At one point in 2020 a majority of insured Americans treated for COVID (>80%) had the majority of their COVID-related treatment waived by the insurer. However, most insurers have been terminating these waivers since January.
Also, to any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month (between employer and individual) in premiums and likely hundreds in various flavors of co-jargons anytime you step the foot in the door of a care provider even for "covered" care. Insurers always like to portray just providing the service you pay more for than you would in most of the rest of the world as altruism on their part. The major insurance companies providing these waivers (Anthem, UnitedHealth, etc.) all saw order $B profit increases over the pandemic.
It is always interesting to me when people claim insurance companies earn a ton of profit when their profit margins are always in the 5% or lower range. How much smaller should their margins be? Even retail businesses like Walmart need a couple percent of profit margin to survive.
Insurance companies have a vested interest in making sure that healthcare costs keep going up. It’s a counterintuitive notion because you would think they want healthcare cost to go down. The reason they want high cost it’s because they’ll be making that small margin on the higher revenue
Insurance companies also have a particular interest in making sure that uninsured healthcare costs are sky-high, while they negotiate better insured costs.
Incidentally, this is also why tobacco manufacturers don't really mind high cigarette taxes: it puts a higher floor on the cost of a pack of cigarettes, which means the overall profit is larger.
Suppose the following price breakdown for a pack of cigarettes:
cost: $3
profit: $1
tax: $1
total price: $5
The government decides to increase the tax by $1, now it's
cost: $3
profit: $1
tax: $2
total price: $6
As you can see, the total price went up $1, but the tobacco company's per-unit profit is the same. They can increase the price by more than the tax (eg. hiking the price by $1.5 rather than $1), but that's equivalent to hiking the price $0.5 without an associated tax increase, which they can do at any time.
So does every business. But just like every other business, they have competitors too, so they cannot expect their profits to rise simply because they keep increasing their cost of goods sold.
Either way, that is not relevant to the claim that was being contested, which was “insurance companies are profiting extra from covid than they normally would”.
Interesting point. I read the original point as contesting the idea that insurers are going to have to eat a loss.
In the end I think both perspectives are insightful: insurers aren’t in the red for 2020, but they’re also profiting from COVID less than they “normally would”
That's my big problem with the healthcare debate. People think that its because of "profit", but if you look at the profit margins of all participants, they're all reasonable. Even if you could shift that profit over to consumer surplus, you're still looking at crazy high health care spending.
Something deeper is wrong with America's healthcare system. I think the third-party payer system and onerous regulations distort the market in costly ways. Just as the simplest example, if you want to open up a health care provider you need a "certificate of need" in most states. This means a board of current health care providers in the are determine whether there is a real "need" in the neighborhood for a competitor.
> Certificate of Need (CON) laws are state regulatory mechanisms for establishing or expanding health care facilities and services in a given area. In a state with a CON program, a state health planning agency must approve major capital expenditures for certain health care facilities. CON programs aim to control health care costs by restricting duplicative services and determining whether new capital expenditures meet a community need.
Ah yeah, lets reduce costs by restricting "duplicative services"
The US wastes $150,000,000,000 a year (the most per capita in the world) in pushing paperwork directly because of our “competing” individual insurance provider model [1]. The US spends the most overall per capita by far on healthcare, while also not even covering all residents. Despite having poor health outcomes and lower life expectancy, the US is the leader in expensive diagnostic imaging and prescription drugs [2]. Its almost like the “competing” private insurance model creates large amounts of wasted effort in trying to extract profit, as well as perverse incentives to push high profit interventions while ignoring actual health outcomes.
> In countries where hospitals receive global, lump-sum budgets, garnering operating funds requires little administrative work. Per-patient billing, on the other hand, requires additional clerical and management staff and special information technology systems. In countries where there are multiple payers, as in the United States, billing is even more complex, since each hospital must negotiate payment rates separately with each payer and conform with a variety of requirements and billing procedures.
> Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions…Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions… Even though the U.S. is the only country without a publicly financed universal health system, it still spends more public dollars on health care than all but two of the other countries…
Ah yes, competition is what causes higher prices. We just need one organization creating the products and services for a given industry and setting prices.
I wonder why no one else thought of this and why we don't apply it to everything we produce
>Ah yes, competition is what causes higher prices.
Since no one said that, I don't know what you are talking about. This has nothing to do with competition being bad or good. The US isn’t the only country with private insurance. The US model competes in a fee-for-service model, instead of based on things like positive health outcomes through global budgeting, like Germany or Canada. The US model has providers negotiate prices which each individual insurer, with the actual costs being hidden and complex, instead of a transparent “all-payer reimbursement rate” for each provider[1]. Maryland, the only state to use global budgeting and all-payer reimbursement, is saving over $100,000,000 per year on healthcare spending compared to the national average[2].
I really do not understand how people can act like quality healthcare at lower prices is some utopian dream, and not the reality in every single high-income country except the US. That people can look at the US spending 3 times more money on paper pushing as the next highest country, while not even cracking the top 10 in spending on preventive or long-term healthcare, and throw their hands up and say “its unsolvable!” [3] How people can look at the American’s barely middle of the road health outcomes and think the out of control spending is somehow actually leading to quality care. The condescending dismissive attitude in the face of mountains of data from working healthcare systems around the world is truly stunning.
>> Since no one said that, I don't know what you are talking about.
> The US wastes $150,000,000,000 a year (the most per capita in the world) in pushing paperwork directly because of our “competing” individual insurance provider model
When you have real competition and the final user pays, as opposed to a third party, you'll naturally have a model in which people pay for outcome as opposed to fee for service. If I take my car to be repaired, I just want the mechanic to fix it at the lowest cost possible. I don't care how many services they have to run. It works in every other aspect of our economy, including safety critical sectors. For instance, I may pay for a safer car as opposed to a cheaper less safe car.
I just want a system in which I can make my own decisions regarding my health.
I don't know why people argue that the US has a free market in health care. It does not, as you have plainly stated. There's a lot of intermediaries and parties involved that are highly regulated and influenced by the state. US spends as much in public spending in health care as other countries. I would prefer to remove the complexity, allow actual competition and remove third party payer as much as possible. Your solution sounds like more of the same but better, which doesn't make sense
My solution: use any tried and tested model from other countries that have better, cheaper healthcare.
Your solution: a free market where you as the consumer can make your own health choices, of which you are not qualified to understand unless you went to medical school, and expect to pay the lowest cost for things you may need to prevent your own death (we all know price gouging in life or death situations is never a thing). Good luck with that.
Just so you know, unlike your car, you can’t just go buy a new life when you can’t afford to put in a new transmission.
> Just so you know, unlike your car, you can’t just go buy a new life when you can’t afford to put in a new transmission.
Exactly why I want to make my own healthcare decisions rather than some faceless appointed regulatory body
Maybe you have more faith in politicians to do the right thing on your behalf. I'm sure these systems will still exist and you could follow their guidance (e.g. the food pyramid). I just want more choice
A great deal of service provision in many countries' systems is private. Even here in Canada, "socialist" medicine often boils down to a private clinic billing the public insurer. Though the major hospitals are usually owned and operated by non-profit corporations, or the local government.
That adage is more useful when looking at individual
companies, or maybe new businesses.
For long established, highly regulated operations, I would expect consistent profit margin figures across pretty much all companies in the business to represent a pretty accurate view of the situation, and to show if they are earning extra profit due to COVID.
I didn't say margin, I said profit, and you can click a tab over on any of those pages and see overall gross profit is up in 2020. What kind of rational baseline is assuming that increasing margin is the default neutral state? How is that a stable dynamic for any system?
I have never heard of a business that reaches $x of profit and then switches to pricing everything so that they get $0 of profit.
And why would I be concerned with gross margin? If insurance companies were profiting more than normal from COVID, then it would show up in the profit margin figure.
> I have never heard of a business that reaches $x of profit and then switches to pricing everything so that they get $0 of profit.
Isn't this the business model of tons of huge companies? Amazon famously ran at very deliberately low profits for years. Uber and Lyft have margins so low they're losing tons of money in an attempt to get market share.
> any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month (between employer and individual) in premiums and likely hundreds in various flavors of co-jargons anytime you step the foot in the door of a care provider even for "covered" care.
Where did you come up with “thousands” and “likely hundreds”?
Just so the non-Americans reading this have a data point, I’m a single person with Type 1 diabetes who pays $200 a month for my insurance premium (my employer also pays $200 a month). I also pay about $110 a month out of pocket for insulin, $1500ish a year for my glucose monitor, and pay about $250 total a year in various co-pays to see a primary care physician, endocrinologist, and ophthalmologist (maybe 6-7 visits total. This is on a “Gold” plan (the best offered by my employer).
The average gold plan in the US is $575 premium per person per month. For the average household that would be thousands. The average monthly healthcare cost across all "levels" is about $975 per person.
If anyone wants a more useful comprehensive data point. Between Insurance premiums and out of pocket spending for services, the average American spends $4,516 a year. Oddly enough, the US also spends $4,197 a year in public spending, the third highest in the world, without the “costly” universal healthcare. Combined, the US outspends all other countries by a large margin. But with that spending we have less doctors, less doctor visits, poorer health outcomes, and lower life expectancy. But we do lead the world in prescription drugs and expensive diagnostic imaging.[1] We also waste $150,000,000,000 a year on paperwork (highest per capita in the world) because hospitals have to haggle with a bunch of different insures for every single thing.[2]
>In 2013, the average U.S. resident spent $1,074 out-of-pocket on health care, for things like copayments for doctor’s office visits and prescription drugs and health insurance deductibles. Only the Swiss spent more…As for other private health spending, including on private insurance premiums, U.S. spending towered over that of the other countries at $3,442 per capita—more than five times what was spent in Canada ($654), the second-highest spending country…Even though the U.S. is the only country without a publicly financed universal health system, it still spends more public dollars on health care than all but two of the other countries…Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions…Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions [1]
Your employer is paying the difference for you. As part of their health plan setup, they select what percentage of the plan to cover for their employees and their dependents.
> Also, to any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month
Also important to remember the "take home" pay in the USA vs other countries. For many software engineers from the USA it would be significantly more than in other countries, for example due to the fact that there are a number of opportunities to earn good 6 figure salaries
Do also take into account that the median wage in the US is only around 35K per year. Clearly most americans are not in line for a 6 figure salary, nor will they ever be.
That's one of my biggest arguments (see my post history). I am super fortunate I am a software developer and earn a decent salary in the US. I pay $700/m for the highest plan my employer offer.
I know I am lucky. I've met many, many people who aren't as fortunate. I worked for 204 days from my little girl's ICU room. I was able to make ends meet. My fight is for the average American, the $30-45k earners, who don't WFH, and have sick kids in hospitals - and are forced to work to keep their benefits, while their kid is alone in the ICU.
Most people in the US aren’t tech workers though. And the pay disparity for many other roles, especially in the middle-low ends of the spectrum, are not very competitive compared to other countries with nationalised healthcare.
My understanding is that it's mainly only software development that has such a disparity though. Doesn't help much if you're not a software dev (or you lose you job due to ill health).
Yeah, I think another field(though I could be wrong on this one) that pays much better in the USA VS other countries is finance. Outside of these field the situation is very different
This must have been tough, I can't imagine going through it.
The bill is eye-opening, thank you for sharing. I have no hard data, but I believe private medical care in the UK is so much cheaper, simply because there is the alternative of totally free health care from the state. It's not perfect, but any condition you have, they (eventually) do, and to a high level of professionalism (exceptions notwithstanding).
I know treating people requires highly trained, dedicated stuff, advanced technology and medication, and those aren't cheap, but I can't help but feel that something is broken in the US. One of the few things putting me off jumping across the pond.
It was rougher/tougher than I ever thought it would be, not for me/my family, but the pain and suffering my little girl endured - to then receive a bill at the end of the day, is just insulting, imo.
I'm actually British, I moved to the US in 2016. Me/my family have used our fair share of the NHS - my mom suddenly died when I was 12, my dad is in remission from prostate cancer after treatment, I've had kidney stone surgeries, 8 years of orthodontics, major jaw surgery, broken bones, bad childhood asthma, etc. https://kingsley.sh/posts/2021/staggering-cost-of-surviving-...
I agree, I got world-class care, by world-class medical professionals, but, I also earn 2x than the average worker, I can afford to pay $700/m, the highest plan my employer offers. We still got a mistake $2.5 million dollar bill, we went to collections 3 times for less than $50, etc, etc.
The icing on the cake was my daughter being denied Medicaid because I earn too much. They skipped over HER 1-in-700m to 1-in-2b diagnosis, and her many disabilities, to deny me because I earned too much. I was told I'd need to spend the GoFundMe money (which ultimately paid for my baby's funeral), my 401k, any/all savings, and maybe even consider getting divorced (I'm here on a marriage green card). I like the good, but despise the bad.
Good God man, I'm sorry. We lost a baby early on too and would never wish that on my first enemy. And yes, the financial aspects are just a slap in the face.
Sorry for your loss, nobody should have to go through that.
How do people in the US who don’t have insurance get treatment for themselves or their family members in situations like this? It seems inconceivable to me that they or their kids are just expected to die?
And generally, if you have nothing, the government will pay for you. However, quality and quantity of healthcare will likely not be as high.
The rough spot is in the middle when you have some assets, but not enough for a secure life, but do not have insurance, then you will have to forfeit your assets in order for the government aid to kick in, and then you are poor.
The interesting concern for me is always "i won't go see anyone about medical issue X because the copay/deductible structure dissuades me from checking". Even if you have a spare $800 for [insert tests here] you're going to be reluctant to spend it unless you're pretty confident it's necessary.
Is this the source of significant delay in diagnosis? Does it increase or decrease overall costs of treatment? Does it meaningfully alter expected prognosis of the middle income US patients etc
Depends on the individual’s finances. Preventative care such as annual wellness exams are mandated to be covered (i.e. free for insured) and you get a blood test with that. So presumably, you are catching most lifestyle or inherited or long term ailments there.
By law, annual out of of pocket expenses are capped:
However, based on the median income in the US, many Americans would have to think twice about scheduling a doctor’s appointment and being on the hook for an unexpected hundreds or thousands of dollars.
It is all a form of rationing healthcare, so having people think twice about going to the doctor at the expense of some people’s health is part of the system.
> The rough spot is in the middle when you have some assets, but not enough for a secure life, but do not have insurance, then you will have to forfeit your assets in order for the government aid to kick in, and then you are poor.
Which is where a lot of elderly people who need long term care end up.
> It seems inconceivable to me that they or their kids are just expected to die?
Basically, yes. Hospitals are required by law to treat anyone who presents themselves to the emergency room (thus the ER is the primary entry point for many people, regardless of symptom) but they get triaged to the bottom of the queue. Hospital insurance administrators can and do intervene in doctor decisions on care.
Medical debt in the US was already a crisis before the pandemic. It can push people out of their homes and pretty much destroy them. Even some with insurance make gofundme pleas to try to cover their medical bills.
Just talk to anyone who works in an ER. Or read the first link returned by DDG: https://www.kff.org/uninsured/issue-brief/key-facts-about-th... which looks at the more general case. Key paragraphs to read (in this regard) are “ How does not having coverage affect health care access?” and the immediately following “ What are the financial implications of being uninsured?”
Worse is the hospital revenue people intervening in care decisions. There was an expose about this in the NYT a few years ago; as far as I can tell nothing has since changed.
Those two sections say nothing about getting "triaged to the bottom of the queue."
As far as "hospital revenue people intervening in care decisions," that doesn't mean people don't get care. It means they may not get super expensive treatments. That certainly may not be the best care, because, all the ER needs to do, legally, is ensure that the patient's condition is non-emergent before they discharge them, but it's completely unrelated to triage. It is, however, a predictable result of hospitals needing to make a profit.
Do you have any hints or keywords I could search to find the NYT article?
I can’t find it either because all the links these days are full of COVID discussion. I originally read it because one of my neighbors (a surgeon) mentioned it. It was a few years ago, I think during the Obama administration (when health care system was a hot topic of conversation). I remember being surprised because it mentioned hospitals and interviewed doctors by name.
But everybody working in an ER knows this so surely you know someone you can ask who will be more authoritative than some rando like me on the net.
You can be ensured or not, it depends. Honestly it’s pretty stupid to end up in ICU when something free has been offered to you in order to avoid just that, so people should just take their responsibility.
> so people should just take their responsibility.
if you get a serious adverse event following a vaccination, however unlikely, who pays for your medical expenses since the link with vaccines is always denied?
Why are you emotionally invested in trying to bump up COVID’s kill count? If you can explain the motive, maybe we can find an alternate way for you to work towards that goal with fewer casualties.
Your health insurance, presumably. It's another argument for public health insurance.
Understand that the expected benefit of getting COVID vaccines should be positive for everyone -- the expected harm from side effects should be less (often much less) than the expected harm from COVID infection.
There could be public policy reasons for being generous with compensation for side effects, just to increase the vaccination rate, but I think that's a separate issue, and has more to do with the unequal distribution of benefit in a vaccinated population. It could make sense for the old to compensate the young, as the old get more benefit out of others being vaccinated.
Everyone, including the vaccine manufacturers, is aware of the possibility of rare reactions. This system exists because "no one will make vaccines because a jury of twelve lay people may award a $500M penalty because little Timmy got autism despite there being no link" is a national security threat.
Delta Air Lines is imposing a $200 monthly healthcare surcharge on unvaccinated employees, citing an average cost of $50k for a COVID-related hospital stay, which were appreciably affecting company health care policy expenses [0].
I wonder when insurers will follow suit. All these totally preventable hospital stays aren’t cheap, and insurers aren’t charities.
I specified for tax purposes because I was not referring to that kind of discrimination, but rather where employer paid benefits to employees have to be offered in a manner that does not discriminate against lower paid employees otherwise they become taxable.
The employer paid portion of the premium is reduced, which is what the non discrimination testing is looking at to make sure employer benefits are not disproportionately going to higher paid employees.
The non discrimination testing is to prevent companies from giving out benefits to higher paid employees disproportion to benefits given to lower paid benefits, in exchange for those benefits being able to be paid with pre tax dollars.
The benefit is the portion of the health insurance premium that the employer pays. For example, if an employee's health insurance premium is $500 per month, and the employer pays 60% of everyone's health insurance premium, then that leaves $200 left for the employee to pay. However, if the employee has to pay another $200, then they are now paying $400 and getting a benefit of $100.
I am not an expert in how the testing is done, but I was just wondering how Delta would get around any issues if many lower paid employees opted out of the vaccine and had to pay $200 disproportionate to the higher paid employees.
I imagine tax law does not have a carve out for pandemics and lower paid employees having to pay extra for not getting vaccinated, so it would not matter what the reason is that the benefit is being given disproportionately to higher paid employees, just that it is.
I think the point being made is that if instead at looking at the wording of the rules, they look only at employee pay and employee premiums, it could be that fewer of the lower paid employees got vaccinations, and thus paid more on average. That might make them culpable even if the rule wasn't inherently biased. They have made a lot of rules like this recently, such that an uneven outcome puts you in breach of the law regardless of the fairness of the policies.
Tobacco use is actually written into the ACA as an acceptable thing for insurers to discriminate on (there’s even a cap to how much they can add on for it — 50% of the total premium IIRC).
I assume Delta’s lawyers know better than I (who am not a lawyer), but I’d be curious to know how this squares with the ACA.
You can argue smoking/addiction is a disease, possibly genetic which reduces the element of choice involved, potentially creating a problem. Vaccination status wouldn't have any such issues.
Why are harmful drug addictions a choice acceptable to discriminate against, but not a harmful food addiction I wonder? Probably because of the huge number of overweight making it socially and politically expedient to have their costs subsidized by others, whereas smokers are a much smaller minority so it's easy to discriminate against them.
I think its a bit apples and oranges. Smoking is a choice, and obesity is (quite often at least) the outcome or symptom of choices. It should be even easier to charge more for obese insured, they already have the symptoms! But that symptom is a preexisting condition which can't be considered. Also, thyroid disorders (1 in 5 women) can also cause obesity with otherwise healthy diets by dramatically lowering metabolism. So can some gut disorders. I think a way around that would be to self certify that I haven't used tobacco, alcohol, or non whole foods in the last 24 months to get my healthcare credits for each. Of have had no added augar (that gets tricky) or haven't eaten in excess of some number of calories based on my height and age.
No I think it's still hypocritical and inconsistent in spirit.
There are reasons why a smoking addiction is not a simple choice in all cases, and conversely if smoking is a choice then obesity is also a choice in most cases being caused by food addiction.
But isn't overeating the choice, not obesity? That is like saying decreased lung capacity, low blood oxygen or lung cancer are choices. Those are symptoms of choosing bto smoke, and insurers absolutely cannot discriminate based on them or emphysema. They discriminate based on the choice, and I agree it is hypocritical that they only ask if I have used tobacco and not high fructose corn syrup, but that is the question they should ask, not my bmi if they want to be consistent.
Employers have indirect ways of approaching that, like giving discounts on health insurance to employees who track how often they work out, eat healthy, and get regular physicals.
It sounds like you're not familiar with the US system. The employer isn't charging for smoking, the health insurance, which is mostly provided through employers in America, is charging a higher premium for smoking since you will cost much more in future payouts.
technically the insurer charges you more. And often they just give you credits towards healthcare costs if you don't smoke, instead of charging you more if you do. As to why this is acceptable, cultural views on smoking tobacco in the US hover just this side of pedophilia it seems like. I don't know a single person who smokes and has a professional career.
