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Discussion (115 Comments)Read Original on HackerNews
- job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point
- except when subject to some kind of union negotiated contract, the employer can change their insurance options from year to year as they try to save costs, but it's not regarded as a mass pay cut when they do
- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"
Though I think the private health insurance system is a dumb waste of overhead and paperwork and misaligned incentives, I do think that people would be more willing to switch jobs if they could know their plan was at least as good as the one they were leaving, both in money spent and in employee satisfaction. Opacity, in part owing to lack of commitment from employers, makes this harder.
It is just a really awful system overall.
United Healthcare is pretty big in the US, they are also famous for forcing people to spend a lot of time on the phone, waiting on hold or advocating for care. I expect this ends up taking time that the employee would otherwise have been working as well as negatively impacting morale.
Hence the "Confusopoly".
The more complex and opaque the system is, the more opportunities for value extraction by those on the inside.
The dental coverage was screwed up for the first 4 months of the year. An assumption was made that all dental plans were basically the same in terms of payments to dentists. This turned out not to be the case.
Everyone should have this, but until we do, it will be a reasonable negotiating point. Why should non-health-care employers be in the healthcare business?
There are countries where private health insurance works great. The problem in US is how it is regulated.
In practice, that is very rare. Usually new coverage becomes effective on the hire date.
Workers changing jobs often just elect for COBRA or selecting a temporary subsidized ACA plan to bridge the gap though. Nobody is really forced to go without coverage.
However, you sometimes have to wait for the plan to begin coverage. Something like "after 30 days of employment", or "on the first day of the first full month of employment". These are indeed idiotic limitations.
Worst case scenario, if you are changing job and something really bad happens during these 2 weeks where you don't have coverage you can retroactively enroll in COBRA.
"how much companies/employees pay for healthcare" is a poor metric too, because it would depend on the demographics of the company. You'd expect a startup of 30-somethings would have lower premiums than a company of boomers, even for the same coverage.
All the job interviews that went to the point of discussing compensation, healthcare benefits were almost always included when negotiating what actual compensation would be. A difference of them covering several hundred dollars a month in premiums and them matching some % of HSA contributions is several thousand dollars a year in compensation differences. When multiple job offers are pretty close, that can make a difference.
Also, the few times employers have offered healthcare concierge as a benefit it was definitely mentioned in the overall compensation package.
But for many normal jobs it’s very normal to use health care coverage as a negotiation or decision point.
That being said, nothing tells me the plans won't completely change in a few months of course. That's just the "game" and I also hate it.
Just give me the money directly and let me pick my plan from a marketplace that doesn't suck balls. If employers still want to give some incentives to be more competitive fine, but I shouldn't have to time my job switching to avoid coverage gaps.
Health insurance has been a primary topic in every job offer I’ve had, my entire career.
If a company won’t discuss the insurance situation or provide details about the employee contribution, that’s a warning sign. This is a routine topic for negotiations and any company hiding this data is not a company you want to be working with.
So it's good to know the details of the plan (so you know your doctor isn't going to suddenly be out-of-network) but there's not much you can do with this info besides "take the job or leave it."
I'm sure when it comes to executive compensation, everything is open to negotiation, but not for us worker bees.
It's presented as part of the negotiation for total compensation.
You have to know the benefits to be able to understand the total compensation, which is what you're negotiating.
really it could not be because government is bad at managing massive programs and provides no incentive for high performance and efficiency....
Nurses and doctors can only handle so many patients. This has not increased that much compared to say farming or most other areas. And while there has been some gains. There is also lot more produces and costs of those.
There are incentives for high performance and efficiency. GPs are private partnerships contracted to treat patients. They can keep profits.
There's been attempts to do more private outsourcing (with the NHS still paying), but they tend to work out less efficient when you consider the whole system, because, for example they might only treat the easy cases and leave the hard ones to the normal hospitals.
But tax deduction or not isn’t what makes individual health insurance so expensive. When you have employer provided health insurance you’re in a completely different risk pool than people buying on the open market.
And that's the issue, we need regulation to break the quid pro quo system we have right now, and an innovative enterprise to design and sell a realistic risk pool for the public.
That might look like the government requiring freedom of choice in your employer healthcare plan -- eg: the employer has to allow you to port a defined contribution amount to any healthcare plan you prefer, including simply taking the money as salary (disincentivized by taxation though).
It might look like regulating mandatory profit caps on high priced insurance -- meaning if you overpay for your actual risk you get a refund, or maybe free months on the plan etc.
I don't want the government to be the insurance/solution, I want them to set standards that make the game fair and companies can play if they want.
>profit caps
We have profit caps on health insurance. It has many downsides though. The first is that it removes incentives for health insurers to reduce healthcare costs. It actually incentives them to want higher healthcare costs because 15% of a bigger number is more money.
Second, it incentives things like spinning out your insurance division into separate company and then buying an urgent care clinic to run as a sibling company to the insurance company.
Then when the insurance company spends their required 85% on healthcare costs, they just make sure a big chunk of that is spent on services from the sibling provider company.
United Healthcare does exactly this.
Of course functional regulators could stop this, but it’s hard and they don’t. Which is why I think offering a public instead of some of these direct regulations of private companies might work better.
The Republicans have utterly failed to offer *any* alternative at all to Obamacare after 16 years, which is insane for many reasons, but especially considering that they could have put decoupling insurance from employment at the heart of an alternative (even more than the ACA) market-oriented reform. Letting individuals choose their own insurance would put more pressure on insurance companies to actually deliver quality care because, unlike employers, individuals are highly sensitive to the quality of care they receive and are more likely to switch insurers if the insurer unreasonably denies claims or otherwise fails to deliver a decent product. On the other side, individuals are also more sensitive to costs so with greater control over their plan choices would be more able to pick plans that are structured to match their anticipated costs.
In other words, individual insurance would improve the functioning of the market, which should in theory appeal to Republicans. Instead, they only focus on making individuals pay more at the point of care, on the theory that cost-sharing discourages insured people from over-consuming healthcare. Yet they don't think about how the current system makes it impossible for individuals to be truly cost sensitive when selecting plans.
I would guess the Republicans haven't adopted the idea because they are not really in favor of free markets, they are in bed with big business, and employer-provided insurance tends to favor larger companies that can demand better terms from insurers, that can amortize the HR overhead over a larger number of employees, and that tend to benefit disproportionately from lower labor mobility compared to small business (people are more likely to be involuntarily locked into a big company job for security than at a small business, and it's harder for people who are worried about maintaining quality healthcare access to move to a startup, reducing the competition experienced by the bigger companies).
Ideally all business would take what they pay for insurance and stick it in the employee's paycheck and then the employee would buy insurance with that money. Reality says, a lot less people end up having insurance if you do it that way. Maybe force companies who once offered insurance to fund an employee HSAs and change the HSA rules so it can be used to buy insurance. It would take some thoughtful design to actually pull off the transition while keeping people on insurance.
The fact that they are not tells me there must be some other financial incentives at work that are unclear to me.
That’s because before Obama picked it up, it was the Republican free market compromise plan in the face of a growing for socialized healthcare.
And now the Republican Party has been taken over by Trump. To the extent any political party has real principles they have given up theirs completely. Their principles are whatever Trump says they are this week.
So the question is “why hasn’t Trump pushed for separating healthcare from employment?” And the answer to that could be as simple as because he doesn’t think it’s exciting enough.
private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person
even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency
in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age
That's why in normal countries public healthcare is a thing and it competes with the private healthcare sector, forcing it to offer relatively affordable premium services.
using what money? Most people get their money from their employer.
It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!
Employer health care may have bad externalities, but it has the extremely important (but... maybe invisible to the median libertarian) property that it constitutes collective bargaining. You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table.
It's so weird that even now, with the ACA having been proved out over decades, that we have to have these weird free market arguments. It didn't work, guys. It's not a good that works well in an efficient market sense.
100% untrue. There were affordable catastrophic coverage plans available, and many were made illegal by the ACA and the requirement to provide boutique services for "free" (i.e., forced to pay for even if you don't use).
The word you're looking for is "convince," not "force." This whole discussion is replete with misuses of words like "free" and "force," and it's a little worrying.
I would say that the ACA is on the free market-ish side of the design space: individuals purchasing (subsidized) insurance from private companies.
Remove the private actors, the adversarial billing, the friction with providers. It, at its best, ranges from bad to outright awful.
(I'd also love to do away with tax prep — the government knows what is owed, so why make folks prepare their own count and hope it matches?)
Which is to say, not uniformly poor?
> I'd also love to do away with tax prep — the government knows what is owed
Sometimes! We would probably have to simplify the tax code first. Otherwise instead of spreading out the work of identifying income and tax credit eligibility amongst taxpayers and such upon them who are most proximal to this knowledge, we would have a centralized body need to know all of the things that you and I know about ourselves, such as how many kids we have, what kind of car we drive, whether we use solar power, whether we invest in crypto, whether we earned money from gifts or gambling or dividends or farming. Or we could just simplify the code, which I would like.
private healthcare - e.g if there's a lot of private clinics - people paid cash, then yeah healthcare costs would go down & most of the care was preventive not treatment. competition naturally will force prices down & since individuals payers won't be able to afford massive amounts, the market will adjust it's prices vs having one large payer (gvt) i.e public healthcare or many private large payers(current insurance industry).
right now - the issue isn't private healthcare - but the wrong incentives to bill insurance companies massive amounts of money. then insurance companies countering back - by having large bureaucratic processes to avoid paying those large bills. typical complex systems.
The term “private healthcare” is mostly referring to the fact that there is no such thing as non-private healthcare for the majority of Americans.
We're up to about a third now.
I have no idea who is supposed to benefit from this system, other than the private health insurance companies.
Who's fault was the opioid epidemic in the US?
I know a lot of blame has been levelled at the pharma involved, and rightly so, however every single one of those patients that got hooked via prescriptions had them from their doctor.
Those doctors aren't suppose to be automatons, just blindly follow Pharma marketing materials, they are suppose to be highly paid experts who's overriding concern is a duty of care to the patient.
There are many reasons the opioid epidemic was an almost uniquely US experience, but the private incentives for doctors was one of them.
Purdue was telling everyone around the world the same thing - but apparently only US doctors were fooled.
Americans are different - they see themselves as not Europe or Asians - and they are proud of that. The "rugged individual" is still an ideal many cling to as part of their identity.
This is not true for Canadians. Many have to travel to the US, India, or otherwise abroad to purchase the healthcare they desire which is not available to them in Canada.
In Canada you have to get sick enough for the system to triage you into the quotas. But maybe you want to stay healthy before things get too bad?
Anybody can choose to which hospital they go, the “state-licensed” crazy expensive one or the “unlicensed” one for 50 dollars a visit.
As far as I understand, currently the pool of people in the US who are allowed to do medical work is artificially limited, and doctors’ salaries are inflated. Just look around the world, there’s a huge supply of doctors with no student debt who would be happy to work for 60k a year. Also tens of thousands of US citizens will just go get a cheap medical degree from other countries, come back, and open private practice.
FWIW, it's about 1500X plus or minus.
> How can we make sure there's enough staff to provide adequate healthcare for everyone?
The solution now seems to be headed towards using FNP's and similar in place of fully licensed MDs. Which for things like primary care makes good sense IMO.
Of course, doctors do not earn nearly as much in England as the USA, thus good luck ever getting something like to change in the USA. In America, most people go to medical school for the prestige and the paycheck, and our system utterly reflects both.
But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.
So much progress isn’t made in the US due to the welfare queen myth. Heavily intertwined with racism, many imagine “lazy” people getting something they didn’t absolutely earn.
It's interesting: 3 states (Vermont, Colorado, and Massachusetts) did recently try to make state-level single-payer systems. https://www.thirdway.org/report/single-payer-health-care-a-t...
(If Americans are thinking, "huh, that sounds like Obamacare / the ACA marketplace!" then you're right.)
In Germany there is nothing like bronze/silver/gold plans. All statutory health insurance covers what is required to be covered by regulations, with just a few bonus services, at the regulated tariff plus just a few percentage points of variation. So the 90% of people in Germany who have statutory health insurance [1] have essentially the same coverage. The tariff is a percentage of income (up to a cap), not a flat fee.
[1] not everyone is required to have statutory health insurance, for example employees above an income threshold and self-employed people
It is like parliamentarianism, campaign financing regulations, gun control, multiple political parties, etc. Americans call these things "Socialism" and then freak out about them and refuse to see any good on them.
Let's not pretend either system is perfect, or that the _underlying principles_ that both systems hold are the absolute correct way to organize a society.
Americans have be primed with _decades_ of rugged individualism and the idea that collective action is inherently weaker/flawed (just don't think about Social Security). It might have been reasonably true 100 years ago that everyone could pay for their own health care, but we're now in a world where the average person is perpetually on medications that are expensive to produce, and will demand increasingly expensive medical interventions throughout their life (heart health, cancer care, etc.). Combine that with AI probably wiping out a ton of industries/jobs - something has to change. I'm not going to pretend to have a solution, but I think it is disingenuous to suggest any EU nation has it figured out either and is obviously correct.
It’s pretty much a no-brainer cost reduction for everyone.
This doesn’t even mean you need to get rid of private insurance companies (see: Germany).
Obviously people will go with the first option, innovation won’t feed their kids.
Make that "many, many billions of dollars of profit". Then add on the probably-millions of jobs which the staggering inefficiencies of the current system support. (Everything from lobbyists for those companies, to the minions stamping "Denied" on health insurance claims, to the opposing medical billing staff who work for doctors & hospitals & such that need to get paid, to ...)
It'd be lovely if the leviathan could be slain, but don't hold your breath.
I would much rather live in the UK where private healthcare is good and reasonably priced than Canada where in most places it's simply not available.
This means we need to have ways in incentivize innovation (AI diagnostics, robotic procedures, drug discovery, deeper R&D).
Free Markets (with government controls against monopoly) are generally better than governments at delivering cost and quality improvements, but healthcare in most countries is somewhere between “100% not a market” and “70% not a market” (the US). In many cases, governments also actively create and enforce monopolies (eg AMA or local hospitals in the US).
There are a million other things but part of what is required for markets to work is skin in the game, which the UK, Canada, and the US all do bad jobs of in their own ways.
Some say medicine has no elasticity. I don’t think that is true for 90% of spend (for gunshot wounds, maybe, but most spending is on chronic diseases where multiple providers and approaches are available and people could price shop).
I would like to see more countries experiment with more free market healthcare. It’s remarkably effective for many pieces of healthcare.
The "Bismarck model"[0] describes a family of healthcare models where people pay into a central healthcare fund, and that fund then pays medical providers -- which can be private businesses.
[0]: https://en.wikipedia.org/wiki/Bismarck_model
It's just there's a single payer. Those businesses bill the provincial government instead of you. Most of the dysfunctions in the Canadian system come down to provinces screw around with billing and payment and funding.
Take your dissatisfaction with the way the government manages payments to the voting booth instead of advocating dismantling what is on the whole a quite equitable system that has a history of actually producing very good health outcomes.
I actually have on the whole extremely pleasant experiences here in my corner of Ontario. And then I hear horror stories.
The system is underfunded and inconsistent. The province is to blame for that.
It may outperform the US, but it doesn't outperform normal countries.
And vote for who? I have yet to hear a compelling solution from any party. At most, politicians advocate for throwing more money at the problem.
> The system is underfunded
Hot take: the system will always be underfunded. The demand for healthcare is nearly infinite in practice. What stops people from going to the doctor for every sniffle is either cost (in a private system) or waiting times (in a public system). If you had infinite resources to offer services, there are some folks who would be going in for MRIs every year "just in case" and getting prescriptions for every flu they have.
Canada's public healthcare system is massively overloaded and it seems to be getting worse.
I really didn't appreciate how much of a problem this is in my 20s and 30s (while I didn't need much healthcare) and it was easy to assume the bellyaching from older folks was overblown. Time makes fools of us all.
Yes. That is the point. This is how capitalism works. Just look at the story of Tetris as the pefect example of capitalism in action. Some Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add? Licensing and sub-licensing agreements. Or, to put it another way, just building enclosures.
The idea that capitalism fosters innovation is a fairy tale. Companies reach a point where the only way to satisfy the market's need for growing profits is by cutting costs and raising prices. All of the inflation we've seen from the pandemic has been the "raising prices" part. AI exists for dynamic pricing. Dynamic pricing is nothing more than raising prices. Nobody is using dynamic prices to reduce prices. Why would they?
But the big part of AI is in labor displacement. This suppresses wages. Those who kept their jobs aren't asking for raises and aren't saying no to extra unpaid labor. Because they're in fear of losing their jobs. That's not a side effect. It's the goal.
US healthcare, if you can call it that, is part of this economic coercion. Being expensive to access out of employment is a feature not a bug. Everybody wins. Employers keep people who want to live. Healthcare company profits go up. You, as the individual? Nobody cares about you. Get back to work.
The end state for all this is something that looks like South Asian brick kilns where workers have debt they can never escape. Westerners are being loaded up with debt for a reason: to enrich various companies and to make sure we can't leave our jobs.