It never occurred to me before that this is an option. That sounds like a good idea.

I also wonder why health insurance should be allowed as an employee benefit. How does it make any sense to tie my access to healthcare with my employment status?

How a big part of the reason the US healthcare system sucks is just a weird fluke of history!

The NYT has a nice overview [1], the relevant passages below. Wikipedia’s coverage [2] is excellent as well.

“In 1942, with so many eligible workers diverted to military service, the nation was facing a severe labor shortage. Economists feared that businesses would keep raising salaries to compete for workers, and that inflation would spiral out of control as the country came out of the Depression. To prevent this, President Roosevelt signed Executive Order 9250, establishing the Office of Economic Stabilization.

This froze wages. Businesses were not allowed to raise pay to attract workers.

Businesses were smart, though, and instead they began to use benefits to compete. Specifically, to offer more, and more generous, health care insurance.

Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means.”

[1]https://www.nytimes.com/2017/09/05/upshot/the-real-reason-th...

[2] https://en.m.wikipedia.org/wiki/Health_insurance_in_the_Unit...

It's an excellent way of reducing worker mobility.

Economically speaking a 20-something will have fewer responsibilities than say a 40-something with a family and children.

So many startups have been funded by 20-somethings having the ability to couch surf and live off their parents health insurance -- likely because they're the only ones that can afford the risk.

The reason often cited for employer-based coverage is that it avoids some self-selection problems, but that's a different and complex topic.

>> A company signing up lots of their employees doesn't increase the size of the pool -- it just adds an intermediary.

I'm not exactly sure what you mean by that. For large group insurance plans, rates are determined by the risk (calculated by the insurance provider, with certain legal restrictions) of your individual employees. If you have 100 employees and 10 of them get a chronic illness, your rates will go up. Similarly, an employer with older employees will have higher rates than an employer with younger employees. The pricing is per group (employer), not based on the entire pool of the insurance provider's customers.

For very large employers, I believe it's common to self-insure, i.e. make a deal with an insurance provider to provide care to your employees at the rates negotiated between the insurance provider and health care providers, but the employer just pays out the total cost of delivered care rather than premiums. Then you get into stop-loss insurance and other interesting complications.

For 1, it's just completely insane that all medical expenses aren't automatically tax-deductible. It's silly that it's advantageous to have my employer pay $200 a month for my insurance plan rather than just pay me an extra $200 and let me use that on whatever plan I want.

For 2, that may be a little trickier politically. Group insurance gets more efficient the larger the group, assuming there's a mechanism to prevent adverse selection. So obviously, we want to increase group size. That was one of the claimed justifications for the individual mandate.

If you're paying for insurance with after-tax dollars, you can deduct it as long as you're a) itemizing, and b) have total medical + premium expenses >7.5% of AGI, but given that people who pay for insurance with pre-tax dollars get that benefit regardless of those criteria, it seems like it'd only be sane to relax the rules so that people paying with post-tax dollars get the same break.

Employers now document their insurance costs for each employee on their W-2 forms, in case you want to see how much yours is paying for you.

The preponderance of a given condition is not a function of having insurance (though complications thereof can certainly be increased by NOT having insurance). And has already been factored in by actuaries into policy pricing.

The biggest issue is that we see health insurance AS insurance, not amortized healthcare costing.

> There has to be some way that the insurance company can make money on the odds.

That's the thing, they see an opportunity to increase profit.

A few comments on that, as someone who has worked in the industry of developing software for health insurance claims management and benefit processing:

1) insurers are incentivized to deny claims, often talking about how "unfair" it might be for "them" to have to pay for a treatment. The irony is that "they" are not paying for anything - the risk pool is. Those premiums were calculated based on actuarial assessment, plus insurer overhead calculated in. What they mean by "them" having to pay out is that we cut into their profits, as they don't refund money to risk pools if the entirety of the pool is not used - they keep it, in addition to the admin overhead.

2) insurers have been known to be outright unethical, if not illegal in denying claims. Some prurient examples: denying Heli EMS for car accident victims from the scene to a trauma center because of "lack of pre-approval" (sorry, as a paramedic I am not "hold[ing] for a nurse consult" as I call an insurer to decide whether they are going to deign to pay for this patient's transport, and retroactively canceling coverage for "failure to disclose a pre-existing condition" that was actually unknown at the time of disclosure, i.e. "You were seeing a physician for maladies X, Y and Z. You had not been diagnosed with anything at that point, but later were, and maladies X, Y and Z were symptomatic of that. Ergo, you had that condition at that time, though you did not have a formal diagnosis, and failed to disclose that you had it. Accordingly we are voiding your coverage for breach of contract".

It should be illegal to drop a person's coverage if a clear diagnosis was not made prior to an incident that required medical intervention and cemented a diagnosis on paper.

Not sure these are "prurient". You may mean salient.

I work for a Fortune 500 and my daughter has probably cost the insurance $1m. No big deal rates didn’t even raise.

Before I worked for a contractor and we cost THEM a million bucks, and they had to get rid of the low deductible plan, and boost insurance rates by $50 per WEEK per employee. We single-handedly destroyed their risk pool from three months of NICU stay, making it so they could no longer offer affordable insurance. Rather than accept the new rates we got cheaper plans on the Marketplace. Unfortunately though those aren’t tax deductible but we still came out ahead.

It’d make far more sense to just have a marketplace for everyone and make the risk pool the entire US population, rather than let giant corps get good rates while small companies get devastated when an employee or their children get sick.

Was this a large group insurance plan (usually 50+ or 100+ employees depending on the state)? If it were a small group insurance plan I don't believe your utilization would increase the rates, since AFAIK all the small groups in one state/region and insurance provider are combined.

If the employer was large enough to have a large group insurance plan, but still fairly small, I suppose one person's utilization could noticeably increase rates at the next plan negotiation. I believe this is why some companies that are too big for small group insurance plans utilize "professional employer organizations" to participate in a larger risk pool.

WWII wage-price controls:

https://www.npr.org/templates/story/story.php?storyId=114045...

How does this make sense, though?

> "The war economy is an entirely different ballgame," Thomasson says. The government rationed goods even as factories ramped up production and needed to attract workers. Factory owners needed a way to lure employees. She explains that the owners turned to fringe benefits, offering more and more generous health plans.

Why is a healthy plan better for employers than paying cash and letting employees buy their own health care / insurance?

The 1943 IRS ruling that health insurance is tax free, and the legislature failing to correct that, is more of a problem. This blatant failure isn't an "accident", it's bad lawmaking that biases toward business, against people.

Wage-price controls prohibited that.

and letting employees buy their own health care / insurance?

Risk-pooling, information asymmetries, "shoe-leather" frictions (having to shop around, individually, for everyone), bargaining power.

Healthcare markets poorly.

In the past, insurance just paid whatever the hospital charged it was called “usual and customary”. This came about because public plans were getting ripped off and gov’t said “no, you can’t charge us whatever”.

Cycle through a series of different reimbursement systems in order to get a grasp on costs and you end up where we are now - chargemaster rates are ridiculously high (because they aren’t allowed to charge more than that) and the payers negotiate rates down as best they can so you end up with massive gross-net differentials.

It’s really a complete mess.

https://en.m.wikipedia.org/wiki/Usual,_customary_and_reasona...

http://sites.gsu.edu/us-constipedia/standard-oil-co-of-new-j...

They remain a massive concern with monopolies today.

It wouldn't. Insurers would still need to approve providers' prices, and those negotiations would have other levers that could be pulled.

But broadly speaking, yes--requiring insurers pay the same price that is advertised and available to the uninsured public is basic price-transparency policy.

Right now insurance either do cover something or they don't. That in itself is problematic. If insurance would cover a procedure up to e.g. $500 at one medical clinic why do they cover up to $0 at another? Shouldn't it be $500 here or $500 there?

Networks inherently pit you against both the insurer and healthcare provider. Instead you and your insurer should be on the same "side" against healthcare providers.

That's vastly oversimplifying. Insurance often covers part of something.

The dumb thing is, the bill won't hit my deductible cap for the year! (The procedure was done in 2018.) So, in any case, I will pay the full bill and the insurance company will pay nothing. But if the insurance company processes the bill, then I get the "discount".

This is mind-bogglingly stupid.

Honestly blue Cross blue shield is just like Facebook ..users are the product not the customer.

I ended up with the last laugh, though--eventually the insurance rejected it as billed too late, denied, drop it. Instead of collecting the negotiated rate they got $0.

The number on the bill before the insurance discount is entirely imaginary, no one pays it.

There is always a built in cash discount for people without insurance.

For example, for a while I was having trouble getting insurance cards (stupid reasons) at a new position so I was paying out of pocket for prescriptions and office visits.

They were less expensive paying cash than with insurance pre-deductible.

Until they don't pay it. Then that entirely imaginary number becomes a very real debt that gets sold and reported.

I was all set to settle my bill actually, but the woman in billing (at the doctor's office) urged me to not give up and file another appeal. Apparently even she agrees that this is bullshit.

The whole experience has been surreal.

Single payer has proven in pretty much every western country to be massively less expensive than the insurance system in the USA.

US voters haven’t had the option for single payer, but they did have options for removing employer sponsored healthcare.

The only way to dodge that is to subsidize it, whether by reducing the budget elsewhere (cough cough the F-35 program cough cough) or raising taxes (cough cough on the ultra-rich cough cough).

Insurance pushes the price of care up by about 5 to 6 times in my estimation, single payer would fix it.

To be fair, the current president ran partly on a platform to end surprise billing and has asked congress to deliver legislation to this effect

It works pretty well, though I've never had to use it. There is a private forum for members to discuss tactics on getting the biggest discounts. A member will typically ask for a self pay discount as we don't have "insurance". In many cases that knocks 25%-50% of the bill off right there. But you are still dealing with the normal hospital or clinic billing department at that rate.

If you continue to decline this "discounted" rate and push to be transferred (in person or over phone) to the billing department's higher ups, you might even be able to get the bill lowered even more... but you must reject these as well. Eventually you will be turned over to a collections company, and right before they file against your credit score you will actually have the most bargaining power. Typically you will be able to knock another 50% off of the bill.

There are many testimonies on the forum of people getting heart surgery or chemo and having bills in the $100k-$150k range and yet in the end, and after lots of phone calls and added stress... they walk away with paying only $20-30k.

So basically, "insurance" does this bargaining for you.

Overall I think a NHS is better.

Are they? Or are they allowed to get away with it?

The question becomes how to break out of the loop.

(GOTO considered essential?)

If we try that, I'd expect medical expenses keep going up and confused_pikachu.gif until people figured out that hospitals were never on their side. If this takes long enough, "bring back insurance companies" will be the solution, and then it won't work, and then we're back in an infinite loop with a longer cycle.

Hospitals need countervailing price pressure, and anyone who doesn't accept that is liable to vote for catastrophically bad policy.

An alternative approach would be to limit how much higher th e price could be compared to the median insurance re-imbursement for a particular procedure. If you set the limit low enough, then going out of network would not be much more expensive. And the total cost of having insurance and using them may be more than just paying out-of-pocket.

The problem you identified is correct but the solution isn't right. You should let people be free to choose to freely associate with one another (or whatever insurance policy they prefer).

Instead, get rid of legislation that makes hospital bills something awful for unensured people. Many things are driven by the insurance companies but others are by hospitals or even just politicians with bad ideas. Remove the barrears of entries and things tend to get better too.

"eye clinics were unable to keep pace with demand.... In four out of five cases, those affected had chronic conditions requiring long term follow up, meaning they are not covered by NHS targets." https://www.telegraph.co.uk/news/2018/06/06/hundreds-going-b...

While pathetic, it's not clear how it follows, as the DW asserts, "This is what will happen in America if Democrats get their way on 'Medicare for all.'" There are lots of countries with socialized medicine without the problem that NHS has. DW fails to mention that, possibly because of its bias. Private insurers in the US, in the meantime, are widely known to pick-and-choose what they will cover ... and will not.

Edit: here's a description of 'Medicare for All' from Forbes. https://www.forbes.com/sites/teresaghilarducci/2018/07/16/wh...

The US is already paying far more for healthcare than the UK, and that stays true even if we only consider government funding and ignore insurance. There's no reason something similar would happen in the US.

Also, that report mentions macular degeneration, and this is a problem mostly caused by terrible pharma practices.

Avastin and lucentis are very similar. Avastin is older, and is much cheaper than lucentis. They can both be used to treat AMD. The owner has licenced lucentis for use in AMD, and has chosen not to licence avantis for AMD. This means that doctors can use avastin "off label". The rights-holders decided to sue the NHS to prevent this off-label use.

https://www.bbc.co.uk/news/health-30138097

https://www.hsj.co.uk/finance-and-efficiency/breaking-nhs-wi...

I don’t think it forces them. I would say it gives them an excuse to do so.

The hospital, a for-profit business in the United States, isn't voluntarily going to give up profit, so they "hack" the system by raising prices. If InsuranceCo says they'll payback 20% of list price, but it costs the hospital $100 to run the test (including some nominal profit; hospitals aren't non-profits, for better or worse), the hospital must charge $500 for the test, just to break even on InsuranceCo's patients.

Which they aren't refuse, because those patients are a significant portion of the hospitals revenues, or due to laws, in some jurisdictions. ER's can't (legally) turn away people they don't like (Eg African Americans or immigrants).

I have never seen a real accounting of these costs so we can see whether they overcompensate. It’s the same with the high drug prices. They always say that other countries underpay and therefore the US has to pay more but you never see any real numbers.

And is been shown that doctors who belong to such are more than 2.8 times more likely to refer patients for imaging.