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I strongly question the insurance-based model for healthcare expenses.
One of the things that makes insurance work is that most people never need to use it. Life insurance stops being a thing (in almost all cases) when people retire - and most people make it to retirement. Car and home insurance are things most people pay for every year and yet use maybe once in a lifetime. Many people go on vacation every year for almost their entire lives and yet never file a single travel insurance claim. One third of physicians have been sued according to malpractice claim firms, but this is across a 40-year career - perhaps one in every sixty or seventy years as a doctor will they be (on average) required to use their malpractice insurance, if that. Most ships never sink. Most buildings never burn down. Most planes never crash.
Health insurance is different.
Many Americans, especially in old age, file health insurance claims most or all years. This is not what the classic insurance model is designed for, especially given the cost of some healthcare, which is why the US has created so many ‘workarounds’ that twist the provision of insurance to ameliorate the fundamental fact that health insurance makes no sense. These include Medicare (for a certain vast class of people no insurer could afford to insure) and Medicaid (for another vast class of people no insurer could afford to insure, just for a different reason). It’s why employers have to contribute to health insurance as a stealth tax, because otherwise many people would not be able to afford it. What is the difference between a system in which the government taxes companies by forcing them to pay for employees’ healthcare and then directly pays for the unemployed’s healthcare, and a classic single payer system? Multiple providers which are never really competitive because of an opaque pricing structure.
As with college tuition, the state has created a monster with no cost control, because the government backstops the most expensive treatment for a growing percentage of the population with unlimited “free” money. In a way, the US already has nationalized healthcare, just like it nationalized college education, it’s merely been nationalized in an extremely inefficient way.
I live in a country with a mediocre public healthcare system, in which almost every doctor and nurse is directly employed by the government in a full time capacity. But the NHS isn’t bad because it’s the NHS. It’s comparatively much cheaper than almost any other first-world healthcare system in a country populated primary by Europeans (can’t compare to eg. Singapore or Japan where people are much healthier and the culture is different). The NHS sucks because everything is done for the cheapest price possible, there’s been no economic growth in 20 years, and British GDP / capita is half of that in the USA, because Britain is poor. Its mediocrity is for the most part a consequence of the British economy, which is poor for largely unrelated reasons.
But I increasingly think the model, or maybe at least the Australian or Swiss semi-public models, could be successfully exported to the US. The usual criticisms of universal healthcare are already rendered bullshit by the American system. Homeless psycho scumbags already get millions of dollars in free healthcare in the US subsidized by the middle class taxpayer that they never pay back, it just gets taken from them in a slightly different way. The NHS isn’t really more “socialist” than the US system at all, because working people are still paying for everyone else in the same way. Old people (by far the most expensive demographic) already get free single payer in America. In fact, the US system is arguably even more unfair, since it costs much more as a percentage of GDP than the British system, which given usage statistics means middle class Americans are relatively redistributing more of their wealth to the old and poor in healthcare costs than many Europeans are.
Minor note - not a nitpick, more of a clarification for people who want to prepare for such things.
The majority of life insurance that gets sold is what is referred to as term life insurance - this is typically what you see advertised where they name a stupidly high number for a very small payment amount, and salesmen play this out as a lie of omission and make people assume that the stated amount is what they'll get when they die(spoilers: they won't.)
That isn't to say there aren't times when term life insurance isn't an applicable economic tool, but it's rarely sold as such.
If you want guaranteed life insurance, you want whole life insurance. This will pay out, regardless of circumstances, will often be much cheaper the earlier you get it, and often can be setup to be payed into over a certain period of time, like a mortgage. Some of them even allow for early withdrawal of the life insurance amount.
If you want to setup any type of additional economic protection for the long run, get one of these, and get them early.
While one has to be clear-headed as to what life insurance actually is, I think for most people, it makes much more sense to get term life insurance: it's a hedge to provide for your loved ones in case of a tragedy and, ideally, by the time time you're old, your death won't represent a significant economic burden on your family. Whole-life is this protection, with some sort of inheritance scheme piled on top... unless you want to screw over one or more of your descendants, it doesn't make much sense to not just save the extra premiums that you'll be paying.
This, of course, assumes similar pricing practices and commission schemes, either product can be, in practice, a worse deal depending on market conditions.
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They could probably rename it to something besides "insurance," because I agree that it functions very differently. The classic insurance is simply a risk pool, helping you pay for rare-but-expensive accidents by having everyone else chip in a little.
Health insurance is more like a real estate agent or full service investment broker. It connects you to a nearby provider, helps you negotiate a fair price from them, but also stops you from getting treatments that you don't really need. Ocassionally this goes wrong (the doctor says you really need a treatment, the insurance company says no, and you're screwed) but it's a reasonable idea. I was on the other end once when I didn't have insurance. The doctor recommended I get an MRI but said it wasn't strictly necessary. I asked how much it would cost and how much it would help. The doctor just kinda shrugged and said she had no idea how to answer either of those questions, she just normally does MRIs for all of her patients with insurance. I feel like an insurance company/medical agent could have helped me there, even if they weren't covering the cost at all.
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I posted this in another thread, but I think a quick fix can be to make healthcare providers bill the insurance company and never the patient for any services provided, unless the patient reads and signs the total bill before the service is rendered. If they provide something that is not covered by the insurance, it's their own cock-up and they have to deal with the expenses. This way healthcare providers will be incentivized to keep the costs down and to converge on necessary and sufficient levels of care.
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Not the middle class. The professional and upper classes. The Medicare tax only covers about a third of Medicare expenditures, and because it's uncapped and progressive, it's disproportionally paid by high earners. The main source of revenue for Medicare is general revenue, which is wildly disproportionately funded by high-income households.
Medicare is a really good deal for the average person, who doesn't come close to paying the net present value of future Medicare benefits in Medicare payroll taxes. The American middle class is carried by high-income taxpayers to a much greater extent than the European middle class is.
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Insurance is a useful model when there is high variability in potential costs. This is certainly true of healthcare, where outcomes range from regular checkups to major surgery. In any given year, healthcare expenditure will not be normally distributed across the population, but instead heavily skewed to a small segment. (I suspect this would also be true even considering the variance in individual lifetime healthcare costs, though it would be difficult to gather this data).
So while it's true that people interact far more frequently with health insurance than other forms of insurance, this doesn't really address the core reason for having an insurance model, which is to protect against those high variance outcomes. Another way to think about this - if healthcare costs were stable and predictable, you wouldn't need government involvement at all (apart from welfare subsidies), as it could be treated like any other essential item you budget for such as food.
To my mind the issue is more a free market vs government regulation issue, and whether or not you have insurers is less relevant. After all, public systems like the NHS are still effectively an insurance model, just one run by the government. The Netherlands may be a useful case study to look at, as its system is entirely based on private insurance, but it is heavily regulated and seems to function fairly well.
I don't have nearly enough familiarity with the US healthcare system to know where it's going wrong, but at least from the anecdotes I hear a lot of it sounds like toothless regulators (or just plain lack of regulation). For example, not knowing what a treatment will actually cost in advance seems to be a common complaint and one that's frankly pretty incomprehensible to me from my experiences in Australia (with both public and private healthcare), as knowing the cost of a service before receiving it is a pretty basic aspect of consumer law. Any provider attempting that sort of thing here would get hefty fines from the regulator. This is a guess though, and it's likely lots of factors, and the US system could well be at a disadvantage just due to the size of the country and the complexity that introduces.
This is extremely true and makes me wonder if we could put a few more chronic conditions in Medicare like we do with dialysis and cut costs enough for everyone else that it could be closer to actual insurance (literally moving the sickest 1% of the population or so could cut premium by 40% - sickest 5%, more like 70%)
Honestly, I kinda wonder why Obamacare wasn't more like this - seems like it would've been an easier sell to put more people on Medicare than what the ACA actually was, and it would've left people alone as far as purchasing more expensive plans? You'd have to figure out how to compensate providers somewhat, but I'd imagine there are ways (bump up Medicare reimbursement rates a bit, slight increase in Medicare taxes, slight increase in corporate taxes to offset decrease in large group premiums from some employees care shifting to Medicare?)
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This only works if the skew is completely random year-to-year. But we know that this is not the case and insurance companies can't really control this with higher premiums.
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Until the AMA and all the associated cartels behind licensing go afuera!, no American system is going to efficiently allocate limited resources, particularly when the least lucrative services (and time consuming to provide) tend to be preventative and routine care, for which health insurance shouldn't be used in the first place.
If you create a barrier beneath which healthcare isn't economically feasible to provide, you end up with shortages and a never-ending dumpster fire of preventable pathologies.
Of course, the momentum necessary to break the cartels up will almost certainly never occur, being that the beneficiaries are the wealthiest and most educated and the maleficiaries are the poor, unhealthy, and uneducated. But it remains true that an Ounce of Prevention is worth a Pound of Cure (and ironically Franklin advocates for occupational licensing in the same letter that coined the phrase).
I don't disagree that the licensing bodies must be contributing to the issue, but I'm not sure this is fully explanatory. In every healthcare system I'm aware of, including well regarded ones in Europe and Australia, there are similar complaints about licensing bodies introducing artificial scarcity by limiting the number of doctors to keep their salaries high. It could be that this same issue is just an order of magnitude worse in the United States than elsewhere, though then I'd want to go a step further and look for the cause of that discrepancy.
Agree that preventative and routine care is necessary to avoid costs down the line, though I'll again point to places like the Netherlands to demonstrate that private health insurance is not inherently incompatible with this. Their system mandates that everyone take out private health insurance (with subsidies provided as needed), combined with government regulation of the base level of service that must be provided, which includes the general checkup / preventative type care.
The reason the US is in a worse place is actually extremely simple - the requirement that foreign doctors redo residency to practice in the US. Australia and the UK both import many doctors from overseas.
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I’ve known people who are on health sharing models as an alternative to insurance, in which healthcare over a certain amount is reimbursed. There are lots of things it just refuses to cover and there is a very large class of people excluded from coverage.
Ultimately, that’s what actual insurance is. Not health insurance as it currently exists.
How does this work exactly? I've heard of similar things offered via churches or other trust networks, but the practicalities seem difficult.
For example, let's say I get an MRI. Maybe the clinic charges me $5000, but then the insurance negotiates it down to $1000.
What price is the health sharing network paying?
Related, but I think one solution to the health care cost crisis is full cost transparency. If you charge Medicare $1000 for an MRI, you must charge all patients the same rate, and all costs must be disclosed up front. Imagine if the price for a hamburger at McDonald's was either free, 99 cents, or $37 dollars depending on who was paying. That's our medical system.
From my anecdotal experiences (which weirdly enough include specifically receiving an MRI as part of a health sharing system) you pay out-of-pocket and that price ends up being equal or lower to the negotiated insurance prices. You may have to do some negotiating yourself, but it’s usually as simple as calling the office and saying “this is unreasonable, give me the real price” and then they do. The $5000 price is there because they know insurance will haggle, and so they can charge the government systems exorbitant amounts, insurance pays the $1000 price, and if you pay out of pocket it’s more like $500, then health sharing reimburses you. The amounts aren’t accurate but the ratios are.
The $5000 price is part fraud, but realistically mostly just because they have to recoup the cost of all the non-payers who receive care and don’t pay for it. It’s basically just backdoor government-funded healthcare for the poor, scummy (has money just doesn’t pay or pays like $10/month), or undocumented. The only ways to bring the costs down are to not allow those people to receive maximum care, which the public doesn’t have the stomach for, or to address the elderly medical cost issue, which is politically untouchable, or address the supply cartel issues mentioned above.
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If everyone pays 100% of Medicare a lot of providers are going out of business. Commercial rates subsidized Medicare to some extent.
I won't accept that the only way the system can work is if the price is hidden. Consumers need to be able to make rational cost/reward decisions and to be allowed to shop around. Prices must be transparent.
oh I'm just saying if you set prices at 100% of Medicare. You can have transparent prices that are higher.
I know United (ironically) has been doing some work around varying copays such that the member is pointed towards providers with more favorable contracts with United. Maybe a little promise there.
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I don’t know what price the network pays. I know that it works on a reimbursement model- you get a big bill, and the network gives you the money to cover it.
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One thing I've heard (correct me if I'm wrong) is that European health systems like the NHS are more than capable of saying no to unnecessary treatment.
The worry is that we lack that ability in the U.S. As a result, we'd end up with all the monstrosities of our current system with even fewer checks on costs. That was certainly the system that Bernie Sanders was proposing during his campaigns.
The necessary increase in taxes could cripple the US economy as well, making us like Britain in more ways than one.
As usually, it comes down to government effectiveness. When the government is effective, it unlocks all sorts of wonderful societal gains: high speed rail, nuclear power, great health care, etc... But when our government is broken and corrupt, more money just equals more waste.
The last few decades have seen government services in the U.S. erode, not due to lack of money but due to lack of competence. In theory, a single-payer system could reduce costs. In practice, it won't. Not with our current government.
In a way, this is part of the problem. A lot of conservative and libertarian criticism of nationalized healthcare is about people being “denied treatment” - almost always terminally ill children who have no hope of survival, brain dead people who will probably never come out of a coma or be non-vegetative, and other cases where the US spends millions of dollars on someone unnecessarily. See the furore about QALYs and death panels. With insurance, premiums can just go up next year, and employers and individuals will just have to pay. Insurers have no real incentive to even negotiate drug costs downward.
The British government is no less easily persuaded by public mawkishness about grandma needing care than the American government is. It is cost pressure and cost pressure alone that forces this kind of pragmatism on the NHS because managers know what the budget for next year is going to be for the entire healthcare system, and increases have to be directed approved by Parliament, the same way defense spending has to be approved by Congress. There’s limited obfuscation, if the industry needs 10% more money next year congressmen have to put their name to that increase. If they don’t, then the system has to cut costs whether it wants to or not.
Do you think that the British cult-of-NHS stuff sometimes mocked by contrarians is about government trying to "pay in appreciation" to make up for things that can't be paid for in real money due to constant cost control?
I think the US system allows the public to dump blame for high costs on insurance executives who are (as we see now) pressured into approving treatments. The UK system seems healthier, in that there’s less anger around healthcare and most people support stuff like QALY-based decisions because the fact that it’s “our” money is more obvious, such that even the median person understands it.
I'm not sure how well the QALY stuff works in practice. I heard stuff about the public being able to pressure the NHS into funding treatments that didn't pass QALY tests. Puberty blockers were also funded by the NHS at some point. Though, I think this treatment seems to be around £1000/year so maybe if your QALY bar is £20,000/QALY then you can make the numbers work if you are able to find some marginal net improvement across the cohort. But I'm very suspicious of these mental health treatments. What if some dude claims if he spends £1000/year on good quality alcohol that passes the QALY bar? At what point does it morph between healthcare and funding utility monster lifestyle choices?
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I don't think this is true, insurers do have a real incentive to negotiate on costs. Here is a basic insurance model, this is about where the money is going from premiums.
Payouts for care (by law an insurer must pay out 80% of premiums collected, the 80/20 rule): 83%
Overhead: 11%
Profit: 6%
I am justifying this model with the below link. You can quibble with the percentages I have assigned, I just guessed at them but they are approximately true.
Now take 2 insurance companies, Company X & Company Y. X negotiates it's drug prices, it gets its drugs for say ~70% of the cost that company Y gets its drugs. This reduces the amount company X needs to spend to provide the same amount of care, now X can either pocket that savings as profit or increase their market share by reducing their premiums. Company X is more effective at giving care, that money goes somewhere. I don't think this is a perfect model, negotiating will likely mean that X has comparatively more overhead vs Y. But I am assuming that companies act in their best interest and wouldn't spend eg $2 to save $1, which is a pretty good assumption.
I think that your model ("With insurance, premiums can just go up next year") really only makes sense when there is only one player in a market and they can do whatever they want, or when the costs of switching insurers are huge. Which I don't think is the case at all.
https://www.oliverwyman.com/our-expertise/insights/2024/jan/health-insurer-financial-insights-volume-12.html
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Maybe you know, but how much chronic illness does the UK wrestle with compared to the US? About the same?
A while ago I went down this rabbit hole about how to combat childhood obesity, and the scourge of associated diseases it causes, assorted advocates are recommending Ozempic as a first line of defense instead of diet and exercise. Because psychopaths are employing HAAS or woke -ISM language to imply diet and exercise is unfair, but Ozempic for toddlers is "equity".
So I sit and I ask myself, does a NHS in the American context make this worse or better? My gut reaction is worse. These people have wormed their way into every level of government policy crafting in a way that has proven (as yet) impossible to uproot. I can't shake the feeling that if we had an American NHS they'd be reporting parents to child services for feeding their kids vegetables instead of pills.
Or take trans kids, an issue I am 1000% against. By and large it's fiat accompli as medical licensing boards have been weaponized, and if even ideologically critical doctors don't toe the "affirm affirm affirm" party line, they lose the livelihood they went into massive college debt and sacrificed over a decade of their life to achieve. All the same, does this get better or worse with an American NHS? My gut is it gets worse. Which is paradoxical as the UK NHS effectively banned the practice of transing kids. But my read on the beliefs of the PMC that would be in charge of an American NHS say the outcome would be the complete opposite.
Because it actually matters what people make up an institution. And presently, I wouldn't trust the federally employed PMC to manage my health. As the groundswell of support for RFK Jr shows, they've done a shit job in their already limited capacity the last 50 years.
Maybe in 4 years, or however long it takes to restore trust in institutions and non-partisan science, my thoughts on this will change. I want to believe things will be different this time around. But I am also prepared for disappointment.
Just a minor nitpick, but since I see this so often:
It's "fait accompli," (French for "accomplished fact") not "fiat accompli" — a "fiat" is an authoritative command or order, and is from the Latin fīat "let it be, let their be, may it become, may it happen" (probably best known from the phrase in the Latin version of Genesis 1:3: fīat lūx, "let there be light").
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Puberty blockers for under-18s banned indefinitely, published just three hours ago. Strange to see a country as culturally close to the US as the UK, to deviate so greatly from the policies of the Metropolis. Maybe Arjin is right, and that transexualism, unlike other minority sexual ideologies, will not achieve permanent victory.
Wes Streeting is an openly gay man and has (like a lot of the Labour cabinet) a fairly consistent record of being pro-LGB and trans sceptic. This is often framed as a matter of "they want to make gay kids trans instead of letting them be gay". Trans activists often frame this anti-trans attitude, the one area of an agenda which the country has otherwise enthusiastically embraced, as being due to the tabloid press. I have to say I agree, the media which has been broadly pro-refugee, gay rights etc. (with the only dissent coming sporadically from the Sun and Express) has been in near lockstep over the trans issue, at least since the Tavistock scandal. Even the Guardian publishes regular TERF-y op eds. Why? Honestly no idea, I mean the outrage stuff clearly sells, but it isn't as if the politicans are all anti-woke, just specifically on this issue.
Far out speculation: there might be a link to the fact that the Conservative party activist wing and MPs are incredibly homosexual from top to bottom, as is Fleet Street. They legalised gay marriage so have their credentials with the LGB crowd already, rather than in the US where it tends to be either LGBT rights OR anti-LGBT. Something there..?
It's interesting speculation, but generally the LGB organisations have taken up the T mantle, and this is no different in the UK (with Stonewall being a strong proponent of trans issues).
Two plausible-ish reasons I've seen come up to explain it are:
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I got into an argument with my long lost British uncle (long story) about why British style gun control wouldn't work in America. And it largely came down to cultural differences.
I can almost understand the promise that a NHS style institution would work better in the US than it actually does in the UK. My misgivings about things like this, this or this aside. My bigger problem is I don't understand how we get from where we are, to there. It feels like the underpants gnomes joke where they leave out step 2.
I hear people selling "Medicare for All" as the magic bullet for this problem. But I simply don't see how it's possibly to effectively outlaw a 1.5T USD market. Especially within living memory of "If you like your doctor you can keep your doctor" being a lie.
I mean, the low hanging fruit is to just pay for EMTALA care at hospitals directly(eg Houston’s gold card system).
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Debate on liberty aside, it wouldn’t work because there are several hundred million guns in America and only the most law-abiding, prosocial, rule-following people with the most to lose would hand them over during an amnesty before a ban, meaning that precisely the worst kind of people (criminals, violent, high time preference) would be least likely to be disarmed.
In Britain it worked because almost nobody owned a handgun or AK, most gun owners were farmers or hunters who were and are allowed to keep their shotguns and rifles.
Also the UK is an island, and doesn’t share a 2000 mile long land border with a failed state run by gangs, who’s third largest industry is smuggling illegal contraband into their neighboring country.
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Hear, hear. US health “insurance” is really a kludgey hodge-podge of at least 3 things that can and should be completely independent of one another:
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I agree whole-heartedly. I'm not sure what insurance actually adds to the system given that the government is already subsidizing the kinds of people that really need insurance and the fact that insurance companies are incredibly reluctant to actually shell out the cash that they agreed to.
Health insurance companies are a tax collector (and insurance premiums a de facto payroll tax) that doesn't get voted out of office for raising middle/upper-middle class taxes, unlike politicians. Also, they (and the provider-level admins fighting them) are a massive white collar welfare program, with millions of marginally to highly educated workers drawing salaries to perform the office work equivalent of digging holes and filling them back up again for no reason.
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Cost control. It's keeping cost from going to infinity even faster than it is, given the limited supply and destruction of price signals by law and custom. The insurance company's reluctance to shell out cash is an essential service.
Untrue, especially in context of the 80:20 rule which means higher premiums directly equal higher profits because margins are effectively capped. Even beyond that, insurance cost control is highly limited to a few high profile cases. And again, much of the most expensive healthcare for chronic or long-standing conditions is funded directly by the state for the old and poor.
There’s no evidence that single payer nationalized systems are more generous. In fact, US private insurers are by far the most generous healthcare insurers when it comes to overspending on drugs and surgery in the entire world. Meanwhile, the most socialized systems like the NHS are often criticized for not paying for million-dollar treatments so that kids with incurable diseases can live in pain for an extra month and play hardball with big pharma even for very valuable drugs.
Yeah, I've seen it said that American lefties dream about Euro-style health care system because they think that such a system will dole out treatments at will and for asking, basically, when that is generally not the case at all.
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One quirk of the UK system is that drugs prescribed by an NHS doctor cost like $12 per prescription to pick up at a pharmacy. This fee is mostly the same regardless of medication.
But the old, the poor, and children are exempted from this fee. Because these people consume almost all drugs, this means that 95% of all prescriptions are free. So all the fee amounts to is an extra tax for 18-60 year old functioning, gainfully employed adults when they need medication. The US system reminds me of this.
One contributor to the UK's economic dysfunction is probably that we have a slim majority of the population with living standards that have been entirely insulated from the wider state of the economy, by pensions, welfare, or otherwise. Causes all kinds of political malincentives to place almost all the burden on a dwindling share of gainfully employed childbearing-age adults, while giving them nothing in return. The prescription exemptions are just a tiny fraction of the whole system.
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