One of the big problems with our private system is that the incentives are out of whack. With most businesses, it is in the business’ best interest to keep their most active customers happy, so that they keep doing business with the company and keep sending them money. If the customer is unhappy they can threaten to leave and the company will take their concerns seriously.
With health insurance, the most active users of the insurance are costing them the most money. If a dissatisfied customer threatens to leave their response will be, yes please go now, let me help you pack your bags. The only downside is possible bad reviews, but given that only a very small percentage of their customer base fits into this group, (most of their subscribers only minimally use their coverage) as long as they can keep them happy they can keep the 4.75 star rating with 95% of the people saying “they made getting a colonoscopy a breeze”, and only 5% saying “they only paid for one night in the hospital after my hip replacement”.
Said another way, the problem is there are two customers. The insurance company’s customer is generally the big (or small) business that’s buying the group insurance coverage.
The medical practice’s customer is a psycho with a split personality. Half the customer (the actual patient) wants lots of good csre delivered with good customer service and no waiting. Which implies lots of excess capacity, shiny amenities, workers who are trained in service, etc.
The other half of their customer is an insurance company whose only interest is cheaper whatever and less of it.
Ther’s no way this tangled tail of greed and deceit ends well for any of the participants.
So, this is where the three-legged stool of UHC comes into play that helps align incentives.
The first leg is to make insurance of some form available to all, i.e., the company must provide coverage to any applicant. They must make it universally available. The second leg is that all potential applicants must buy into the system, i.e., the individual mandate. This way, risks are spread around and you don’t have people only buying health insurance at the exact moment they need it. The third leg is that the government must subsidize so that coverage is affordable for all. If you’re forcing companies to sell and individuals to buy, then government must make sure premiums & co-pays are affordable. If you have all three of these legs of the stool, then you can achieve UHC.
The US is completely absent on the 2nd leg, as there are people who could afford to buy into the system but aren’t penalized for not doing so. And the US is substandard on the 3rd leg, as there are people who simply can’t afford to buy into the system.
The US also has the problem that the for-profit insurance companies are motivated to refuse covering treatments because those cut into their profits. Even people with “good insurance” have horror stories to tell about times the insurance refused payments, and the patient ended up on the hook for some or all the costs of treatment. That’s the part that’s most fucked up about the US; you can do everything “right” and still end up bankrupt because of some insurance company policy.
Good luck getting your insurance to pay for any sort of life flight if you are in an accident or need to be flown for specialty treatment that local medical services cannot provide. Those bills can be in the many 10s of thousands of dollars that you are personally responsible for. I speak from experience.
Gentle mod note: It’s ok to quote another poster and emphasize the portion of the quote you wish to address, but please don’t overlook to add a notation that the emphasis is your own and not the original poster’s. Thanks.
Yes, as I’ve said before and will say again, the idea of health “insurance” in the same sense as car insurance is fundamentally flawed right from the start. The problem is that everything about it is completely contrary to the principle that health care is a basic human right and must be available to everyone. The insurance companies’ best interests are exactly the opposite of that, and are served by minimizing or denying claims (which in their terms are “medical losses”), and by adhering to the immutable insurance principle of charging according to actuarial risk scoring, so that those seeking individual coverage with the misfortune of having chronic conditions or otherwise at higher risk of costing the insurance company money may be charged extortionate premiums or discouraged from getting coverage at all. And risk-scoring applies to employer group insurance, too, only it’s based on group characteristics like demographics, type of industry, etc. And of course, no insurance = no benefits. The practice of group insurance tied to employment creates a serf-like dependence on one’s employer and greatly exacerbates the impact of job loss.
The US government, while implicitly endorsing the fiasco of private insurance, nevertheless grudgingly acknowledges the imperative of health care as a human right by creating programs like Medicare and Medicaid, but these are far from universal and have huge coverage gaps and inadequacies, and the attempt to intertwine Medicare with private insurance creates a staggeringly complex administrative nightmare. The incredible complexities of Medicare options and its various “parts” never ceases to amaze me.
And the routine business of insurance necessarily creates massive amounts of paperwork and associated administrative costs; that, and the absence of any effective cost control, are why health care in the US is so expensive. Those who are accustomed to the US private insurance system are often surprised to hear that in a single-payer system like the one in Canada (technically, the systems that exist in the various provinces and provincially administered) there is no paperwork at all from the patient’s point of view. When I visit a doctor I may or may not have to present my health card (usually not, if it’s already on file) and when the visit is done I just leave and that’s the end of it.
Same with a hospital. When I was admitted a few years ago with a heart condition, I was there for nearly a week and probably accumulated tens of thousands in medical costs. After getting fixed up, I thanked everyone and left. No forms, no “approvals”, no payments by me. The doctor or medical establishment submits an electronic statement to OHIP with the appropriate code(s), and gets electronically reimbursed the set amount(s). Those amounts, incidentally, are established by negotiation between the medical establishment and the government (in Ontario, between the Ontario Medical Association and the Ministry of Health).
There’s another aspect about my hospital experience that’s worth mentioning. There was a bit of a debate about the best course of action to treat my heart condition, the options being bypass surgery (classic open-heart surgery with all its attendant risks and side effects) or percutaneous coronary intervention (PCI, also known as angioplasty with stenting). The doctors were initially in favour of bypass because it’s the traditional rock-solid fix, but I pushed strongly for PCI. The critically important thing here is that the final decision was made on medical grounds, with my preference weighing in, but with no consideration whatsoever about cost. There was no insurance company bureaucrat involved, potentially meddling in the clinical decision-making for reasons of cost. This is a hugely important aspect of single-payer health care that is often overlooked.
The only form I ever see is when I renew the health card every five years, although my last renewal was done online and didn’t really involve anything more than confirming my address, and, unlike the driver’s license that I also renewed online, health card renewals are free, again reflecting the mandate of universal access.
This isn’t at all consistent with the definition of insurance. Insurance is when you pay a party on a periodic basis to pay you later if a specified event happens. How the cost of the premium is determined doesn’t matter.
True. However, that’s one thing the ACA actually addressed, or attempted to address, as it gave individuals a way to keep coverage even if they left their job. Until Biden’s recent reforms though, most ACA coverage was too skimpy & too expensive for middle-class people. It might actually be better now, with the stronger subsidies in place. But still, there are some who fall between the cracks when they lose their job due to things like the medicaid gap in states that don’t accept the medicaid expansion.
Of the two, Medicaid is the most problematic, because a lot of doctors don’t take it. Just about all doctors take private insurance, because it pays the most. Then, most will take Medicare, which pays less than private and more than Medicaid. Then, Medicaid pays the least, and people who only have Medicaid often only have a few doctors that will see them, due to the low reimbursement rate. Side note: My mother has Medicare Advantage and seems to like her coverage. She has used it quite a bit, too, as she has a myriad of health problems. My brother has both Medicare and Medicaid, due to a disability. His doctors see him, and bill Medicare. They don’t take Medicaid. He’s able to get his prescriptions paid for by Medicaid, I think…Anyway, Medicare & Medicaid are incredibly important to a lot of people. However, particularly with Medicaid, there are problems.
I have private insurance through my employer, and have not had difficulties getting claims paid or anything like that. Once, we were over-charged by a hospital by about $640, and after a few months, they paid us back. All of this is to say that I have what I think of as good insurance, and it’s very affordable to me. I’m one of the lucky ones. But even with that, it’s still sometimes a hassle, such as the $640 example…hospitals that are crooked can be an issue down here in the US…
I agree, it is insane, and makes no sense whatsoever. Single payer or nothing is my viewpoint. But doctors and pharmaceutical companies have us by the short hairs on this. It’s amazing that Obama was able to even make a dent in their monopoly.
The worst part of it is that you have to be a nuclear scientist to even figure the plans out, and every year they change them. I had Humana Medicare Advantage, and it was the worst insurance you could get. Nothing worked right, especially their customer service. I was able to get switched over to United Medicare Advantage, and it just plain works. Every part of it is first rate, and it’s actually a pleasure talking to their customer service people on the phones. Getting a primary care physician was a matter of only making one phone call!
But, I just got lucky. A lot of people are not going to jump thru all the hoops I had to to get this going, and they will be in poor health or even die because of it. That is the true tragedy.
I’ve used the marketplace every year since it’s inception. Have been able to keep the same insurance plan/ hosp provider too.
What gets tricky for me is estimating income. My household relies on seasonal and part time employment. The MP place wants to figure your monthly income and make it annual. And there’s that federal povertly level Cliff. Make $1 over 400%of the FPL and you’re screwed at tax time. Though recent legislation from the IRA and ARPA have supposedly mitigated the Cliff.
2023 I though our estimated income would be too high, as it’s above last years and we got screwed at reconciliation. Nope ACA says we’re eligible for a subsidy again. I just hope that holds true at tax time as we are still over 400%fpl but our income will be less than 8.5% of the cost of individual ins premiums.
How is one supposed to know and understand the inner workings that determine eligibility.
My advice is to update update update your app for any little boost in income.
First, let me say that I wish you the best in your work & money situation overall. Second, the cliff was mitigated greatly during the Biden administration. So, going over 400% of FPL is no longer the horrific thing it used to be. You’re in a better situation than you were prior to Biden. Period.
Now for the bad news…those stronger subsidies which Biden implemented to help people like you will sunset in 2025 unless congress extends them. This is due to political deal-making that was required to get this implemented. I hope congress does the right thing and extends these subsidies. But we can’t be sure that they will.
Im wondering if our new older retiring soon tax guy overlooked something reconciling 2022.
I never adjusted our income throughout the 2022, ended up about 14k over. Yet I believe still we should’ve been cushioned from the cliff fall. But maybe that’s a hard ACA rule, one’s income must match at or below what you estimate it at. Otherwise you underpaid and now you gotta a tax problem.
Right- a lot of our problems are failures of regulation. And a lot of that is because our “system” isn’t really a system, in the sense of a top-down designed, coordinated and integrated whole.
It’s something that grew up like some kind of petri dish of competing ways of doing things, and just sort of coalesced over the years into what we have today. And every time some clever person thinks up a way to provide some sort of service outside of the doctor/patient relationship, the only thing stopping that service from becoming adopted (or for that matter keeping others from being dropped) is whether or not it helps someone’s bottom line.
So we end up with all sorts of third-party organizations doing weird stuff like prescription benefit management, that aren’t doctors, aren’t insurers, and most importantly, aren’t accountable.
A higher level of government regulation in terms of not bankrupting individuals for necessary care, as well as not having bean-counters making decisions on what is and isn’t covered for a doctor to prescribe or perform. I mean, if my doctor was to decide that some third-line blood pressure medicine is right for me, he and I shouldn’t have to prove that to the insurance companies by having to cycle through a set of cheaper medications first. And nor should the insurance company have the ability to decide that it’s my problem to pay for that. Good regulation would prevent that sort of thing and prevent abuses like over prescription of antibiotics and pain medications. Same thing for procedures- better regulation would allow a little more leeway for doctors without subsidizing cosmetic or elective surgeries.
The fundamental problem is that the system was allowed to grow into its current state with little to no oversight or regulation, so that the profit motive is the prime driver of most everything outside of the dr/patient relationship.
…he obvious and straightforward way to achieve all of these “three legs” with zero administration is to fund public UHC through general taxation. Contributions that are progressive and means-based; services that are needs-based and free at the point of service.
It’s true that if you underestimated your income, and thus got more of a subsidy than you should have, you will have pay back the excess at tax time. But it isn’t a penalty: The total net subsidy you get will be the same as if you had estimated correctly in the first place.
Also, if you overestimated your income, you get more of the subsidy back as a refundable tax credit.
Both those things have happened to me in recent years. Like you, my income is extremely variable so my estimates have been wildly off, in both directions.
Is that the “obvious and straightforward” way? I’m not sure of that. Most countries don’t do it the way you described. Some do, but many don’t. I can tell you that in the US, what you described is politically impossible, although at this point, UHC itself is just about politically impossible. Regardless, I think the most “obvious and straight-forward” way depends on where you are standing prior to implementing UHC.