way by having a more expensive home that cashflows.

>Do you setup and LLC or trust?

LLCs are more for business-related liabilities, and trusts are weird and expensive enough that I haven't looked into them. Besides which, there's a perfectly reasonable alternative to a trust - annuity and insurance products. Both their value and payments to you are exempt from attachment and seizure in Texas, again with the exception of child support payments and "fraudulent transfers" made after incurring the debt. So essentially, if an insurance company is holding your money and giving it back to you in a structured way, creditors have a really hard time getting at it.

I see. What if you want to FIRE? You can’t have all your $ tied up in a house.

You can likely actually swing it between accessing IRA funds, having a paid-off duplex/triplex/quadplex, and purchasing an annuity or the like. Wouldn't lose all that much efficiency, depending on things.

Only that insurance takes 3 weeks to process the claim. Delaying care 3 weeks for that guarantee would have caustic medical implications.

imgabe just said in network not that the claim gets accepted. There's been a couple cases where not everyone administering as part of the procedure was in network so there's a surprise bill for one part [0]. You can do all the right homework to make sure the principal people involved are in network and still get screwed!

[0] https://www.cbsnews.com/news/out-of-network-anesthesiologist...

If the procedure is not covered it doesn't matter if its in-network. You will face the same issue: the provider doesn't know if he will get paid from insurance until at least 3 weeks later.

I agree, however this is the unfortunate reality of the private healthcare system maximizing for profit. Consumers rarely have proper choice in shopping around or choosing doctors and insurance providers take advantage of this by inventing as many different systems as they can to avoid paying out.

That's why I think full free market healthcare simply won't work. It's far too much at odds with people that need medical care, made worse if you need timely medical care.

> unfortunate reality of the private healthcare system maximizing for profit > Consumers rarely have proper choice in shopping around

If you have a M4A, you have less choices not more.

> That's why I think full free market healthcare simply won't work

The last thing I would call healthcare in the us is free market.

I need healthcare, not an infinite number of unaffordable "options".

Less options doesn't make it more affordable. More options does.

The reason this doesn't work is because not all doctors are equal.

Insurance companies want to contract with the healthcare providers with the highest quality outcomes that don't have overprescription, relapses, and readmissions.

Search terms: "narrow networks"

1) Pass law providers require to support all insurances

2) Make insurance company that reimburses 1$ per visit

3) Profit

> which should in theory make it more efficient for the sake of maximizing profit

There are multiple reasons why this doesn't work for healthcare even in theory.

- Emergency care can't be substituted without massive cost. Providers compete on distance not on price.

- Emergency care can't be denied (or at least we don't want this) on the basis of price.

- Health is not insurable like cars, etc. You can't predict in advance when you are going to get in a car wreck so you better buy insurance when you get the car. If you could, the price of the insurance would be the price of the car, and therefore worthless. But you could just wait until you feel sick to get health insurance. This is why the ACA has to be paired with the individual mandate to work properly.

Emergency care being expensive is not a problem of insurance. Public hospitals are also expensive. Its related to other things.

It's not the expense that's the problem the expense is a symptom and the problem is the attempt to treat healthcare like a market when consumers a) have very little ability to discover the price, b) have little option in substitution (if my appendix is ruptured my substitution to getting surgery is dying!) and c) many purchases are made under emergency situation with no time to price shop (or often the ability, no one can comparison shop unconscious in the back of an ambulance).

> to treat healthcare like a market when consumers a) have very little ability to discover the price

There is HUGE price discoverability capacity in healthcare. But the US is not a free market: every single player has some sort of regulatory capture to mess it up, including workers, that get tax benefits and are blind to price through employer provided insurance.

Price sensitivity does work for high deductible plans, pointing to the basic economic principal-agency problem of the current system: if you have low copays and you cant choose insurances because your employer pays for it, you are a price insensitive patient.

My favorite example is OneMedical: one of the biggest complains patients have is "why do I have to pay 150 a year", while their healthcare plan is thousands A MONTH and a single doctor visit costs 300 U$S!

> have little option in substitution (if my appendix is ruptured my substitution to getting surgery is dying!)

Emergency healthcare is a small fraction of overall healthcare spending, and it is NOT expensive because of insurance, its expensive because hospitals are expensive. It doesn't make sense to complain to an auto-insurance company that fixing cars is expensive, its completley out of their hands, and they actually work in your favor to reduce costs if they can.

And medicine has PLENTY of substitutes. From cheaper drugs, to less accessible and lower quality healthcare. It's called the Iron Triangle of Healthcare: cost-quality-access. You can find your place in the triangle.

Churning health insurance with a high deductible plan + HSA is an even bigger timesuck.

Just yesterday I sent in the paperwork to roll over my HSA from one bank to another-- the punchline is, my insurance provider didn't change and my insurance login was the same (Premera ConnectYourCare), but it looked like the 15k in my HSA account inexplicably disappeared. Needless to say, this was concerning.

A few phone calls later, and I come to find out that my 15k with Bank_0 was available on the backend, but since Bank_1 was preferred by my new employer, Premera shows Bank_1 on the frontend. Keep in mind, all interactions with your HSA bank account are abstracted away from you. So you must track down your Bank_0 and Bank_1 account numbers (I used my tax paperwork) and mail in honest to god physical signed forms authorizing the rollover.

Then I come to find out that I should have done this anyway-- HSA accounts are laden with monthly account fees, paper billing fees and investment fees that my previous employer wasn't paying anymore, and these aren't covered by my current employer. HSA bank accounts are one hell of a moneymaking venture for the big banks-- 0 risk because employers send yearly contributions into the account; high likelihood that people will forget to roll it over and the account will drain via fees.

HSAs have the hugely hidden cost of managing this separate account+tax entity, and I did not know this when I signed up for one. I'm not even sure that my hours of labor on it are worth the tax savings.

It's painful. After going through something similar (with UMB and ConnectYourCare/UMB), I ended up over at Lively. No fees, and you can invest with TD Ameritrade for free. I hear Fidelity is a good option as well.

Isn't it pretty cost-effective and efficient to keep you on the phone for three hours in the hopes that you just give up and don't undergo a medical procedure?

This is exactly what I was thinking during the whole read. It's what Comcast did in the early 2000s when they were scamming people by adding random charges. Just keep them sandbagged long enough to give up, and it's basically free income.

I think your phenomena might be due to startups? Obviously this is a startup focused board so I am not saying this to mean go one way or another, but I ditched the startup, job hopping life a little while ago, and had to deal with "insurance bs" roughly two times in 7 years.

I am either the luckiest person alive, or maybe there is additional benefits not obviously well represented here to working for a stable, revenue producing organization, but I don't seem to encounter what seems to be the well-represented insurance pains documented here (probably a little bit of both, in my guess).

I'm not at a startup and have better than average insurance, however it's still a clown show.

For example, I recently got prescribed a medical device, but was then told that if I didn't have a follow up appointment between certain dates I'd be billed out of pocket for the device.

The prescribing physician, of course, has no open appointments until a couple months after the given follow up interval, despite knowing the potential issue and prescheduling the followup.

And of course the device provider, the physician, and the insurance company all tell me completely different things about the situation.

The current "solution" is "just see your primary care instead," not sure how it'll go.

Not due to startups necessarily so much as changing insurance a lot. I'm on my 6th insurance plan in 4 years (Job 1, not a startup, lasted 9 months. Job 2, a startup, changed insurance 2 months after I started then again the next year for a total of 3 plans over 2.5~ years on the job. Job 3, a startup, had better than average insurance (with a weird/awesome reimbursement plan so I pay 0 deductible and 0 premium and get to cover my wife for free too!). Then one month after I started we got acquired and so in 2019 I now have a normal (still good) corporate insurance policy.

On top of that insurance frustrates my wife so before we were married when she was on PhD student insurance I generally managed that too, plus her transition to my insurance after marriage.

So I'm definitely out-of-norm on this. If anything I like to think that means I'm more qualified to call out how bullshit the world of insurance is, atleast in terms of end-user UX, but obviously that's just my opinion.

The phenomena is linked to how often someone switches jobs in the United States irrespective of the type of company or employment (full-time, part-time, self-employes etc).

No matter what an individual’s stance is with respect to another individual’s professional history in terms of frequent changes or gaps, I don’t think that has to correspond to level of healthcare that the latter individual is able to obtain.

I think it depends on your state's insurance market as well as the priorities of your employer. If your state has a plethora of plans available, your employer is tempted to shop around more often. In that case, it depends on the priorities of your employer, weighing the cost savings versus the cost (financial, employee morale, time) were they to switch to a cheaper plan.

I've worked for employers of varied sizes and profitability (self-employed, small nonprofit, very large health system [including its own insurance plans], midsize for-profit), and I haven't noticed a consistent pattern that would differentiate them in terms of health plan stability. In all cases, the goal is to minimize cost while providing an acceptable level of coverage.

Of course, job hopping and employer-provided coverage are a painful combination. My family had to reach our deductible twice last year, which wasn't fun (the increased salary and other benefits of the new job made it worth it).

I'd love to see health coverage detached from employment. If traditional Medicare-for-all isn't feasible, then let's go with Medicare-Advantage-for-all instead.

My partner has been employed with the same large international company for 8 years. She had an elected procedure done that is required by law to be fully covered by insurance. She had 3 calls leading up to the procedure with her health insurance company each time asking them if they were certain it would be covered 100%. I thought that this was overkill but she was worried to the point of being paranoid about it. They assured her each time she would not have to pay any money at all for anything.

The procedure was in December. After the procedure she received a 6-figure bill, which she then had to follow up with hours of phone calls back and forth to the insurance company, hospital, and doctor's office. They sent her a revised bill for somewhere around $8,000, and then another revised bill for around $4,000.

The insurance company says it's because the doctor coded the procedure incorrectly. The doctor says the hospital coded it incorrectly. She has had to file an appeal with the insurance company, and the only reason it looks like it will work out is because the insurance company records all phone calls and was able to get records of her original calls before the procedure asking if it would be fully covered. She has still been told to expect that they will deny her first appeal and she'll have to appeal a second time in order to get it covered. This has been causing her immense stress for the past 4 months as she does not have enough money to pay even the $4,000 bill out of pocket.

My experience is that your experience actually is extremely uncommon in America today. Most people who have to interact with the health care system beyond annual checkups have to deal with something like this.

I am fortunate to have had the experience of growing up with a rabid Greek mother who would get to the bottom of any shenanigans with any sort of insurance agency, bill collector or anything. I now have my own experience. Yes the first time was stressful, but reading your story, trying to put myself in your partner's shoes this would not have ended up causing me any stress, especially if I knew the law is on my side. I certainly wouldn't paid any bill until it was all sorted out. I also have experience where a medical charge that was suppose to be covered as a legitimate procedure was not and charged off onto my credit (because again, I refused to pay). I was easily able to negotiate with the credit reporting agency to remove this negative mark on my credit. (Negative marks due to medical bills affect your credit much less than say missing a credit card payment, IIRC, I was still able to obtain credit cards, get loans, and generally had decent overall credit).

My father currently undergoing treatment for lung cancer. He has medicare and supplemental coverage through Humana. Bills are still in excess of 150,000, so I definitely understand the other side of it.

She is lucky she is getting that even partially covered if she only got a verbal agreement. My insurance policy has a clause that anything they say over the phone is not a promise to pay. You have to call AND get something in writing to even be eligible for a dispute later.

My previous employer had my insurance totally wrong. According to everything I signed at open enrollment, I had a $6k deductible and $6.6k Out-of-pocket max. This was for the family, no individual deductible.

When I go to the insurance site, it lists me with a $2k individual & $4k family deductible. It says my OOPM is $7.5k. Of course I hit my deductible this year, so I'm getting billed an extra thousand.

My employer and insurance company both swear it's the other one's fault and even filing a complaint with the state insurance commission doesn't seem to have helped. :(

In the future the way to avoid this is for the hospital/doctor to submit a prior auth request. Then you have it in writing.

>This can be done via taxes but insurance is a private market solution which should in theory make it more efficient for the sake of maximizing profit.

Imagine there's a single, private, insurance company, A.

Wouldn't the natural interest of A be to maximize health costs (i.e. make paying for health coverage expensive, as thus their insurance more desirable and more expensive in return)?

And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition (so, having us end up with an even larger company)?

And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?

And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?

All those seem inevitable (and profitable) in a market economy. How would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?

> Imagine there's a single, private, insurance company, A. ... Wouldn't the natural interest of A be to maximize health costs ... ?

Sure, but as an insurer they don't have any control over health care costs. They could bid prices up, I suppose, but that eats into their profits; such a strategy would cost them more than they could possibly gain.

> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition ... ?

The smaller companies would have to agree to that. Some of them could be co-ops or other organizations structured to represent their members and not interested in being bought out by a company which doesn't share the same principles.

> ... wouldn't it make sense for them to collude and keep prices and profits high?

Cartels are notoriously unstable. Every member has an incentive to cheat on the cartel to gain market share. And then you have the aforementioned co-ops and others who wouldn't be interested in joining the cartel.

> ... isn't it their natural interest to spend on buying politicians ... ?

And here we come to the real issue. Not that companies are interested in buying politicians—that's only to be expected, under the circumstances—but rather that (a) there exist politicians with the power to forcibly interfere in the market without being branded as criminals, and that (b) these politicians are willing to be bought and to support laws actively harmful to their nominal constituents.

In order to have a private market for either health care or health insurance you must first get the politicians out of the market.

> Wouldn't the natural interest of A be to maximize health costs

A, an insurance company, is the one fighting to get the cost down from B, the healthcare provider.

> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition

Monopolization is more dangerous from the healthcare provider side, though it happens both ways. Basically, insurances compete against each other at state levels, while hospitals only fight the nearest hospital, maybe.

> And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?

You can see that health insurnace companies are not really profitable. They have lower margins than auto-insurance.

> And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?

Noone has more interest than to implement national health insurnace than politicans. It's the biggest political boon plus almost unlimited spending they could get. If something like M4A passed, the state would grow in the order of 10% of GDP.

> ow would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?

By keeping at bay provision costs vs quality. In Healthcare there is something called the Iron Triangle: Access vs Quality vs Cost. If you unleash access, you need to lower quality or increase cost.

>A, an insurance company, is the one fighting to get the cost down from B, the healthcare provider.

If the healthcare cost is zero or negligible the need for insurance is also zero. You just pay it out of pockets.

The insurance company might want to lower their bills (when they do pay for your treatment), but they have a counter-incentive to health costs being lowered too much, and a positive incentive to get health costs higher for the uninsured.

> If the healthcare cost is zero or negligible the need for insurance is also zero. You just pay it out of pockets.

Tautologic, of course, the service insurance gives is precisely the individually unforeseeable cost of disease.

> The insurance company might want to lower their bills (when they do pay for your treatment), but they have a counter-incentive to health costs being lowered too much, and a positive incentive to get health costs higher for the uninsured.

The great enemy of insurance companies is direct-to-provider pay (and insurance one of the historically great political enemies of doctors as well). It's been unfortunately regulated from its inception, but its an intuitive proposition to say that insurance companies win by how efficiently they apply the actuarial model, and how they control the risks and the payouts. Insurance companies that pay more to providers and restrict less coverage of their patients will soon be out of business.

>So then if it's supposedly more efficient, why do I waste multiple hours dealing with insurance bullshit literally every few months?

It's friction costs for splitting up the decision-making process into multiple entities. For any bill, the insurance company pays $X, the patient pays $Y, and the provider has $Z in costs. The $X that the insurance company pays is what they optimize for, not $Y and certainly not $Z. This has the side effect of somewhat optimizing $Z, since $Y is limited by how much money people have and if $Z is consistently bigger than $X + $Y, the healthcare provider loses money and goes out of business.

Honestly, the way to go is to treat the entire process as interaction with hostile bureaucracy. Document everything, and look like you'll generate a regulatory incident if you don't get what you're legally entitled to. Otherwise the insurance company will happily reduce their costs by offloading it onto you or the healthcare provider through pulling bullshit stunts.

So you think if we paid more in taxes and turned all of it over to the government, the current level of beurocracy would decrease?

I’m about to graduate college and I just last week had to take an hour to learn insurance vocabulary to decide if I should go to a doctor for something. It’s disgusting how complicated it is now compared to how simple the concept of insurance initially was when it was created.

The insurance companies profit massively from the confusion they have created.

Ironically, indirect government interference.

The market is doing its job perfectly well maximizing the value defined by government constraints and influence (since govt is the largest payor).

The problem isn't the insurance, but the fact that your insurance is tied to your employer. There's reason health insurance should be treated like car, life, and home insurance. You shop for what you want and switch whenever you find something better. Unfortunately the current system is so ridiculous that most people think private insurance itself is the problem.

You can fund private insurance via taxes as well. That's not a limit to private market insurances.

But I tell you one thing that really affects why insurance sucks: that you get sweet tax exemptions if you get it through an employer, and to be an insurance that works through an employer you need to overcome massive regulatory hurdles.

Welcome to the world of regulatory capture.

I wonder if the increases in the gig economy (ride sharing, charging, food delivery) will lead to more people eligible to file these incomes as sole proprietorships, allowing them to deduct health insurance.

Even M4A includes removing the tax exemption. But it will not be popular when workers get a Marginal tax rate jump on their entire income.

That subsidy should die and healthcare should be finally decoupled from the employer. That would unleash massive market forces.

Ask your employer to pay your benefits amount in salary. That way you don’t need to change insurance when changing jobs.

I've always heard that your benefits amount at a large organization is almost certainly not enough to pay for the same benefits as an individual, because companies get group rates that you can't get.

It’s also not taxed as a medical benefit. Also, companies have to maintain certain enrollment proportions to avoid non discrimination testing, and so allowing people to take cash in lieu wouldn’t work out for employer.

> If I could choose to just pay more in taxes

One of the fallacies in play is buying insurance is put in one category. Whereas paying taxes for insurance is another. The first is 'good' because it's 'free market' and the second is 'bad' because it's the government taking your money's.

>One of the fallacies in play is buying insurance is put in one category. Whereas paying taxes for insurance is another. The first is 'good' because it's 'free market' and the second is 'bad' because it's the government taking your money's.

Well, I'm in favor of socialized healthcare and generally receptive to increased taxation, so that's definitely not the implication I was going for. But it is true that there doesn't need to be a categorical consideration at all. A more sound statement would be "I as a consumer am willing to pay dollars equal to twice my current premiums to get healthcare coverage while avoiding hassles while receiving routine healthcare"

In truth I'm not making a blanket argument for any government-run healthcare system because alleviating my pain points necessarily depends on said system being efficient and well implemented. But I KNOW that the free market isn't suddenly going to start improving on these pain points without introduction of regulations to manage issues like competing doctor networks, confusing healthcare coding and opaque pricing, etc, and I have no trust that the free market types in congress have any interest in regulations of any kind, so I personally err on the side of socialized healthcare on this one.

> A more sound statement would be "I as a consumer am willing to pay dollars equal to twice my current premiums to get healthcare coverage while avoiding hassles while receiving routine healthcare"

Ah, but are you willing to force everyone else pay twice as much so that you can get the health care you want? That's the real question. You said you were in favor of socialized healthcare, so I would guess the answer to that question is "yes", but let's at least be honest here—the private vs. public debate is never about how much you are willing to pay. Under a private system you're free to buy as much healthcare as you can afford. The point of socializing healthcare is making other people pay.

> generally receptive to increased taxation

Yes, that's the "making other people pay" part.

Right I guess you were being rhetorical then, I'm saying I'm okay with it

> are you willing to force everyone else pay twice as much

Comparisons to other (first-world) countries with socialized healthcare systems suggest that it shouldn't be necessary for everyone to pay twice as much. If everyone paid exactly the same amount as they currently do (in tax + insurance premiums) there should be plenty to fund a first-world-standard national health system.

> you're free to buy as much healthcare as you can afford

It's difficult to know what you can afford when you can't find out even an approximate price until it's over and the bill arrives.

> If everyone paid exactly the same amount as they currently do (in tax + insurance premiums) there should be plenty to fund a first-world-standard national health system.

Right. Regardless of whether health care is paid for privately or via taxes, it's obvious that the problem isn't that we're not spending enough money.

> It's difficult to know what you can afford when you can't find out even an approximate price until it's over and the bill arrives.

I agree that prices and billing should be more transparent. It's crazy that they expect you to agree to pay whatever they might choose to bill, months or years after the fact, without even the courtesy of a binding estimate. I think a good argument could be made that these are not valid contracts and you should be able to walk away from them without penalty; they only get away with this sort of borderline-fraudulent behavior because the law grants health care providers special status. This situation is not improved by changing things so that health care providers don't even need your formal consent, or any interaction at all for that matter, to bill you via the IRS, with no contractual obligation on their part to provide any services whatsoever in return.

> The point of socializing healthcare is making other people pay.

Yes. Especially you personally. Honestly, I don't even care about socialized healthcare as long as your tax rate is > 90%. Think of it as a "stupid libertarian tax".

I think most people will be in support of this measure, as hopefully it will force you to work so hard you don't have time to make inane internet comments.

What I don't get is why do you think paying 2k to a private insurance is any worse than 2k to the state.

Because the private insurance company is incentivized to optimize for profits and the state is incentivized to optimize for a healthy population.

> the state is incentivized to optimize for a healthy population.

The state is incentivized to be a political boon for politicians, not to give "healthy outcomes".

> Etc cetera. There's no end to the nuisance. If I could choose to just pay more in taxes (hell I'll pay way more than my current premiums) and never deal with insurance again, I would do it in a heartbeat.

If you have a high deductible, you already chose to pay less. Revealed preferences and all that.

I'm not sure I follow your logic.

You can choose to have less insurance hassle by choosing a more expensive insurance plan where you don't haggle for the deductible.

Sorry what do you mean haggle? This is just one of the 3 plans offered by my employer where the deductible is much bigger and the premium is lower. I did need to open a savings account but I figured that would make things easier to pay, idk haven't used it. Otherwise my behavior as a consumer has been identical. maybe I'm missing something

If your employer has a low deductible plan with a higher premium your insurance coverage issues will be a lot lower (as you could eat the copay cost instead of negotiating).

what negotiation are you talking about?

Capitalism as it exists today in the US (and other parts of the world) is a paperclip optimizer. The pressure is for those with power to leverage that power toward their maximum short term financial benefit. One consequence of this is that health care has essentially been parasitized by profit seekers who extract money from the system as if it were a strip mine. You can easily see the impact of this in the gross statistics in the form of the extremely high spending on health care in the US vs. comparatively poor return on that spending in terms of overall health outcomes. This is a corrupt system which today produces health care only as a side effect of its main purpose of wealth extraction. That is a natural consequence of our culture, economic incentives, etc. combined with the vast power imbalances between health care "providers" (hospitals, drug makers, device makers, etc.), insurance companies, employers, and individuals. There's no such thing as a patients or insurance holder union, the imbalance is enormous and there's very very little to tip it back from being dominated by the interests of the powerful.

>>> This can be done via taxes but insurance is a private market solution which should in theory make it more efficient for the sake of maximizing profit.

In reality, it's less efficient.

Efficient? For who and what purpose? Its efficient for insurance companies, and for the purpose of making money. What do you expect? Any consumer friendliness comes from regulation.

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