Comment by nradov
3 hours ago
The actual labor share of income is significantly higher when you include employer contributions to employee health insurance premiums. Healthcare costs have been rising faster than overall inflation for decades, and while many of those costs are passed on to employees the employers have also absorbed a significant chunk. If we want to increase the labor share then we'll drive down healthcare spending.
And no, there's no simple solution to this problem. The notion that something like "Medicare for All" would solve the problem is a total fantasy, disconnected from actual US healthcare economics. Any real solution will have to work on multiple angles including preventive care, PBMs, provider wages, rationing, drug prices, fraud, malpractice insurance, interoperability technology, etc.
Why wouldn't a single-payer solution work? The margin that the insurance companies take for themselves seems like a good place to start. From there it would spiral out to the third to half of time that all of the clinical staff spend just dealing with insurance issues and insurance billing.
I'm not necessarily opposed to a single-payer system but the margin that for-profit insurance companies take is a tiny fraction of overall healthcare spending. You could zero it out and it would barely move the needle. And many of the largest commercial health plans such as most Blue Cross Blue Shield Association members are non-profit. There is literally no margin.
Provider organizations spend a huge amount of effort dealing with Medicare and Medicaid, which are pretty close to being a "single-payer solution" already in many cases. From an administrative overhead perspective they aren't always easier to work with than commercial health plans. Plus they have enormous problems with fraud, waste, and abuse.
The mandated low margin is part of the problem. When your margins are regulated, the only way to increase profits is to just make everything more expensive. More revenue, same margin, more profits. Humane health care is incompatible with free market economics.
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I don't think the core issue is the health insurance companies stealing money, it's the deep inefficiencies that come from the position the insurance companies hold.
How many man-hours are spent dealing with insurance paperwork? How much do hospitals and doctors spend each year just dealing with that interaction, rather than treating patients?
> Plus they have enormous problems with fraud, waste, and abuse.
I'd say "enormous" requires some evidentiary proof. Obviously there is fraud and waste. But almost all large scale systems have that. We should certainly try to minimize it wherever we can but I don't think "waste and fraud exist" are a reason to not pursue a path.
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For what it's worth I know you've worked on FHIR and probably know a lot of details I don't. Actually I'd be interested in talking to you about FHIR.
That said!
1) In the big picture isn't the US clearly paying more than other countries? I'm sure some of this is eg a janitor in the US costs more than a janitor elsewhere, but still...
2) Isn't the cap for the margin that insurance companies can take 20%? That is, they have to pay out 80% as claims take 20% for overhead
3) Doesn't insurance also induce more work done by everyone else who has to deal with them? So the margin the insurance company itself takes is not the only cost they add. Maybe they make providers do more paperwork, or let patients order tests etc that they would not if they were not spending other people's money, or some other reason. Say insurance pays out 80%, but 30% of documentation or actual work is not done by insurance but only exists because of them, now we're down to 56%.
I say this because literally yesterday, my wife, a pediatrician, after she spent the day seeing patients and got home to go through notes, had to leave a message with an insurance company: she saw they faxed her clinic on Saturday, when the clinic was closed, to cancel care for a patient with an ongoing chronic condition with no changes unless the insurance company got a reply in 48 hours (again, while the clinic was closed!). Now she has to schedule some kind of I don't even know what with them, to confirm the condition is the exact same, except she sees patients all day so it's a pain to schedule...
idk the fact that BCBS is a non profit and has no margin in some technical sense does not seem like a big consolation, something is rotten no?
(edit - the insurance company in the anecdote is not BCBS)
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There are countries in Europe which have entirely privatized healthcare systems (not even medicare/medicaid equivalents). US tried adopting some of their practices with Obamacare and even that didn’t work out. Singlepayer isn’t really necessary to have a reasonably affordable and accessible healthcare system proper regulation is.
As successful as Obamacare has been it didn't really do much to lower the cost of healthcare or claw back the billions wasted to insurance company profits. There might be some kind of regulation just as effective as single payer, but we've never seen it anywhere in the US.
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insurance issues are provider and insurer going back and forth detrmining if doctors assessment of necessity is agreed upon.
i am not familiar with universal system. In that system if your doctor thinks something is medically necessary then thats the end of it and its gets done?
In my experience, insurance issues are usually insurer and patient going back and forth and then patient getting 6 different answers from 6 different representatives, then reviewing the 3000 page plan document, finding the single line that properly describes what should have happened, calling the insurance company, explaining to the rep how your plan works, and demanding that it be reprocessed. Like my wife has to do this frequently and spends several hours per month dealing with this but she has saved us probably tens of thousands of dollars in mis-processed claims that the insurance companies can't even properly handle. I usually am the person carefully reading plan docs, finding the proper billing codes, and explaining things like that to the insurance company. Sometimes we have to get the doctor's billing people to code things, like once they coded something that was an outpatient appointment as a minor surgery which could have cost us a lot of money.
So in my book since we get to speculate about what the system should look like, it should absolutely result in people getting care without all of this run-around. It's about eliminating as much misery as possible from the system and letting people just get treated and providers just get paid. We can talk about efficiency once the misery is gone.
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All healthcare systems have some form of rationing. Even if your doctor thinks something is medically necessary it can only get done if the system actually has capacity.
In most countries where there is universal coverage with a single payer, certain expensive treatments have long waiting lists or are simply unavailable at any price. Thus we see wealthy Canadians coming to the USA as medical tourists and paying cash for procedures like MRI scans or joint replacements in order to avoid the queue back home. There are always trade-offs, it's just a matter of what we want to prioritize.
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You're citing some of the results of a runaway healthcare industrial complex, such as drug prices, as reasons why the thing that would keep such a complex from emerging won't work.
Employers might be contributing more to healthcare costs, but that's because they have to in order to keep coverage for their employees at all as premiums increase, and individual out-of-pocket costs are still rising as a result of coverage denial and high deductibles.
While healthcare spending isn’t included in some economic measures like wages (which has contributed to the distorted productivity-pay gap discourse), labor share as discussed in this article is actually calculated using total compensation, the “total of payments to labor to produce output, including wages, benefits, and other monetary or nonmonetary payments,” which includes employer contributions to medical care not just wages and salaries.[0] They do discuss payroll share later on though, which doesn’t include non-wage compensation.
[0] https://www.bls.gov/opub/hom/opt/calculation.htm
I've built and audited medical billing systems and billing practices. It isn't an economics issue in a traditional sense. Infact it would drastically reduce complexity of these systems and payments over time, even allowing private insurers to exist but have to compete with a base general coverage. (many smarter people than me at princeton did economics showing this worked out as a net less expensive than what we are doing now) The biggest reason why its not the simplistic solution, is politics of all the middle men (me) making exponential returns from solutions to these systemic issues.
Too much money in the system being flawed, look at pricing for any HIPAA safe products and thats just technology. Money is so hard to get for healthcare providers it is its own industry of revenue cycle management and thrid party billers. Most of these physician lead practices charge more is because planning your account around reemburcement cycles from insurance companies are 30-120 days if your lucky is an advanced accounting problem. (Thats excluding complexities of audits, LOPs, network rates etc.) Medicare/medicaid the fraud side has lots of tiny wins through leaning on tax information more, taking the model from the successful basic income studies and trials worked out.
I'm not sure what you mean by pricing for "HIPAA safe products"? It's not particularly expensive to comply with the HIPAA Privacy Rule, and honestly that level of privacy and security is the minimum we ought to expect in any industry that deals with sensitive consumer data.
There aren't as many physician-led practices anymore. Most of them have been rolled up into larger health systems in order to achieve economies of scale and increase negotiating power with commercial health plans. Which is one of the factors driving up overall healthcare system costs.
Do other countries' state healthcare system costs count towards their labor share of income? If not, it seems sensible not to account for them that way in the US, or you're creating a much more serious apples and oranges problem for international statistics (which are often cited/compared for these figures)...
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The data here would already include healthcare contributions.
> If we want to increase the labor share then we'll drive down healthcare spending.
It may not be simple but it's clear the United States is doing something catastrophically wrong. All the other healthcare systems on the planet in developed countries have problems, sure. But we spend magnitudes more money to receive middling-to-shit healthcare. Medical debt and bankruptcy is a unique American problem that also happens to be the most reliable way for otherwise productive and prosperous members of our society to end up fucking homeless. Because they got SICK. I rarely use the word "evil" but that really fits IMO.
Like you cannot tell me with a straight face that the insurance industry couldn't be blown the fuck off the map tomorrow and literally everyone who doesn't own an insurance company isn't instantly better off.
If the insurance companies disappeared tomorrow, presumably all medical care is paid for at point of use by patients? That would mean stochastically facing catastrophic bills from providers. I am sympathetic to the idea that healthcare providers and systems here should be making no more than in, say, Europe, but an orthopaedic surgeon being paid the $300k USD-equivalent in Germany instead of his $750k USD income today at median would be very unhappy.
> would be very unhappy.
Significantly increasing the supply of doctors would solve that, though.
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> but an orthopaedic surgeon being paid the $300k USD-equivalent in Germany instead of his $750k USD income today at median would be very unhappy.
I'm sure he'll manage.
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What the US is doing is nonsensical. Modern Healthcare is an industrial system designed to handle large populations in bulk. But it only works if everyone can get timely access. This is true for things like mass screenings and medication.
The insane thing is denying it to half of the population doesn't really mean the other half gets to save that much money in real terms.
I strongly agree that socializing the healthcare industry will not help in any way. To the extent that healthcare costs have skyrocketed, it's precisely because of government intervention in the U.S. Healthcare industry has massively increased over the last 50 years, especially in the form of tax incentives for employers to compensate employees by way of health insurance. Anyway, with respect to the labor share of income, that is not correct. Employer contributions to employee health insurance premiums are included in the labor share.
> To the extent that healthcare costs have skyrocketed, it's precisely because of government intervention in the U.S. Healthcare industry has massively increased over the last 50 years, especially in the form of tax incentives for employers to compensate employees by way of health insurance.
It fails to follow logically that one specific way the government got involved that drove costs up means that any possible intervention is worse than completely being hands-off. How do you explain pretty much every other developed country in the world having more government involvement but lower costs than the US?
The problem is, quite simply, insurance.
When something is paid for from a big nebulous ball of money rather than straight out of people's pockets, the downward pressure on prices just isn't there in the same way. The conversations between practitioners and insurers are about whether something is necessary, not about whether or not the practitioner is charging too much for it.
Here in the UK we see it, too - not so much in human healthcare since we have the NHS - but very definitely in animal healthcare; vets' bills have skyrocketed over the last couple of decades, in a mutually-reinforcing feedback loop with the rise in pet health insurance.
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Health care costs across the developed world have skyrocketed for exactly the same structural reasons. Yes, implementations have been different in their details, but the larger structure is the same no matter where you look in the developed world. Government intervention has increased. That means more top-down management and less bottom-up self-organization based on private property and individual incentives.
This is not some spurious speculation. That market-based systems drive down costs enormously is replicated across dozens upon dozens of industries. It's one of the most replicable results in economics to the extent that economics can be replicable. As for why the costs in other countries are not quite as high as the U.S., it's because health care costs also increase as per capita GDP increases and the U.S. has higher per capita GDP. Moreover, because the U.S. has some aspects of its health care system still living more in the private sector, there is less top-down rationing. Other countries see very clear examples of rationing, so people spend less on end-of-life care.
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This is true in the sense that if I sell water in the desert at $100 a bottle, at 900% profit margin, doesn't mean that if the government steps in and pays half of it, that the resulting system is somehow good, just because less people are dying of thirst.
> I strongly agree that socializing the healthcare industry will not help in any way.
It would eliminate the tens of billions that are wasted on insurance company profits.
Yeah, I guess the rest of the developed world doesn’t really ‘get it’ - fools!
Could America be wrong? No, no, it's the other countries!
they get subsidized by usa pharma industry. Their costs will rise if pharma prices are negotiated by govt here too.
That sounds good to me. Why should millions of Americans die every year because they can't afford their medications just so that other countries can get their meds at extremely low prices? Let's also have the US government negotiate our prices and let things even out across the board.
> And no, there's no simple solution to this problem. The notion that something like "Medicare for All" would solve the problem is a total fantasy, disconnected from actual US healthcare economics. Any real solution will have to work on multiple angles including preventive care, PBMs, provider wages, rationing, drug prices, fraud, malpractice insurance, interoperability technology, etc.
I have been saying this for years. I'm so tired of social media memes turning into sage wisdom for an entire generation who can barely spell healthcare, let alone have any vague understanding of it.
I'm and-then'ing, not disagreeing, but the big healthcare cost fix, IMO, still centers around education cost reform, and fixing the supply of mid-levels+ across the country.
Removing a useless middleman party that needs a profit margin, and removing the perverse incentives of them having to prove their value thus having inflated prices with fake discounts, and centralising all healthcare purchasing power in a single entity, is absolutely going to solve a lot of challenges US healthcare faces
Is there a reference you can cite with corrected numbers? Honestly this sounds like excuse-making, especially when used as a jumping point into a decidedly partisan take (complete with scare quotes!) on the essentially unrelated subject of public health care financing.
The idea seems to have merit, but it's unconvincing to people outside your bubble and I'm dubious.
You misinterpreted by comment. It was not partisan, and was based on reality and cold economics rather than ideology. None of the major US political parties have workable reform proposals that could actually be implemented and achieve net positive results.
This is a complex topic with no tl;dr possible. If you want to be able to participate in discussions on a rational, quantitative basis then a good starting point is "The Price We Pay: What Broke American Health Care--and How to Fix It" by Marty Makary, MD. It goes into the numbers far better than I can cover in a short HN comment.
https://www.bloomsbury.com/us/price-we-pay-9781635574128/
> [my comment] was not partisan, and was based on reality and cold economics rather than ideology
That's what all partisans think. Nonetheless you put needless scare quotes around Medicare for All, dismissed it as a "total fantasy", and, I guess, helpfully suggested I read a book by (literally!) the head of the Trump administration's FDA as a reference for "What Broke American Health Care".
If that was all done in good faith, then you're in an echo chamber and need to escape.
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