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Comment by NikolaNovak | Hacker News Reader

I know this is a low-quality comment, but this may be the #1 thing Hacker News has taught me over the last decade: USA health/insurance system is an Orwelian nightmare multiplied by a hundred. No straight-up evil guy with a vision and mission statement could imagine and successfully implement something as brutal as apparently we've systemically created ourselves through a million small steps.

I'm a bright guy but I don't know how I'd live with the cognitive workload, stress and uncertainty over having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything). More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".

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>> I'm a bright guy but I don't know how I'd live with the cognitive workload, stress and uncertainty over having to deal with all of this (the networks, the uncertainty over price and bills, the bills coming for weeks and months after care, the myriad involved parties, the rules and limits and interpretations and just... everything).

When you have a real issue, it takes hundreds of hours to deal with it. Smart employers know that this eventually comes out of company time and productivity, esp since most of these calls need to take place during business hours.

Smart employers will advertise "100% paid health plans, etc, etc."

Penny-wise employers, even white-collar jobs/offices, will often provide the bare-minimum coverage, and pretend it has no effect. Except it does. You can see it when your cubicle-neighbor is on a 2hr call with insurance, etc. I've had colleagues who will block a 4hr meeting on their calendar titled "calling insurance companies to figure out bills" as open protest. I've had people in the office just spend a day or two on the phone with doctors' offices, visible, both out of desperation and as a subtle form of protest for the organization's choices in health plans.

Health insurance tied to employment is the second biggest scam in American history after Reaganomics. It forces people to stay in crappy jobs to maintain coverage and fucks with collective bargaining rights.

We need universal, single payer healthcare.

> Health insurance tied to employment is the second biggest scam in American history after Reaganomics.

And yet, sadly, even the "liberals" push for tying it to employment.

Mostly the liberals. In 2008 Mitt Romney pushed for ending the favorable tax treatment of employer-based plans (https://www.commonwealthfund.org/publications/fund-reports/2...), which was instantly attacked by the left for "taking away your insurance". Then the ACA set up the marketplace for individual plans which was good, but also inexplicably added employer mandates.

It's the same problem as ending subsidies for higher education and tax deduction of mortgages. In the long run it might be the right thing to do, but in the short term, without offsetting factors, it would cause measurable harm beyond what we should be comfortable tolerating.

It started as a reaction to a market distortion during/after WWII. There was a government-imposed salary cap during the war (Stabilization Act of 1942), so private companies had to get creative to attract talent. One thing that stuck was offering additional health insurance to employees. The rest is history.

Further reading: https://www.chicagotribune.com/opinion/commentary/ct-obamaca...

If universal healthcare was adopted during the Truman administration, wonder what employers would move on to as their major bargaining chip to woo talent.

> More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".

Nobody says that, and no one proposed the current system as is, either. Its not even a conscious, mutually unsatisfactory, compromise between competing visions, its simply the current state of an ongoing battle between multiple radically opposed views in a political system which is not good at resolving disputes of this kind, where some elements are successful attempts at implementing sabotage of broader components with the hope that the resulting failure will help politically support a conpletely different design.

>> More to the point, I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".

1. Many of the most painful core issues dont manifest until you have a real issue. So people assume it will work for them, until it does not.

2. There is so much money being made on the other side that there is a huge push for lobbying to keep the system in place.

> I don't understand how anybody, on any party or political spectrum, can say "Yup... this is a reasonable system that helps people and needs no change".

The commonality between this and (including, but not limited to) homelessness is that the tragedy is laundered into political ammunition used against their opponents in the next election. I dislike the trite expression "Don't let a good tragedy go to waste", but I'll say it to preempt the reply. But it's true: if you can't use human suffering (denied medical coverage | no place to live) to attack your party's enemy, you are less powerful as a candidate.

The other factor is lobbying. These companies (just like in many other industries) have US congress bought and paid for. The suffering aspect keeps people distracted and divided, so we never really hear about campaigns to end lobbying (because it would apply to both major political parties). Instead we joke about it and roll our eyes at how ridiculous it is (but still told to "get out and VOTE!" as if that somehow matters). My opinion is that it should go beyond financial contributions. Industry and trade groups should not have access to congress at all, it should be citizens only.

My wife is very effective contacting insurance companies and getting our claims approved. She spends hours on the phone but we usually get our way. This requires understanding our benefts, the CPT codes and denial reasons. She used to do this working for a high net wealth family office for the entire family's medical expenses.

We were trying to think of a way that she could offer this skill as a service for people. It would require some difficulties with HIPAA, but I think there is a opportunity here to help people.

It's a low-quality comment but no worse than every other comment in this thread that similarly indicates zero understanding of how insurance actually works.

Your claims are paid with the money collected from your, and other members', premiums. Everyone wants insurance that covers every single claim with few questions or limits, but that insurance company would quickly have to make the choice between dramatically increasing premiums or going out of business.

Every time a government entity mandates that insurance plans cover additional services, the cost of care goes up and subsequently so do premiums. When premiums go up, people / businesses shart shopping around and leave the pool, meaning the risk is spread out among even fewer (likely sicker) people and the premiums go up even more.

The alternative is just having everyone in one giant "single payer" pool so risk is minimized, with participation mandatory. Then, that entity (government probably) would just pay all the claims because in theory there would be less incentive to watch the bottom line. In reality, we've already tried this: Medicare is the largest single-payer health insurance system in the world, plus we have 50 Medicaid single-payer systems at the state level and additional single-payer systems at the federal level (Tri-Care and VA benefits). All of these systems face the same fiscal challenges and have been implementing every cost control measure they can think of for the past 2 decades. Medicare has been trying to move from Fee For Service (FFS) to outcome-based reimbursement for a long time now.

Those of us who know, know: the problem is COST in the system. Healthcare is EXPENSIVE.

I don't think that government-run health insurance (i.e. Medicare, Medicaids, Tricare) == "single-payer" healthcare system, especially in terms of the effects described by the parent comment.

My perspective is being under Tricare. You can imagine it like a closed system in which Tricare beneficiaries just go to Military Treatment Facilities (Defense Health Agency and service-run hospitals and clinics) for everything, and everything done in those facilities is covered with no questions asked and no bills or money changing hands. But that isn't how it works in practice. A large amount of stuff, like most specialty care, gets referred to places "out in town" (at local, for-profit, civilian providers). Most ER and urgent care visits happen out in town. At times, my wife and kids have been on Tricare Select which works like a PPO and involves all the usual discussions about who does or doesn't take Tricare, in-network or out-of-network, whether something needs pre-authorization or not, why a claim has been denied and how to appeal it, whether we've reached our annual deductible or catastrophic cap, etc.

So under Tricare, I think I feel more protected from profit-driven shenanigans and expensive mistakes than most Americans, but there's still a "cognitive workload, stress and uncertainty." I think a true single-payer system means that you don't have this (because it works like the closed system described above).

These are all fair points.

My sense is that Americans are equal parts traumatized by our healthcare system(s) and under-educated about how it works in other countries. We hear about how the rest of the developed world has had socialized medicine for 80 years and just assume that means you can go to any doctor, for any reason, anywhere, and get unlimited care with no cost sharing.

In reality it doesn't work like that anywhere. As you described well, certainly Tricare doesn't work like that, and neither does VA, Medicaid, Medicare, the NY Essential Plan, the UK NHS, or the Canadian provincial health systems. Every system has cost controls in place and almost all are facing fiscal pressures to implement more. Care is rationed with deductibles, coinsurance, waiting lists, limits on covered services, hybrid public-private managed care plans that implement closed networks, and so on. Not to mention the fact that when other countries' governments artificially limit what can be charged for certain drugs, equipment, and services, they're often doing so under a de-facto subsidy by the US government and the US healthcare industry. This is because so many of these innovations are made by US companies; the cost of care is meant to recoup the development expense. The less these companies can earn worldwide to recoup expenses, the more that cost is passed on to US rate-payers and to the US government (read: US taxpayers) in the form of grants and other transfers of money from government.

I worked with some coworkers who emigrated to the USA a few years back. They all shared similar fears about the US Healthcare system. Once we showed them how it worked, how to use our insurance company's website, and how to confirm that services were authorized they had no real problems.

HN, Reddit, and the rest of the internet have become really good at sharing horror stories, but increasingly many of those horror stories are either misleading or based on old laws that no longer apply. A popular trick on Reddit is for people to post the part of their bill that goes from their provider to the insurance company and say "This is how much it costs to have a baby in the United States!". However, nobody actually pays the amount that gets billed to the insurance company. They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.

We even recently had new laws against surprise billing, which plugs many of the holes that created those horror stories about going into a hospital and discovering you were out of network after the fact. Technically there are still holes where this can happen, but if you look carefully most of the horror stories online are from many years ago.

Is the system perfect? Of course not. However, in practice people aren't going bankrupt every time they go to the doctor like you'd think from Reddit posts. When it comes to pre-authorizations, these tend to get negotiated between your doctor's office and the insurance company. Doctors offices know how to push pre-authorizations through if they want to put in the effort, but many some will shrug it off because it's not billable time for them.

> However, nobody actually pays the amount that gets billed to the insurance company...

While mostly true, the system always strikes me as insane when I see the amounts billed to my insurer alongside the amounts "allowed" or paid by my insurer (or paid by me until we hit the deductible). I'm talking about the negotiated rates, I guess, not even co-pays. I regularly see things like $8,889 billed and $149 "allowed."

Thanks, but more money isn't worth the stress of dealing with that bullshit. I'm not moving one inch from Europe.

Especially, I have no interest whatsoever in having my health insurance tied to my job.

> They pay an amount determined by their insurance deductible, co-pay, and out of pocket maximum. Once you go past the out of pocket maximum for a year, everything is covered 100% in network.

You know how much deductible, co-pay, and so forth we paid for my father's 3 month long stay in the ICU with leukemia and chemotherapy? $0.

I recently emigrated to the USA and I hate the healthcare system here. It feels like the system is we tie everyone down to train tracks, then we hire someone to semaphore to the conductor to pull the brakes just in time. Most of the time, for people who can afford a good signaler, the locomotive stops a few inches before it turns them into strawberry jelly, so no-harm no-foul, the system works?

The signaler, conductor and roper all work for different faceless corporations constantly trying to screw each other and/or you though, the semaphore language is so complicated no human being can speak it, and the message in it can't be known until the locomotive is a few hundred feet away though. You can only choose 1 of 2 options for every role too, so everyone involved is terrible.

Sure we closed some of the loopholes where the locomotive could start again after braking, or the signaler could refuse to do their job because the brakes were offbrand. Really though what I'd like is to just not be in mortal peril at all, which is not the same thing as barely avoiding getting liquified by a steel behemoth by a complex confluence of forces beyond my control.

What about the 5 million people in my state who don’t have health insurance? Should they be worried about their medical needs?

If you study the history of how the system came to be, it turns out to be a combination of: Drs like money, and (like most things in the US) racism.

The reality for people with a well paid white collar job or a union or that work for the government or a non profit or in healthcare is that everything is fine. The employer pays for 100% of the premium. With insurance like Kaiser you pay your copay and that is all. Everyone at Kaiser in network, most directly employed, no surprise billing. Pre auths are easy when everything is in network. Your out of pocket max is as low as $2k.

Thankfully, the ACA made insurance mandatory for everyone. Not only do we have a garbage system, we're obliged to participate in it.

1. You have always participated in it, regardless of whether or not you pay an insurer.

2. There are no penalties for not having insurance, that part of the ACA has been torpedoed.

3. The people who torpedoed it have no intentions of fixing a damn thing about this country's medical system.

This is sarcasm, right? The individual mandate was struck down.

In my opinion, this was a brilliant strategic move by those opposed because it guarantees the eventual financial inviability of all of the ACA. Decreasing the size of the risk pool by allowing people to opt out will guarantee that it won't work long-term.

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