If you read or hear the things people are saying, they’re expressing frustration over the way they’re treated by insurance providers and their policies. The costs across the industry are insane, and insurance companies sit at the intersection of all the money, leaching away 15-20% (your numbers) as profit. Go to a Reddit thread about this murder, and you’ll hear stories of all sorts of families who faced existential questions of paying exorbitantly for or losing access to necessary healthcare. Because of a UnitedHealth policy.

It’s a boiling point of the increasingly divided society with growing wealth inequality. It doesn’t matter what the regulations say, people are suffering and they’re lashing out. The narrative isn’t actually about UnitedHealthcare and their profits.

I am not trying to get political, or be flippant, I just truly marvel at how easily we are programmed. I mean all of us, myself included.

Private Health Insurers: Free Market!

It came down to this simple realization:

In a somewhat socialized healthcare system,[0] every dollar not spent to benefit the patient is called waste, and we work to reduce it.

In a for-profit healthcare system, every dollar not spent on the patient is considered shareholder value, and we work to increase it.

My hardcore libertarianism ideals died right there, at that realization.

[0] Let's keep it local and say that's medicare/medicade.

[0.1] Sorry, I did get political.

And if we had single pay, wouldn't people still die but now there is someone else to blame? Meaning there is still a budget for care, it is not infinite. There will still be a group to decide what to accept and what not.

Also, a key difference with single-payer healthcare is (generally) the distribution and accountability of program. We'd dispense with "preexisting conditions" and "in/out of network" and provide this service to everyone. Every single person would be eligible, it'd truly be for the citizenry. Because of this, coverage becomes a legislative practice, and if coverage or care is not meeting expectations, it can be changed.

(also, UnitedHealth profit margin was consistently > 20% pre-2024)

I don’t really know what narratives you’re objecting to. But I want to point out the existence of that regulation doesn’t make healthcare companies passive bystanders in the cost of healthcare in America. e.g., notice it collectively incentivizes them to drive the overall cost of healthcare up as much as possible, to maximize the size of their slice of the pie.

The fundamental problem is running healthcare as a profit-driven system. The incentives operating the system cannot possibly be aligned with the people the system is ostensibly meant to serve. (Not that it’s not going to be unraveled, short of literal revolution.)

Here I am paying out of pocket for a medically necessary and covered service simply because the insurance company is playing games. I would prefer they not try to cut their costs by playing stupid games like this about valid claims in the hope that I just give up so they don't have to pay. It's feeling like I'm going to have to sue them to get this resolved. At least it's harder for corporations to play games with process service.

> On the 2021 phone call, which was recorded by the company, nurse Victoria Kavanaugh told her colleague that a doctor contracted by United to review the case had concluded that McNaughton’s treatment was “not medically necessary.” Her colleague, Dave Opperman, reacted to the news with a long laugh.

>“I knew that was coming,” said Opperman, who heads up a United subsidiary that brokered the health insurance contract between United and Penn State. “I did too,” Kavanaugh replied.

> Opperman then complained about McNaughton’s mother, whom he referred to as “this woman,” for “screaming and yelling” and “throwing tantrums” during calls with United.

I don't have a lot of sympathy for these people.

One of my early crap jobs was the mailroom at a Wausau Insurance branch. A claims adjuster gave me a case to make copies of, not warning me I’d be seeing graphic pics of a kid smashed between a dumpster and a wall. I guess she was so immune to that stuff by that point that it didn’t occur to her.

When I gave it back to her I remarked on how tragic the incident was. Her reply was that the mom had two other kids and was going to make a lot of money off this. Naturally the claims adjuster was white and the kid was black. There was testimony in the case about how much their brother’s death traumatized the two surviving boys, who saw it happen. How they tended to just cling to each other in meetings with a therapist.

On top of that the incident occurred because the insurance company had told the Rent-A-Center that their employees weren’t allowed to help delivery trucks back in, specifically because of liability if something like this happened (kid ran behind the dumpster to get a ball right as a delivery truck hit the dumpster).

The job warps these people into losing their humanity.

My conclusion is everything does. This conveniently makes it easy to dismiss criticism of any one part (all of which are responsible) because “well they’re just increasing it a little—go look at these other things, they’re bad too, and if you add up all of that, they’re worse!”

Right, but if you keep not addressing the one in front of you because of that kind of misdirection, you never fix any of it, because all of it is taking too much money.

I will say that our private insurance system in particular seems to be responsible for most of the insanely-high indirect costs of our system.

Dozens of hours for patients and their families lost per major incident, playing middleman between insurance and provider billing departments, trying to make insurance do what they’re supposed to. Stupid billing systems where the prices are all kinda fake, which wastes time in a few ways. Tons of time shopping for and managing healthcare plans by folks in HR. Government social safety net people having to dick around with private insurance nonsense to sort out who’s getting what from where. Employees losing time poring over plans to figure out which one they should get (is it just me, or if you’re offered three is there always one that doesn’t make any sense compared to the other two, no matter what kind of usage pattern or expectations you can think up?) Tons and tons of overhead staff at providers.

I say this as someone who wound up owning one business in this area (health insurance agency/producer) and was looking at expanding directly to the insurance providing aspect. I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.

Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.

What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.

Yes, because the US is currently experiencing an adverse selection bias where healthy avoid enrolling until an issue occurs. See this: https://www.aeaweb.org/articles?id=10.1257/app.20170117

> Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.

Government funded but it's not a social safety net or mandate in a conventionally sense: it's an insurance subsidy. It effectively incentivizes depressing your own personal income to achieve high-subsidy plans (namely, the silver plan in most if not all states) resulting in abnormally high subsidies. It's just a form of tax planning today. See people taking "early retirement" with substantial assets (>1mm, which isn't much for HN but substantial in much of the country) at 40, reducing disbursements, and effectively costing the taxpayer ~36k/year in subsidies.

In an idea world, your assets would be subject to seizure under means testing on assets, not just income, before subsidies are provided. Seriously, go check out reddit /r/fire. They talk about it (and how a reduction in ACA subsidies in 2025 will force them out of retirement at the advanced age of 45).

> What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.

I'm going to be real: this is just wrong. Price controls only works in two circumstances:

* You are willing to tolerate reduced availability of goods and services * You are actively willing to prohibit others from purchasing goods and services with their own money

1 is complete anathema to the US consumer market. If price controls were to be implemented, the elderly would likely get care first, which is unlikely to yield practically the needed result relative to current costs curves -- keeping the working population working with preventative and minimizing the cost on the elder bracket. In my opinion, this mispricing is in part due to the ACA, but that's neither here nor there.

2 would require Norway style controls of Ozembic and similar. I don't think Americans would ever tolerate "your money, you aren't allowed to buy it". Prices are high because Americans can pay in dollars more than other nations and are willing to do so.

There is a very real perception that medicine can fix poor health choices and we should spend arbitrarily large amounts of money to fix it. It's a fantastic business to be in -- people insist "healthcare is a human right" and are willing to tax others to pay it.

As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.

> I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.

Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.

In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?

At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.

Sort of: as you get older, time catches up to you. In the USA for, heart disease kills 1015/100k for both genders (see: https://usafacts.org/articles/what-are-the-top-causes-of-dea... in Germany, it is just 673/100k for just men alone. We have an obesity problem, not a healthcare problem, when it comes to life expectancy.

> Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.

The question here is QALYS. We quite literally avoid this discussion in the US at all (see this: https://pubmed.ncbi.nlm.nih.gov/19738253/). The issue isn't that we disagree about the issues: it's that the issues are not addressed and Americans pretty much always say "spend more".

Europe has already begun rationing, by the way (see this: https://pmc.ncbi.nlm.nih.gov/articles/PMC1831659/#:~:text=Be....) It's not as though it doesn't already occur; we simply choose to blame insurance companies instead of a national system.

> In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?

Healthier populations. Americans make awful health choices.

> At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.

Not really. Margin shifts along value chains; it's rarely destroyed. All that would happen is the profits would shift to another location. Then the game becomes how to get there.

Lots of developed nations have private insurance systems, somewhat similar to the US. Both Japan and Germany have such systems, yet healthcare costs here in Japan are pretty cheap usually. (Here, it's a public/private system, kinda like Obamacare: if you don't have a job or are between jobs or a part-time worker, you'll get government-provided insurance, which you have to pay depending on your prior income I think; when you have a regular full-time job, you get private insurance that your company contracts for. But the insurance works basically all the same way: you pay 30% of the actual cost, and the insurance company pays 70%.)

There's something uniquely bad about the American system, but honestly I don't know what it is. I suspect it has to do with very bad regulation, or a lack of it. Here, it seems the costs for many things (like necessary medical procedures) are strictly regulated by the government. Also, no one pays bills to insurance companies AFAICT: you just pay the healthcare provider, and they go to the insurance company for the remainder.

It’s a regressive-tax-funded white collar makework jobs program. JFC.

I think the Nation’s quote of him on the topic points out something that may be true, which is that he might have balked at doing it given how many people would be laid off (hundreds of thousands, surely) and what the optics of that would be, though I kinda doubt the quote itself.

But yeah, even if he’d been gung-ho behind it, it wasn’t happening.

Like a major premise of US healthcare policy is that preventing investment reduces costs. Good luck when that's the starting condition.

For example, reducing costs is the justification for limiting how many doctors are trained. Fortunately, our planning has been perfect rather than disastrous.

You conclusion reminds me of yesterday's thread about Rogue where one the best players was that way not due to some amazing trick or skill but because he was just a bit better than average on most aspects of the game. He didn't have to be the best at anything, all the little parts above the median added up.

If you stick a gun in someone's face and demand they hand over their cash, you're a criminal.

If you do the same thing with contracts, paperwork, and quarterly reports for Wall St, you're a CEO.

There is no difference between these. One is camouflaged by the abstractions of profit and bureaucracy. But both are murderously violent, and there should be no legal or moral distinction between them.

Likewise climate change and ecocide; online disinformation, media lies, and other kinds of semantic pollution; workplace violence, and other "externalities."

Invention and daring can be good things. But when all you're contributing are death, stress, illness, mass bankruptcy, declining opportunities for most of the population, and other symptoms of corporate sociopathy, you are over the line.

In the US system, insurers are the only actor with any real incentive or ability to constrain costs by limiting consumption; a very large part of the bureaucracy involved in the insurance system is about trying to manage consumption. We're seeing exactly how well that's working out for them, spilled all over the sidewalk.

Talk to people in the UK or Canada or Germany or Australia. See how their media covers healthcare. They're furious about their healthcare systems too, they're talking about a mounting crisis, just for different reasons. These systems accept long waits and the flat refusal to fund less cost-effective interventions as a necessary evil.

It’s laughable that anyone can have this reaction of “gee, maybe if people only understood _why_ a CEO makes billions and has the highest rate of denied claims, they wouldn’t accept violence”

> enormous increase in administrative overhead

Do you see the problem here?

As an outsider it's hard to say, but clearly there is some ginormous loopholing going on here.

I haven't found much in the way of details, but apparently one of the reasons why insurance companies are buying up medical practices is because it enables accounting dipsy-doodle to avoid the healthcare spending requirements.

But rather than getting bogged down in all of the regulatory-captured details that of course just sum up to the broken system we have, let's put the bare reality quite plainly: "Those who make peaceful revolution impossible will make violent revolution inevitable".

Political campaigns rejecting government-based reform only work if the industry uses the breathing room to clean up their act on their own. When it throws those political campaigns out there in bad faith merely to run interference so it can continue collecting rent while not actually reforming, eventually people will have had enough and cheer on escalations past those neutralized avenues of reform.

This is a good start comparing america's healthcare expenditure to other countries' expenditures: https://randomcriticalanalysis.com/why-conventional-wisdom-o...

The short of it on a national level:

Health spending is determined by income

Income predicts changes in health expenditure

The rising health share explained by rising quantities per capita (not prices!)

America spends much more because it consumes much more

The claim that US health care prices are inexplicably high was never well-evidenced!

Real health inputs (labor) increase rapidly with income levels

High overall wage rates and profit margins cannot explain much.

Physician take-home pay explains even less

The composition of the American health workforce is consistent with trends observed elsewhere.

and finally...

Diminishing returns to spending and worse lifestyle factors explain America’s mediocre health outcomes

These headline claims map to large sections of the linked content. I highly recommend chewing through it all.