[cs702]

Health "insurance" companies in the US are not actually, primarily insurers. For the most part, they are not in the business of insuring rare events. Maybe they were primarily in the insurance business at some point in the past, but today they are mainly in the business of entrenching themselves in the middle of all interactions between patients, doctors, and hospitals, and extracting rents from all of them. Health "insurance" companies have become extractive businesses that produce nothing of evident value except unpleasant paperwork, and extract an economic rent for it, to the detriment of everyone else. I call them "paperwork-shuffling processors."

[WorldWideWebb]

Accurate. They are literally middle men taking a cut without offering anything to the process. Switch to single payer, dump the middlemen, and have our taxes pay for essential services (keeping us alive and healthy). Seems simple enough but…

[jzb]

But regulatory capture ensures that can’t happen.

[tptacek]

But literally every state in the country disagrees with you and so it's not going to happen.

[rrrrrrrrrrrryan]

Most Americans support a public option, which is the transition step toward a healthcare system that more closely aligns with other first world nations.

[tptacek]

Only in the abstract. When you work out a concrete proposal that involves people paying for programs, support evaporates.

[antisthenes]

People are already paying for the healthcare one way or another, whether they understand it or not.

[tptacek]

Oh, you can get a lot of stuff done if you just assume you know better than voters do and make the decisions for them.

[mostlysimilar]

(decades of propaganda and state capture by the insurance companies later...) oh I guess the people just don't want it! Too bad.

[bdangubic]

true but that doesn’t make it right when people are running these states are paid by the same people who benefit from the current system…

[tptacek]

The people in those states do not want it, which is why state single payer referenda fail.

[paulryanrogers]

Romneycare and the ACA were a pretty big step in the single payer direction. Popular enough to overcome vetos and attempts to roll them back.

[tptacek]

I like the ACA. I think the Swiss system makes a lot of sense. Community rating, guaranteed issue, mandate, subsidy, then universal single payer at retirement, where costs are concentrated. It's a sane system. The problem isn't the system structure.

[tbrownaw]

> Switch to single payer, dump the middlemen, and have our taxes pay for essential services (keeping us alive and healthy). Seems simple enough but…

... But you still have group A (patients) paying group B (doctors) with group C's (taxpayers', or currently insurers'/policyholders') money.

[MattPalmer1086]

Sure - but it's a lot simpler with less middlemen and way more cost effective.

What point are you making here?

[sundaeofshock]

Uh, group A and group C are the same. We would see much more preventative care if such care was free at time of service.

[rich_sasha]

I suppose, careful what you wish for. The NHS (UK's single payer health provider), allegedly the envy of whole wide world, is failing under the burden of insufficient funding, aging society and years of mismanagement by politicians. We're talking, properly dysfunctional, like ambulances taking hours to be dispatched to life-threatening emergencies or people dying on emergency wards due to neglect.

[piva00]

The NHS was properly sabotaged by the Tories, exactly because they wanted to privatise it. Starving the NHS has been per design, no accident there.

- https://tribunemag.co.uk/2023/07/defunding-the-nhs

[stackedinserter]

Same for Canadian healthcare.

[tptacek]

Literally the same thing is true of health care providers, which is why we have artificially constrained supply of physicians, sky-high delivery of procedures other countries don't routinely do, and integer multiple compensation across the board for practitioners.

[cs702]

Yes. I almost added a comment about that too. In my experience, all doctors, nurses, and other caregivers with whom I have interacted at hospitals have told me they feel treated like "factory workers" who must meet stringent "quality of care" KPIs, set by hospital executives far removed from actual patient care.

[tptacek]

So why are we putting jerseys on and taking the field against the insurers when virtually all of the actual money is going to providers? We could zero out all insurance costs, putting insurers into literal de jure indentured servitude, and get nothing more than a grocery store circular coupon discount on health costs, because insurers are not in fact where the costs are.

[tbrownaw]

Shooting the messenger is a rather common hobby.

[cs702]

They are an integral part of the mess we're in, and they have a vested interest in the status quo.

Otherwise, I agree with you.

[tptacek]

I'm certainly not going to valorize insurers, but I find it deeply frustrating the providers are getting a pass here. You can see it on this thread, where there are commenters expressing surprise that I'd even suggest providers are the primary beneficiaries of the current system.

[cs702]

Yes, I see what you mean about the comments elsewhere on this thread/page. For what it's worth, I was only trying to avoid going off-topic ¯\_(ツ)_/¯

Regarding providers overcharging, the following article by Atul Gawande (from 15 years ago!) had a big impact on me -- it agrees with you:

https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... / https://archive.ph/g8zXl

[huttyoop]

But why are you bringing it up, tptacek?

You’re even replying this to a comment that literally contains “I agree with you”.

It’s like stepping between your friends complaining about jet lag to talk about how your corner bodega raised the price of bubble gum.

If you just want to talk about providers then write a screed on it. People will comment their opinions on the subject you want to discuss.

[joe_the_user]

The entire health care system is broken but insurance companies tend to be the pain people experience so that's what people lash out at.

But you don't expect someone dying from losing health care to shut up until they come up with rational cost management system? The point isn't that the average person needs to how to portion blame but that the health care system needs to stop treating people in the fashion it does.

[tptacek]

That's a problem though when the blame is so screwy, because it leads people to solutions that are not solutions. Medicare itself drastically overpays for medical services compared to the G20. The biggest problem is with providers, and it's exactly stuff like anesthesiologists overbilling for surgeries.

[joe_the_user]

Yes, the blame apportioned by the average person is screwy. But that should be clue to the experts with a more sophisticated view. What it should tell them is that health care reform schemes that rest on the average person exerting or responding to incentives are not going to work.

[apsec112]

A lot of private "health insurance" at large companies is just:

- the company pays out-of-pocket for all employee health expenses

- they don't want to directly deal with bills from doctors and hospitals, so they contract that out to a third-party administrator (TPA), which purely handles paperwork and has no financial role at all

but this doesn't remove the tension between the employer wanting to pay less, and the patient wanting more to be paid for

(and for single-payer systems, you still have the tension between taxpayers wanting to pay less and patients wanting more care, although those groups at least overlap a lot more)

[tbrownaw]

Insurers will also sometimes contract out their claim handling to those same TPAs.

[econ40432]

If I go to a doctor or get Lasik surgery, can't I pay them directly without using my insurance?

[tptacek]

Yes, but unless it's literally Lasik, which has a robust private market, your provider will probably literally make a price up on the spot. That happened to me several years ago, when we needed urgently to get a CT scan for our daughter; it was late in the afternoon, the provider couldn't get the insurer on the horn, they proposed to do it the next day, I was jumpy and said "fuck it I'll pay out of pocket", they looked confused and then just made up a price: $1000.