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PaperclipPerfector  10d ago (text post)   2619 thread views

Small-Scale Question Sunday for December 8, 2024

Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?

This is your opportunity to ask questions. No question too simple or too silly.

Culture war topics are accepted, and proposals for a better intro post are appreciated.

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Re: United Health CEO, I feel that I'm among the extreme minority of the population that thinks it's bad to celebrate political assassinations and also that it is a social good for companies to offer insurance in the US. I am astounded by how relatively unprofitable being an insurance company is and also why anyone would go into this industry and put up with the abuse and general scorn.

Imagine being at a party and saying you work at a health insurance company. Total hatred from almost everyone.

It's amazing that people do this at all?

I think the more amazing thing is that we had this huge healthcare reform and if the insurance companies were regulated before, they are hyper-regulated now, and yet almost no people pay any attention to any role the regulators play in the system. I mean for all people eager to murder healthcare CEOs, at least some percent of them should direct equal hate to their local congress-critter whose stuff literally wrote most of the rules the CEOs play by (and whose campaign is financed by the same CEO, too). Yet nobody is even trying to think in that direction and link the huge achievement of Obamacare with the present state of healthcare market. It's like they brain run on KamalaOS 1.0 - "we made absolutely no mistakes and we need to fix everything urgently!".

Also, twitter haters probably occupy much smaller part of the real world that one might think when opening twitter.

I mean for all people eager to murder healthcare CEOs, at least some percent of them should direct equal hate to their local congress-critter whose stuff literally wrote most of the rules the CEOs play by (and whose campaign is financed by the same CEO, too).

The problem is, it's not the "local congress-critter" that actually wrote the regulation, it is, as you note, their staff (I'm pretty sure that's what you meant, and "stuff" was a typo or autocorrupt). Taking out a congressman is probably harder than taking out a CEO, and it likely leaves his replacement inheriting that staff.

And you can't change things by taking out the staffers, because while they may have less physical security, it's compensated by their obscurity — first, you have to figure out who they even are. Second is their numbers — taking out just one of them won't do much. Third is their replaceability — they're even more interchangeable than politicians.

(You can't stop the Machine by popping a few expendable human cogs within it. You've got to demolish the entire institution.)

"stuff" was a typo or autocorrupt

yes

Taking out a congressman

I'm not calling to murder congresscritters, Heavens forbid (neither their staff of course). But at least we may want to discuss their part of the responsibility for the problem, if we perceive it to be the problem? Given that I would define it as "very large" - they have the means to form the system, and they formed the current system as it is now, and they have the power to change it. A single healthcare CEO could probably hire marginally better customer support, and make the rules marginally less strict, but within given regulations and 4% average profit margins, they don't have much space for a radical change.

You've got to demolish the entire institution

You mean the glorious proletarian revolution? If past experiments teach us anything, it's that proletarian healthcare is not going to be better. As somebody who experienced both, I'd like to personally confirm this.

You mean the glorious proletarian revolution?

No. Absolutely not. When I spoke of demolishing institutions, I wasn't referring to the health insurance industry, I'm referring to the institution of Congressional aides. Of "legislators" who don't actually legislate.

But at least we may want to discuss their part of the responsibility for the problem, if we perceive it to be the problem?

Why? To what end? If you want to fix the portion of the health industry problem for which Congress is responsible, you have to "fix" Congress. But, like so much of the US Federal government, the only way to "fix" Congress is to tear it out and replace it with something else. As you note, health care CEOs "don't have much space for a radical change"… and if "radical change" is what you want, the only way we're getting it is overthrowing the United States Government.

So no, I don't mean a "glorious proletarian revolution" in healthcare. The opposite direction, really. The glorious Caesarist reaction when we finally get our Augustus, who ends the Republic.

For example, nobody is angry at this guy: https://x.com/OcrazioCornPop/status/1868084582425170121 - who openly admits at passing healthcare policy by deception, and now we are witnessing the fruits of his labors. Nobody even remembers he existed - and he will be writing the next "healthcare reform", whatever it is, and one after that - or somebody who is exactly like him. Did you ever hear discussing anything about that anywhere in MSM or among those internet people that this week are all healthcare experts?

Why? To what end?

So that sometime, somewhere, somehow we could eventually learn to associate the problems we have with the people we appoint to solve those problems who instead cause even worse problems, and then maybe, just maybe, we start trying to realize maybe there's a better way to do things than just giving all the power to whoever looks most slick on TV and then murdering random rich people because it feels good. They way to solving the problem must go through at least seeing the problem, and I am observing just the opposite - a giant effort to avoid any hint of looking in the general direction of the problem.

celebrate political assassinations

Thompson wasn't a politician, so his murder doesn't fit the "political assassination" label.

Imagine being at a party and saying you work at a health insurance company. Total hatred from almost everyone.

"Yeah, I'm stuck working for Health Insurance Co right now, it sucks- know anywhere hiring [for skillset X]?" got me sympathy and suggestions. Granted, I wasn't claims or legal, but I know people who've worked in both and it's not the social penalty you'd expect from redditors, at least in Alabama. Similarly, someone can mention having an investment property and there isn't frothing at the mouth.

yes, if you completely disavow your work you can salvage it

still not an appealing call to join the industry!

Mistake not Twitter outrage for consensus.

This particular incident is getting a level of coverage that I, too, find unsavory. The posts exist because people want to be edgy; they get signal-boosted because it’s a slow news week. Compare reports about mass shooters, who receive unwarranted fascination even when their manifestos are objectively stupid.

is and also why anyone would go into this industry and put up with the abuse and general scorn.

There are a quite a few industries like that. Working in finance, oil/energy, certain tech companies like Palantir will involve large numbers of people thinking you're selling your soul to an evil cause. I think the answer is simply that most people will take jobs that pay them well, or offer some other form of professional advancement.

The assassination isn’t celebrated online because he worked in insurance, or because he worked in health insurance specifically, but because the company is accused of violating a life-or-death contractual commitment by “delaying” and “denying” the promised coverage, in order to extract money from people who are sick and dying. This was literally written on the bullets (now stained with the CEO’s blood), based on a title of a book about these practices. The salary, industry, etc are all side points. United was apparently the worst offender in the industry. Read the exchanges between Vinay Prasad and the numerous doctors who disagree with him and single out United as the worst offender.

A thought experiment is helpful here. Let’s say you and I become stranded on an island. I promise to hold the heavy medical supplies in case one of us is injured, and in turn you provide me with more of your rations. You gash your leg, and I renege on my commitment to provide you the promised medical supplies. If you have a weapon, what would you do? The ethical intuition of normal people is that certain things become permissible.

Now, the greatness of civilization is that you don’t need to resort to weapons because you can take a large company to court. But that’s not a silver bullet! Because our third bullet reads defend: healthcare companies can hire the best lawyers and lobby better then you. So it’s an open question whether today’s civilization provides a remedy that is sufficient to stop someone from taking the less civilized remedy. It seems most people have no problem with the less civilized remedy in this particular, very unusual instance.

Yes I understand why the general public is mad, and bloodthirsty, and titillated.

I am in the minority because I also have the curse of basic education in economics and also have worked in a different financial services industry that was widely hated, but from the inside it was clear that most of the hatred was based on magical thinking and ignorance.

They might actually be evil! But my default is to not trust these narratives.

In The Rainmaker, the villain is a CEO of a health insurance company who sells door-to-door and then denies delays defends. It culminates in a court scene where they read from the real secret manual that states their policy to initially deny every claim. What I got from it is that the incentives of the insurance business, and health insurance in particular, are horrendous. Nowhere else do we give ruthless people a nice, clear, legal chance to fuck us over for hundreds of thousands of dollars. Of course it’s immoral, but I would argue it’s also immoral to tempt your fellow man like that. And stupid.

It’s like feeding a wild beast scraps of meat for years, and then, when he’s grown to terrifying proportions, you walk into his cage and announce that not only won’t he be getting any meat going forward, but you expect him to give you most of his food now. The real question is why anyone is naive enough to expect anything but immediate disembowelment and consumption.

It culminates in a court scene where they read from the real secret manual that states their policy to initially deny every claim.

That's a movie though. No real world insurance company has such policy. Or any "secret manual" at all - how would they even keep it secret? Would they murder their ex-employees? Wipe their memories? Relocate them to the remote uninhabited islands? US Government can't keep secrets. US Army can't keep secrets. How can you expect that a "secret" policy which literally every adjuster should be familiar with - otherwise how could they deny every claim? - would be kept? Movies are fun, but they are also fiction.

Of course it’s fiction. But unlike countless other movies where the CEO sends an assassin after the hero, I find this one’s motive, means and opportunities frighteningly realistic.

As to the detail of the secret manual, I don’t find it that far-fetched. In my experience of the professional world, a lot of shit of questionable legality and morality goes on, but people have mouths to feed and everyone’s doing it, so they just get on with it. I’ve observed that most people, if their boss tells them to lie or to ignore a tax the company should pay, they do it without fuss. I'm not sure they'd put it in a manual though.

if their boss tells them to lie or to ignore a tax the company should pay, they do it without fuss.

Sure, that can happen. However, if the boss had a manual, given to every single employee that joins the company, that instructs, black on white, to not pay taxes and lie to the IRS - wouldn't you expect at least one disgruntled employee over the years to send it to the IRS (or, alternatively, the local anti-corporate crusader) and the boss get in trouble? Unethical orders are often given verbally exactly because it leaves no proof and provides plausible deniability - "I didn't mean that, he just misunderstood me!".

Government can't keep secrets. US Army can't keep secrets.

Not that I disagree with your main point, but this is only true for a given value of "can't". We didn't find out about Rachel Levine putting pressure on the WPATH to remove minimum ages for gender affirming treatments, in violation of their own procedures, because some good soul either in WPATH or in the Public Health Service decided to squeal, we found out about it through a set of improbable events that culminated in the Attorney General of Alabama getting access to internal WPATH emails.

This is without going in to more obvious things like: you can't know about secrets that stayed secret.

Sure, I don't claim every secret will be promptly revealed. I claim a secret of this magnitude - existence of a secret manual which is given to every claim adjuster in the insurance company, and plainly states every claim must be denied - is very unlikely to survive for long. I'm sure there are secrets - probably very dirty secrets - that do survive, but they are probably not as widely known and as easy to reveal.

The problem is that they get blame that ought to go to the medical system generally.

Why is heterosexual Bill paying for homosexual Joe's PREP? Why is thin Larry paying for fat Pete? It's another instance of the social contract meme: https://x.com/kunley_drukpa/status/1858551504073834615

Thin Larry pays for fat Pete just as fat Pete pays for him. Perhaps less, since premiums might have some correlation with health.

Slicing the categories arbitrarily fine just destroys what advantages insurance actually provides.

I agree with your opinions regarding violence. However I think the issue with insurance is when it becomes mandatory or defacto mandatory, because then you lose proper economic controls on the price via supply and demand. Demand for car insurance is artificially inflated by it being literally illegal to drive a vehicle without it. Demand for health insurance is artificially inflated by regulations requiring companies to provide it to employees, and tax penalties for private individuals who don't have any. Therefore, prices artificially inflate. (Similarly, healthcare prices are artificially inflated by regulations requiring severely limited-supply medical degrees).

Now, these regulations exist for reasons, but that doesn't undo the economic damage this causes to people. And then all the perverse incentives with their battles against healthcare providers and customers creates tons of paperwork and principal agent problems. I am wholeheartedly convinced that the existence of insurance companies and their role in our society is uniquely responsible for healthcare prices in the U.S. Now, this isn't necessarily the fault of the CEOs, it's really the politicians who created this niche, but I definitely understand the anger people have for them.

Theoretically insurance could be a useful and legitimate service. But that requires it be voluntary so that people can choose of their own free will whether they think it's worth the cost or not, which in turn forces companies to provide a product worth paying for. Just like with every other good and service. The current system is extortion with extra steps.

However I think the issue with insurance is when it becomes mandatory or defacto mandatory, because then you lose proper economic controls on the price via supply and demand.

Failure to consume food is much more quickly and reliably fatal than failure to buy health insurance, and that market works fine. It just isn't true that supply and demand don't apply to necessities. I may have to buy food, but as long as I don't have to buy from you, you're not going to have much luck selling me potatoes for $10/pound.

The bigger problem is just that health care is really expensive. Supply constraints may play an important role here: The US just doesn't have enough doctors. Coverage mandates may be another issue. The government mandates coverage for treatment x, which adds $y to the premium. How many consumers, when fully informed, would a priori actually be willing to pay an extra $y per year for x to be covered?

Lack of price transparency is another issue. Lack of competition among insurers may be an issue, but insurer profit margins are pretty small, so it's likely a minor issue.

Coverage mandates may be another issue. The government mandates coverage for treatment x, which adds $y to the premium. How many consumers, when fully informed, would a priori actually be willing to pay an extra $y per year for x to be covered?

I think this is part of what I mean about it being mandatory. It's not just that the government forces you and/or employers to buy some sort of insurance, but also that insurance has to have certain properties, which if applied universally across all of them prevents competition by undercutting.

So perhaps the analogy would be if all foods sold must contain at least 2% caviar by weight. The store is going to sell potatoes for $10 per pound because they have to in order to cover the costs of the caviar that comes with it, and they can't be undercut because all the other stores have similar prices for the same reason. Maybe I decide to forgo potatoes and buy carrots instead, but those come with caviar too. It's only 2% of your diet, but it ends up being a much larger percent of your budget.

I do agree with your other points about things contributing to the cause. Lack of price transparency is also an issue (although the latter is tied to the role insurance companies paid, since they're the ones paying rather than customers, leading to principal agent problems). But if it was normal for the majority of people to not have health insurance then there would be strong pressures for more transparent prices and I think that issue would resolve itself.

Regulations requiring overly limited medical degrees is also an issue that this would not resolve. Although is similarly the government's fault.

Demand for car insurance is artificially inflated by it being literally illegal to drive a vehicle without it.

That's not true, at least in some states, like CA. You can post a self-insurance bond instead. Virtually nobody does that because for most people it doesn't make any financial sense.

I am wholeheartedly convinced that the existence of insurance companies and their role in our society is uniquely responsible for healthcare prices in the U.S. Now, this isn't necessarily the fault of the CEOs, it's really the politicians who created this niche, but I definitely understand the anger people have for them.

That scans. Private insurance is actually aligned with medical care becoming an ever bigger proportion of GDP. They want premiums to go up, so long as they all go up at the same time.

Yeah, it's bizarre. Why would people sign up to be a scapegoat?

The same logic applies for the people who run Comcast, the DMV, TSA, or other hated organizations. It's an impossible job. The people in charge are operating within the constraints of a system designed to fail.

Naturally, the CEO was never really a member of the elite. He was more like a middle-class midwesterner who did well from himself.

Thompson was born in Ames, Iowa, and received a bachelor of business administration with a major in accounting at the University of Iowa in 1997. From then until 2004, Thompson was a manager at PwC, then moved to UnitedHealth Group, becoming the CEO of their UnitedHealthcare unit in 2021.

This whole episode has convinced me that the average person is not just stupid but evil as well. They'd be more than happy to line their enemies up against the wall if they ever had the opportunity to, just like they burned witches 500 years ago.

The line separating good and evil passes not through states, nor between classes, nor between political parties either – but right through every human heart.

Unfortunately, certain modern things like social network tend to highlight and incentivize the evil side. I mean, for me it'd be weird to parade my evil side publicly, under my own name, for all to see. But it looks like for a real lot of people, it's something they would eagerly do. Let's not kid ourselves - everybody has this monster somewhere inside them. Though not everybody lets it roam in public.

It is a very important job. Somebody has to tell doctors and patients no. That said, I sure wouldn’t want to do it.

I think it is hypothetically possible for a health insurance CEO to be so cartoonishly evil that murdering him on the street becomes ethically justified. I haven’t seen the evidence yet. I assume if it existed it would be plastered all over the internet.

It is a very important job. Somebody has to tell doctors and patients no.

And, empirically, making that a for profit middleman who gets to keep the money when he says no works badly. There is a reason why self-insured employer plans are the majority of the private market, and the insurers with the best reputation are provider co-ops (like Kaiser) or non-profits (like most of the BCBS affiliates).

The situation in the UK is different because private insurance is a top-up to the NHS, but once you exclude self-insured employer plans the biggest non-profit insurer is sufficiently dominant that "BUPA" is used as a generic term for private healthcare in the same way as "Hoover" or "Xerox".

I assume if it existed it would be plastered all over the internet.

Have you been looking at the same internet I have? I haven't done the rigorous fact-checking yet, but nurses and other health workers were ostensibly celebrating what happened. The stories I've seen were that his health company denied twice as many complaints as the industry average, had a kick-back arrangement of some kind with an epilepsy drug manufacturer which meant they forced doctors to hand out medicine that they knew wouldn't work before approving anything that would and that this ceo approved an AI/algorithm with a 91% error rate to deny claims.

I hadn't seen any of those stories yet. The last is particularly interesting. I will Google it but a link from you may be nice too.

The problem with complaints about claim denial rates are that all insurers in America make more money the more claims they approve. They are only allowed to make a specified margin between premiums and claims.

There are only two "evil" reasons to deny claims:

  • Fewer approvals mean lower premiums. In any market with competition (not many in the US) then UHC can be cheaper
  • Denying Claims lowers administrative costs somehow and allows a greater allocation of margin to profit

They are only allowed to make a specified margin between premiums and claims.

If they've already reached their statutory minimum of 85% of premiums collected paid out in claims, doesn't paying additional claims reduce profits? I can see how there's a global incentive for all insurers to pay more claims in general, so that they stimulate cost growth in health care and premiums have to go up overall, but at some point they have to try to stop paying claims to cover admin and shareholder returns.

If they've already reached their statutory minimum of 85% of premiums collected paid out in claims, doesn't paying additional claims reduce profits?

For a given year? Yes. Then, the next year, they will destroy and recreate the plans with higher premiums.

at some point they have to try to stop paying claims to cover admin and shareholder returns

This is true, and I'd be interested to see how claim denial rates line up with a given FY cycle. They could be just vastly incompetent, making all of their customers hate them for no reason by being unable to predict claim demand, even with the vast swaths of data they have.

More likely though, it has to do with being lower price in any competitive market. After all - consumers generally don't see the premiums, but do see the denials. They may be making another $3k a year because their employer saved money on health insurance, but that's rarely transparent to an employee.

This is true, and I'd be interested to see how claim denial rates line up with a given FY cycle. They could be just vastly incompetent, making all of their customers hate them for no reason by being unable to predict claim demand, even with the vast swaths of data they have.

I am very curious about this as well.

Though comparing claims denial rates between insurance companies isn't useful without more context? It's true Kaiser has a denial rate of 7%, but aren't they famously (though not exclusively) an HMO? 7% seems low, if you ignore the fact that (pulling this out of my ass) 99% of medical providers are not allowed.

Do you have a cite for the epilepsy thing? I'm not able to find anything.

AI/Algorithm ... deny claims

This sounds bad but the details are too short for me to judge with.

FWIW the case is still pending but UHC argues that it was not used for coverage decisions. The Stat News article which describes it in detail is paywalled, but here's Ars for a teaser

https://arstechnica.com/health/2023/11/ai-with-90-error-rate-forces-elderly-out-of-rehab-nursing-homes-suit-claims/

Also, sorry for the look but I was wrong - it isn't epilepsy drugs but seizure drugs.

https://old.reddit.com/r/nursing/comments/1h6hm17/unitedhealth_ceo_attacked/m0epbzz/

Reading this article makes it sound even worse than I thought when I first heard about it, and by the time I got to the end of it I supported the assassin more than I did at first.

I used to work on Wall Street and every time an article was written about something nefarious we were supposedly doing, it was so incredibly wrong and ill informed that it burned me out on investigative reporting. Doubly so if it's about an unpopular industry.

My knee jerk reaction in the situation, as someone who really doesn't understand the health care business, is to remain skeptical.

I'll probably have to wait six years for the court case to work itself out before I draw conclusions.

I'm willing to infuriate my colleagues by supporting insurance companies at times. For instance insurance companies increase documentation burden on us to make sure we don't over bill. It's annoying trying to keep track of the constant web of changing requirements here...but they do it because there are unethical doctors who would take advantage and up code everything. Every year medicare finds someone who does this and comes down on them.

However a lot of what happens is comically unethical, with united being one of the worst.

Dr. Glaucomflecken, (the one good medfluencer) has a story of how he died at home (cardiac arrest), and had to spend nearly a year after his resuscitation trying to get United to pay for the hospital stay because he didn't take the right ambulance. While he was dead with his wife manually pumping his heart.

Another common thing that happens is that insurance companies will randomly deny things. If I bother to schedule an appeal they will usaully decide to cover, but they know we are busy so if they randomly deny a good number of things will be dropped. Especially cheap drugs - sometimes it's easier to send the patient to Walmart and cash pay than fight the insurance company. I have a limited amount of time. They abuse this. When they do decide to fight your "peer to peer" review is generally with someone in another specialty who retired 40 years ago and has no idea what the actual standard of care is.

They effectively practice medicine by controlling the purse strings but are able to avoid the scrutiny that should come with that by claiming they are not in charge.

If you go on meddit you'll see weekly threads complaining with horrifying examples. Not all of it seems to make sense, for instance they'll refuse to cover rehab stay for a patient and suggest they stay in the hospital instead, hoping that the person will improve enough to be sent home instead. This is a risky gamble that I'm sure works actuarially, but the human cost is somebody's grandma getting a hospital acquired infection and dying and because the rehab stay wasn't covered in time and she wasn't safe to go home with a broken hip.

You'll see asinine stuff like "get an x-ray" "we already have a CT that shows the finding, and is more reliable" "my algorithm says you need an X-ray" "so you want to expose the patient to more radiation for now reason" "it says I have to."

"You said the patient is sick, according to my documentation you need to edit the note to say the patient is ill" (in this example replace sick/ill with specific interchangeable technical terms).

Another classic is that their exists a number of inhaler products for disease like asthma. They are all mostly equivalent and very expensive. Each year, or quarter, the insurance changes what they cover (some have speculated kickbacks are involved). They don't make this obvious. So suddenly the patient goes for a refill and has a massive bill and then we have to spend a bunch of time switching agents and hopefully getting good clinical effect...

Now everybody does this stuff but somehow United is appreciably worse.

Thanks for the reply!

In general, reading about this is fascinating to me. It sounds like an arms race and like providers can get an edge if they have research and analytics firms (or departments) staying on top of this stuff and helping them route through each company's bureaucracy.

Another common thing that happens is that insurance companies will randomly deny things. If I bother to schedule an appeal they will usaully decide to cover, but they know we are busy so if they randomly deny a good number of things will be dropped. Especially cheap drugs - sometimes it's easier to send the patient to Walmart and cash pay than fight the insurance company. I have a limited amount of time. They abuse this. When they do decide to fight your "peer to peer" review is generally with someone in another specialty who retired 40 years ago and has no idea what the actual standard of care is.

This sounds like a class action lawsuit waiting to happen so I'm surprised they do it, but maybe I'm naive about the wheels of justice.

Now everybody does this stuff but somehow United is appreciably worse.

Are they better or worse than Medicaid?

Few providers in my area take Medicaid, and the ones that do have very long waits to see. I understand it's because they have pitifully low reimbursements but also have high claims denial rates.

Oooh! Wait! One more, one more!

The insurance landscape in Hawaii is famously bad, they'd rather fly patients to another island and put them in a hotel room for multiple days than pay a fair wage to specialists on whichever island the patient was coming from. Now I'm sure the negotiating math makes sense such that this is ultimately the better decision. It is also insane.

The insurance industry lobby is extremely profitable and has excellent PR, they are very good at turning people against doctors for instance. See this discussion on Meddit for example: https://old.reddit.com/r/medicine/comments/1h9lli9/the_vast_majority_of_us_excess_healthcare/

They have a large number of loop holes they can use "we aren't practicing medicine, you are practicing medicine, you recommend what you feel the patient needs, we just won't pay for it" is the most famous example. Another common one is using the reviewers as liability sponges. I haven't worked in this environment so I don't know how it works exactly (and nobody is willing to admit to it haha) but I suspect they make it understood somehow that you need to deny a certain number of claims, and then fire you if you don't, then if regulators look they fire the reviewers and claim they were bad actors. Proving systemic malfeasance is challenging.

Pharma and insurance are absurdly profitable and influential, and again they both are very adroit at blaming other aspects of the system. See me banging my drum every time someone complains about physician salaries or the "AMA cartel" those are distracters from the real villains and not really part of the problem.

Medicare and Medicaid are both also awful but generally for different reasons. They are government entities so you can imagine how pleasant they are to work with. They still have deals with manufacturers that are almost always to the manufacturers benefit and very confusing but are more above board more or less because it's directly from the government. You also get weird stuff like instead of prior-authorization you may get an audit afterwards that decides if what you actually did was justified and then you get paid or not paid accordingly. Miss a new rule that requires you to document X required thing? Guess your practice or department is in the red. With private insurance you can at least try and adjust in advance.

The bigger problem is that they are often below cost. You'll have to forgive me on the numbers because it's been a few years since I looked this up, but it's something like Medicaid pays .8, Medicare pays .85, and private pays 1.1-1.2 times cost.

If you have a payor mix of mostly public insurance, you go out of business or require bailouts. Hahnemann University Hospital went under a few years ago mostly because of this and that caused huge problems (it had the most residents of any health system).

This also results in some services flat out not being offered anymore in a non-emergency setting, or things like public insurance not being taken.

If you see a doctor who is willingly taking Medicaid/Medicare (usually they are taking it because they are employees of a health system and the system takes it, often because of government funding or legal requirements) that means they are deliberately taking a pay cut to help people (which happens a lot because of martyr complexes) or have some way they are abusing the system (which can actually be legal and fairly harmless but isn't always).

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My redpill was all the stories about how white the tech industry is.

If your only tool is a hammer, everything is a nail...

I'm still not sure what makes socialized or single-payer systems inherently less cruel. They are rationing care too? Not only do they have longer waits, but from what I can tell the providers often follow the government's story: you have abdominal cancer? So sorry. It's fatal. Consider assisted suicide.

At no point is the patient informed that you can actually do a long shot treatment for this, and it's very expensive. And it's only available in the US.

Canada performs 14,000 assisted suicides a year. Are we really sure all of those persons have terminal illnesses? Or is the same cold hearted private health care denial of payment still there, but translated into denial of all hope as well?

I'm not even sure it's wrong! If a patient has a cancer with a very bad prognosis and the treatments are expensive and kind of grim, it might actually be better to lie to them and say they're fucked instead of telling them to try to raise $200,000 in a few months and maybe you have a small chance at surviving.

But I hardly ever see socialism enjoyers acknowledging that this is the system they plan to build. They just smugly declare that in our system all receive treatment regardless of means.

Yep.

Healthcare in the U.S. is comically complicated, expensive, and frustrating - with an intense human cost in what we do to the people who work in it.

In return we get best in the world access to care, immense human capital investment, the highest quality of care in the world (both for the poor and even more so for the rich - outcome problems are driven by our poor health in the country aka obesity). In addition because of the amount of profit available we do a huge portion of the world's research.

When people talk reforming the system they almost always propose things that are sure to break one of those pillars (like introducing rationing) with much more questionable ability to actually decrease costs.

much more questionable ability to actually decrease costs.

Funny, I was pretty gung-ho about M4A until I read that Elizabeth Warren's own research she linked which showed how meager the efficiency wins would be. Surely the system is super expensive because it's very weakly coordinated! but apparently single-payer's biggest crusader doesn't think so?

I think cost disease in general teaches me we aren't going to improve the cost side of the system with M4A. Too many bad actors and hands reaching into the till. If I was god, or failing that a dictator, I could probably do it (with appropriate subject matter experts obviously). But nobody is, so zero chance of that happening.

A good example is physician salaries. Obviously I care about this because I'm a doctor and want to get paid, but a lot of people want to crash MD salaries as much as possible, it will be one of the first things that happens when M4A inevitably happens. It also doesn't do much to help costs because MD salaries aren't a major driving factor. However you'll get a dramatic reduction in quality and shortages as people flee the field. A lot of nurses retired from bedside nursing because of a lawsuit result that was totally justified and wouldn't negatively impact nurses at all, they just didn't like the vibes. The jobs are so miserable that people are champing at the bit to leave and cutting salaries drastically is only going to hasten that.

And that's just one specific line item in the many catastrophes that would inevitably happen.

There are plenty of things we can do to improve things without crashing the system however. Tort reform is the obvious example. You don't even need to remove the ability to sue, just put in expert juries (and that doesn't need to be all doctors) instead. As it is now you can follow the standard of care and still be sued for all that you are worth. The protection isn't to never make a mistake, because you can still get sued for not making a mistake, instead its to provide the "safest" care possible which is super expensive and can actually be a negative for patients (unnecessary imaging leads to increase in lifetime cancer risk but is hard to sue over thirty years later).

Fix the things that are actually fixable first and see how stuff looks.

Make all insurance functionally non-profits, cap administrative salaries, etc as another example

I don't know that health insurance is particularly unprofitable. Profit margins can be misleading, because they're a percentage of revenue. With health insurance, it's easy to take in huge revenues, because you get thousands or even tens of thousands of dollars per customer every year. It's one of the highest-revenue industries there is. Of course, you also have to spend a ton of money. But due to the high revenues, a health insurer can have large profits with a small profit margin.

Also, profits go to the shareholders. Maybe there is a wage premium for employees.

Not to dispute the broader point, which is that insurers provide an important service. The irrationality of the public puts them in a bad position. The public wants low premiums, low deductibles, and unlimited coverage, and they will always side with providers over insurers. There's no good way to satisfy them.

But due to the high revenues, a health insurer can have large profits with a small profit margin.

don't they have high capital requirements and aren't they also required to rebate excess premiums if they spend less than 85% of it on benefits?

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