I am in my 40s, I make pretty good money. My life is good.
My mom died last year. The medical system and her medicare "advantage" plan killed her. She had a stroke. However, within a day, she was up and walking around with assistance.
However, the hospital was understaffed so two things happened. She fell going to the bathroom AND after that happened, they did not get her moving enough and she got a huge bed sore.
The huge bed sore would not have happened if her medicare advantage plan hadn't denied denied denied having her moved to get physical, occupation, and speech theray. If she had just good ole medicare, they would have approved it the day of request (it was requested the day after the stroke, I was warned that her plan was going to deny because they always do where medicare always approves). Instead, she rotted in an understaffed wing of the hospital for a week while I fought to get shit approved.
After getting approval to be moved, she was making slow slow progress due to the bed sore. It is hard when your body needs to recover and you have a huge wound on your back.
Once again her medicare "advantage" plan denied giving her more time in therapy. Guess what? Medicare would have just approved. Her advantage plan said the "community" could care for her and she could just get better over time. Do you know what that means? They wanted me to quit working and care for my mom 24/7. That is what they meant by community care. I am an only child with no other family except my wife and kids.
The hospital social worker was great and refused to discharge my mom because she knew I couldn't physically move my mom around or give her the care she required. That started a month battle where her insurance was refusing to pay anymore hospital bills, refused to get her more therapy, and essentially killed my mom. If the social worker had allowed my mom to be discharged, I would have been fucked.
She slowly got worse and died. The american medical system with its private "advantage" plans took what would have been a recoverable bad health incident and allowed it to kill my mom for greed.
BTW, after a month of fighting, emails to the insurance board of directors and CEO, I got more therapy approved for my mom but it was too late by then. She died a few days later.
You can probably guess how I feel about the CEO's murder........
The incentives are pro-social: insurance companies have an incentive to delay payouts, because their profits come from interest (they pay out more money than they take in) so the longer they can hold onto money the better. But that's reversed for this hypothetical loan issuer - they want to make the payout as fast as possible in order to earn as much interest as possible as quickly as possible.
And if there's a systematic tendency for medicaid advantage plans to deny claims that eventually get approved, and if you could predict which ones will get approved 'just' by really understanding what medicaid would approve, then this might be self-sustaining or even profitable?
What possible benefit to the patient is having a whole bureaucracy sit between the gov't insurance and the person in need of medical care? It only exists to make money off the backs of the people they are harming.
Now, if you don't know why people sign up for them, you don't understand what they are doing. My mom, like many others, was on a fixed income. If you sign up for a medicare advantage plan, they will do things like give you an extra $100 a month to you directly. Why would insurance be willing to PAY you? Because they make all their money billing medicare and denying you coverage.
18 billion in profits last year running a middle man between patients and medicare
Why would the government introduce an intermediary in the first place?
https://en.wikipedia.org/wiki/Balanced_Budget_Act_of_1997
> The act had a five-year savings goal and a ten-year savings goal following its enactment in 1997. The five-year savings goal was $116.4 billion which would be achieved by limiting growth rates in payments to hospitals and physicians under fee-for-service arrangements.[7]
>This plan also involved the change of the methods of payment made to rehabilitation hospitals, home health agencies, skilled nursing facilities, and outpatient service agencies as well as the reduction of payments to Medicare managed care plans and the slowing of growth rates of these same care plans.[7]
>The ten-year savings goal was $393.8 billion using the same savings methods as the five-year goal to achieve the savings in 2007.[7]
Nah, better to have millionaires lying to the sick and dying about the company not having the money to pay for the coverage that the sick person paid a hefty monthly premium to provide.
If any such niche existed, for any system, then this niche would be the system.
The solution would be to remove useless leeches providing no value or benefit to anyone other than shareholders, not add more of them.
And what do you know, most of the rest of the developed world has managed to do that. And even the parts that have private healthcare have managed to put strict rules controlling it, and costs and outcomes are much better.
How many people die for greed? Is that not violence?
- Kendrick Lamar
The other MCOs all had net income less than $8B (CVS/Elevance/Cigna/Humana/etc).
There is no way a business earned a profit of $18B just from Medicare and it not being visible on their net income figures.
That is not to say Medicare Advantage is good for most customers (the common advice is to stay away from it), but fantastical numbers don’t help arguments.
But even supposing that the business earns $18B from Medicare Advantage after all is said and done, it doesn’t pass the smell test because at that level of profit, these businesses should shut everything else down and just do Medicare Advantage.
And for all of that, you’re stuck paying at least 20% of everything, on top of separate deductibles for each part and no out of pocket caps at all (meaning Medicare isn’t even an ACA compliant health care plan). Part C simplifies this for so many people by rolling all of Part B, Part D and usually vision and dental into a single premium and puts out of pocket caps on the amount of money you might need to shell out. Is it any wonder people keep choosing Part C even if it means their providers have to fight the insurance more?
It really makes me sad, but thank you for sharing your story.
If y'all feel that way, why don't you vote for a "socialist" healthcare system like we have over here in communist Europe?
I mean, I'm over here in Germany and I'm not going to claim the system is that great, but it's really not half bad either, and it does seem to prevent the most extreme tragedies.
A number of states have implemented individual mandates; including Massachusetts under Mitt Romney.
It seems quite clear that you'd get it if you (collectively) voted that way, or not for candidates who very actively oppose it.
Be it a privately run for profit insurance system that runs on perverse incentives, or a government agency that runs on power and influence and corruption.
Guess how many people get told their anaesthesia won’t be covered for their full surgery. That shouldn’t even be a question, and yet the US system makes it one.
I had my appendix out a few years ago, I walked into the ER at 2PM, had the surgery done by midnight, and was able to be discharged by 9AM the next day. The only cost was my parking, because I drove myself over. Meanwhile, I've also had friends in the US who were clearly quite ill, and made the conscious decision to not go to the ER because it would have cost them hundreds of dollars.
It's all a balance, but I'm happier with my single pay system, because for the most part, health decisions aren't at the whim of my bank balance being too low. I personally wouldn't be as disappointed in the US system, if the reason someone can get a surgery immediately didn't balance out with something like UnitedHealthcare's 32% rejection rate, because someone wanted a $10MM / yr salary or a $40MM yacht.
https://www.cms.gov/marketplace/private-health-insurance/med...
Although, if increasing the rejection rate allows the insurance company to decrease individual premiums, which causes a lot more people to sign up for coverage due to low cost, that could increase total premium income, total spent on healthcare, and salaries.
Not to mention Canadian expats are generally the ones who would be able to afford the American healthcare costs.
Why can’t the US just copy paste them? It’s not like single payer is the only option..
https://www.cms.gov/marketplace/private-health-insurance/med...
and Swiss doctors are paid very well compared to let say German ones. There is long waiting list of German doctors that would like to practice in Switzerland.
This is just completely not true. Take France and Germany for example.
> Guess how many people get told their anaesthesia won’t be covered for their full surgery. That shouldn’t even be a question, and yet the US system makes it one.
So anesthesiologists should be able to ask for any amount their heart desires and the insurance is the bad guy if they don’t want to pay it? Anesthesiologists have a profit motive too, you know.
> Does Germany have free public healthcare? Yes, all Germans and legal residents of Germany are entitled to free “medically necessary” public healthcare, which is funded by social security contributions. However, citizens must still have either state or private health insurance, covering at least hospital and outpatient medical treatment and pregnancy.
Obviously not; if they're billing 72 hours a day, that's fraud.
If my procedure goes long because of a complication, I'd still prefer they not wake me up mid-procedure for a credit card and signature.
But it was presented in popular media as if the insurance company was trying to shift the cost of overlong procedures onto the patient, rather than onto the anesthesiologists. Thankfully there was a public outcry and the anesthesiologists won, well-deservedly so considering they must be barely scraping by on a median income of $470,000/year.
The policy even had a path for the anesthesiologist to justify the overrun so that portion could be covered too. No doubt Anthem would scrutinize the justification closely and reject cases where they detect abuse, and the incentives are for Anthem to be too strict, but there was nothing wrong with the policy on its face. These sorts of things are absolutely necessary in order to drive healthcare costs, which are absolutely obscene, down.
When you remove profit from the equation, you also remove the incentive to increase supply.
That's like saying 2+2=5, then when someone points it out, saying the sky is blue.
The same is true for those working in healthcare.
United healthcare wouldn't even exist if there was a ton of people who wanted to found, fund, and work at nonprofit health insurance companies.
Do you think doctors and nurses work for free in countries with socialized healthcare?
They do get paid. A lot if you're a specialist too - it's a very lucrative field to be in. Admittedly, not for everyone - nurses and junior doctors usually don't get paid very well, but it's my understanding that in US it's not like these professions make bank either.
>>if there was a ton of people who wanted to found, fund, and work at nonprofit health insurance companies.
That's the whole point that Americans are missing - you don't need the insurance companies in the first place, if the entire system is owned by the public. You go to a hospital, you get an operation done and that's it, at no point is there anyone sitting there are processing your "claim" - if the operation is one allowed by the system(and it almost certainly is) then it's just done and the system pays for it from general taxation budget. No one negotiates rates with the hospital, argues about your excess or premiums or in or out of network coverage. Health insurance is something you get for travelling abroad, like if you have an accident while skiing and need a helicopter to get you out, not for visiting a doctor or a hospital.
> No one negotiates rates with the hospital
No one negotiates period. Coverage decisions are made unilaterally by government officials, and services that those officials deem too expensive are simply not offered. The same issue exists with medical equipment. The wait time for an MRI is absurd in eg. Canada because government only funded so many machines. In the states there are simply more machines, because supply was more elastic, and more freely able to meet demand.
>>when patients in the US with appropriately good insurance receive them as first line with far better outcomes.
The problem I have with that is basically you're saying the quality of the treatment depends on what insurance you have. In socialized healthcare everyone gets the same treatment.
And in fact this is reflected in the average quality of care received on average, with outcomes in US being much worse than elsewhere. US has mortality from "preventable causes" twice as bad as Australia, Japan or France(paragraph 5). So in US few people get amazing care better than anywhere else. And most people get worse care than anywhere else.
https://www.kingsfund.org.uk/insight-and-analysis/blogs/comp...
>>Things like cutting edge cancer treatments (often developed in the US) are many years late arriving to public healthcare systems.
Obviously it's hard to make a general statement on this because every country has varied policies around this. But to share an anecdote - my own dad was enrolled into an experimental programme at a leading oncology hospital in Poland because he had a very rare and ultra aggressive cancer which had no known treatment other than a brand new(then) Glivec, which wasn't even approved for that cancer yet, but he had the whole course of his treatment fully funded under our socialized healthcare. In those very very rare cases where regular treatment is not available there are avenues to explore experimental treatments, and they then serve to direct general treatment plans for the rest of the population. Again, this is a specific example from one country.
> people being denied lifesaving care because insurance companies decide it's not worth it
You get what you sign up for. Like in any business transaction, doing your due diligence and understanding the details of both parties obligation is table stakes. We also have courts precisely for cases when such disputes become intractable.
> so in the meantime you get no cancer drugs for months while they do their process.
No one is stopping you from paying for the drugs yourself. Insurance will reimburse you once they validate your claim. Bureaucracy takes time.
> the average quality of care received on average
And the quality of care on the upper end is markedly worse in many ways. Wealthy people from all over the world travel to the US for their medical procedures for a reason. You're effectively arguing that net-contributors to society (people who pay a lot of taxes) should accept an increase in their tax burden for the privilege of a degradation in their personal access to and quality of care, in order to bring up the average. I hope you appreciate just how directly this opposes the interests of this class.
> From each according to his ability, to each according to his needs
You can't have a system like this in a free country. I want the freedom to associate (in an insurance pool) alongside other people with a similar risk profile to myself (eg. no drinking/drugs/smoking, daily exercise, good sleep, healthy body composition) to the exclusion of others. I want my insurance company to carefully scrutinize its applicants and claimants, on my behalf, to ensure that my interests are being well-represented. Insurance does not mean absolution from personal responsibility.
Same for state employed healthcare professionals, which have salary set by the state.
>When you remove profit from the equation, you also remove the incentive to increase supply.
Yes, socialized system countries have doctors because they pay doctors, ensuring supply. This proves the point above.
If you pay people to do something, you get more of it.
Health insurance companies dont provide healthcare. They dont stich you up or manufacture pills. They are in the business of vetting and denying claims to ration healthcare provided by others.
>No one negotiates rates with the hospital, argues about your excess or premiums or in or out of network coverage. Health insurance is something you get for travelling abroad, like if you have an accident while skiing and need a helicopter to get you out, not for visiting a doctor or a hospital.
It works different in various socialized systems, but there is always someone negotiating with the hospital, the workers, and the manufacturers. Sometimes this is the government, sometimes it is private insurance.
I dont know which country you are talking about, but almost every country has some sort of Health Insurance. What differs is the level of involvement by the citizens in selecting it.
A classic example would be Germany, which is a multiple payer system with both government and private insurance. 85% percent of people have the government health insurance, which is paid by employers and employees and mandatory. the government manages and negotiates rates for this plan. You can opt out and get private insurance instead, and those insurers have sperate negotiations and offer different services. There is also supplemental insurance, also private, also negotiated separate.
And yes, of course you can supplement that with private insurance if you wish, but vast majority of people don't.
And yes, of course the government negotiates with providers - but when you get treated that's not something that affects you. You don't get a bill that says "your treatment was £10k, but the goverment will only pay £5k, cough up the rest". In fact no one(patients) gets any bills ever.
I think the vast majority of countries have some sort of a situation with the government as at least one of the payers, and Private health care providers.
I completely agree that the US is an outlier in how involved the patient is in the payment of their healthcare, and the fact that they can be left with the bill instead of the provider if the insurance is denied.
On a psychological level, I think people are more frustrated by being offered care that they can't afford and dealing with uncertain coverage then not being offered the care at all.
I'm a huge proponent of healthcare reform in the US. That's sad, I think one of the biggest problems with getting it past is unreal expectations. Americans have a caricature of European healthcare in their mind that is totally inaccurate.
No system could afford to spend unlimited amounts for anyone wanting it. You get triaged since resources are not infinite.
Pick your favorite system, say the UK, and google UK healthcare rationing to find state policy on what limits people face.
Here is the govt Medicare page about Medicare Advantage Plans, with references to all the pages of legislation and Medicare rules such plans must comply with.
https://www.medicare.gov/health-drug-plans/health-plans/your...
For example, select “What should I know about Medicare Advantage Plans?”
It states, among other things, “ Medicare Advantage Plans provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) benefits (also called “Original Medicare”), including new benefits that come from laws or Medicare policy decisions”.
Op claims Medicare “always” provides PT, which is not true. Here’s some rules about it: https://www.healthline.com/health/medicare/does-medicare-cov...
Note in particular Medicare advantage will provide any PT where Medicare would.
If you look at peer reviewed research, MA outperforms M in outcomes and satisfaction by a slight amount.
These are reasons why forming or reinforcing beliefs on anecdotes and not understanding the truth is a bad way to make claims.
So now that you see this outcome was medical care “set and enforced by the government” and not the outcome from “anonymous profit-seeking insurance company board members,” will you redirect your outrage?
I get that system needs to push folks into working hard and motivate exceptional efforts (and luck), but sometimes this goes into properly bad directions where few gain and majority loses. In any functional society, all this is never isolated and it has ripple effects.
No merely healthcare, but employment, housing etc. It's easy to single out healthcare for obvious reasons.
Suffice it to say, constructive criticism is vital for democratic improvement.
That's a weird conclusion. For me, it's rather "The USA has its flaws (for me - healthcare and higher education financing above all) so we as a society should focus on fixing these problems". Killing people or leaving the country are not solutions, they are are an equivalent of short Twitter replies on a nuanced subject.
- You
It's because the whole image is fake. In theory everything is fine but you know there is something very bad about the healthcare system, and the power of an institution to decide about someone else's life or death is just one aspect of it; prices inflated beyond imagination is another one (these two are related). So we pretend to live normal lives but in the back of our head we pray we don't ever need to become a victim of this system. But on the outside yes, it looks like everything is fine and we have decent lives.