Discussion The cost of for profit healthcare

[FelixDeCat]

I think this should be its own thread.

I've long blamed the "Affordable' Care Act for increasing costs for most Americans because in the end while you may be "covered", the insurance company doesn't really pay for anything.

Most people try to stay healthy. Who wants to be sick or injured? No one! But if you have a something come up during the year (like I have several times), the first few thousand dollars of costs are PAID BY YOU! That is DESPITE all the money you pay in premiums.

Until you meet your deductible, you are on the hook. And to make matters worse, if your claim is not approved and will not apply towards your deductible. I had some necessary treatments back in 2022 that cost about $4,000 and my deductible was $3,000. Because the insurance company said they were "not medically necessary" they refused to pay anything (at least $1,000 I figured they owed).

To add insult to injury, not only did they DENY my $4,000 claim, THEY DID NOT GIVE ME CREDIT TOWARDS THE $3,000 DEDUCTIBLE!

And now we are finding out that insurance companies are averaging 30% or higher denial rates for claims while paying billions of dollars in stock buybacks, dividends, etc. I also read that there are roughly 100,000 people working in healthcare and 130,000 working to administer claims.



^ Picture from this video (MSNBC):

 

[biostud]

I think this should be its own thread.

I've long blamed the "Affordable' Care Act for increasing costs for most Americans because in the end while you may be "covered", the insurance company doesn't really pay for anything.

Most people try to stay healthy. Who wants to be sick or injured? No one! But if you have a something come up during the year (like I have several times), the first few thousand dollars of costs are PAID BY YOU! That is DESPITE all the money you pay in premiums.

Until you meet your deductible, you are on the hook. And to make matters worse, if your claim is not approved and will not apply towards your deductible. I had some necessary treatments back in 2022 that cost about $4,000 and my deductible was $3,000. Because the insurance company said they were "not medically necessary" they refused to pay anything (at least $1,000 I figured they owed).

To add insult to injury, not only did they DENY my $4,000 claim, THEY DID NOT GIVE ME CREDIT TOWARDS THE $3,000 DEDUCTIBLE!

And now we are finding out that insurance companies are averaging 30% or higher denial rates for claims while paying billions of dollars in stock buybacks, dividends, etc. I also read that there are roughly 100,000 people working in healthcare and 130,000 working to administer claims.

View attachment 113306

^ Picture from this video (MSNBC):

Yeah, your system doesn't seem to benefit the society as a whole. If anything you should probably move it towards Germanys Healthcare system.

Competition of the 21st Century: United States vs. Germany – Which Healthcare System Is Superior?

sites.gsu.edu

 

[ivwshane]

I disagree with your premise. Health care costs have always been rising, the ACA slowed how much it rose. Also the rise in costs could be due to the repeal of the individual mandate in states where they didn’t implement a state level individual mandate. Without the mandate level of risk went up for insurers, less people putting into the system leaving the people left in it who are more likely to be at a higher risk. Lastly, with no mandate it also meant lower income people/households lost out on federal subsidies.

The rest of your issues most definitely need to be addressed. What doesn’t make sense is that the ACA has an 80/20 rule that caps insurers profits to 20% and 80% for medical care with a required rebate going to its members when they exceed that ratio.

 

[FelixDeCat]

I am going to start a business covering your health care costs. You pay me 300 a month or 3600 a year.

I won't pay your first 3,000 in losses and I will deny 30% of your claims. You can appeal but expect to be denied again even if your doctor can prove it was needed.

And just to make sure I don't pay for nothing but the barest of required expenses I will also NOT count your DENIED out of pocket healthcare costs against your deductible.

How can I lose? Especially when I get to do this to millions every year and get away with it because we all do the same thing. You have no choice.

Set up an HSA and fund your own expenses because I sure am not paying them.

Most people never meet their deductible under these circumstances.

All you are paying for is a discount service.

 

[BoomerD]

The 600 lb gorilla in the room is the wages/salaries doctors (especially specialists) get...In the mid-2000s, my pain management doc, an anesthesiologist by trade, was making north of $400,000/year.

 

[mikeymikec]

The 600 lb gorilla in the room is the wages/salaries doctors (especially specialists) get...

That's the line that the establishment would have you believe.

For example:

Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5450906/

 

[Fenixgoon]

That's the line that the establishment would have you believe.

For example:

Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5450906/

That's a hell of an exponential curve

 

[Brainonska511]

I've long blamed the "Affordable' Care Act for increasing costs for most Americans because in the end while you may be "covered", the insurance company doesn't really pay for anything.

Arguably, the thing insurance companies are doing first is providing you with a network to use where they have some cost controls in place and a way to limit your total yearly costs. Then the cost sharing, if you have a HDHP, kicks in once you meet your deductible. If you don't like this particular arrangement, there are always more traditional plans available, where you have co-pays up front, but they often have higher premiums. That's kind of the rub, isn't it? Just need to figure out how to minimize your yearly total OOPs (including the premium).

I had some necessary treatments back in 2022 that cost about $4,000 and my deductible was $3,000. Because the insurance company said they were "not medically necessary" they refused to pay anything (at least $1,000 I figured they owed).

Sorry that this happened to you. I feel like for some categories, there are a number of treatments that are not really supported by evidence, giving companies and easy out to not pay a claim. But you'd still face this problem in a government run system.

 

[Brainonska511]

That's the line that the establishment would have you believe.

For example:

Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5450906/

Except in-patient and out-patient costs are some of the largest drivers of cost in the US:

What drives health spending in the U.S. compared to other countries? - Peterson-KFF Health System Tracker

The U.S. spends more on healthcare per capita than its peers. Most of the additional health spending goes to providers for inpatient and outpatient care.

www.healthsystemtracker.org

Doctors make a lot more money here than they do ex-US. There are also other factors involved (because it turns out its complicated and no single thing is going to be a magic bullet that gives the US affordable healthcare).

 

[FelixDeCat]

Arguably, the thing insurance companies are doing first is providing you with a network to use where they have some cost controls in place and a way to limit your total yearly costs. Then the cost sharing, if you have a HDHP, kicks in once you meet your deductible. If you don't like this particular arrangement, there are always more traditional plans available, where you have co-pays up front, but they often have higher premiums. That's kind of the rub, isn't it? Just need to figure out how to minimize your yearly total OOPs (including the premium).



Sorry that this happened to you. I feel like for some categories, there are a number of treatments that are not really supported by evidence, giving companies and easy out to not pay a claim. But you'd still face this problem in a government run system.

We have a more traditional choice that collects a much higher premium for a lower deductible. I did that the math and it turns out in the end, no matter what, you are paying $4,000 either through the deductible or higher premiums (at least through my employer).

 

[FelixDeCat]

Here we are, two weeks away to YE 2024 and yet AGAIN, the insurance company paid nothing and kept all my premiums.

I spent nearly $2,000 OOP this year and they paid zero....

$1950 paid YTD out of $2,000 OOP limit / $3,000 expense limit.

After that, 90% of claims paid.

Sorry, no cigar.

 

[Brainonska511]

Here we are, two weeks away to YE 2024 and yet AGAIN, the insurance company paid nothing and kept all my premiums.

I spent nearly $2,000 OOP this year and they paid zero....

$1950 paid YTD out of $2,000 OOP limit / $3,000 expense limit.

After that, 90% of claims paid.

Sorry, no cigar.

You're buying into the network which gives you a discount relative to list prices and protection from risk.

You're free to not buy insurance and just pay cash. Not sure if that would work out so hot if you needed a surgery or other serious care though.

 

[BoomerD]

You're buying into the network which gives you a discount relative to list prices and protection from risk.

You're free to not buy insurance and just pay cash. Not sure if that would work out so hot if you needed a surgery or other serious care though.

I’ve said for years…no uninsured person should have to pay a medical provider a dime more than the lowest negotiated price with an insurance company.

 

[FelixDeCat]

You're buying into the network which gives you a discount relative to list prices and protection from risk.

You're free to not buy insurance and just pay cash. Not sure if that would work out so hot if you needed a surgery or other serious care though.

I told them that back in 2022 when they denied my $4,000 claim.

My doctor and I sent emails back and forth for 6 months of appeals and repeated denials. In the end my final email to them was to ask why I am paying them each year just to be a discount service.

In the end, I negotiated my unpaid bill down.. I did my own discount.

Before the ACA, the deductible was $500 and my annual premiums were $60....PER YEAR!!

 

[Brainonska511]

Before the ACA, the deductible was $500 and my annual premiums were $60....PER YEAR!

And what were the details? What was actually covered? How sliced and diced was the network? What was the lifetime cap?

$60/year for a premium seems rather incredible and unbelievable unless there was some fatal flaws to the plan or it was 1970 dollars.

 

[Fenixgoon]

And what were the details? What was actually covered? How sliced and diced was the network? What was the lifetime cap?

$60/year for a premium seems rather incredible and unbelievable unless there was some fatal flaws to the plan or it was 1970 dollars.

Felix never used it, and people who needed it were denied coverage under pre-existing conditions because their care was costly.

See! It's a great system!

 

[[DHT]Osiris]

And what were the details? What was actually covered? How sliced and diced was the network? What was the lifetime cap?

$60/year for a premium seems rather incredible and unbelievable unless there was some fatal flaws to the plan or it was 1970 dollars.

His was one of those plans that wasn't real the moment you needed to use it. The ACA banned those plans.

 

[Brainonska511]

I told them that back in 2022 when they denied my $4,000 claim.

My doctor and I sent emails back and forth for 6 months of appeals and repeated denials. In the end my final email to them was to ask why I am paying them each year just to be a discount service.

In the end, I negotiated my unpaid bill down.. I did my own discount.

I'm sorry your claim was denied and you had to go through that. However, having insurance doesn't mean that everything under the sun gets approved and has cost-sharing. How do we know it wasn't $4000 of some scam, not proven to work medically treatment, or if there was another provision in your contract that stated you had to try X and Y first before going to level of treatment you received? A claim denial isn't something that is going to go away if a government-run single-payer system poofed into existence today.

 

[IronWing]

Before the ACA, the deductible was $500 and my annual premiums were $60....PER YEAR!!

How much was your employer paying in premiums?

 

[FelixDeCat]

As the video has indicated, for profit healthcare has managed to game the tragedy that is ACA for maximum profit through lobbyists and loopholes of denying maximum claims on a whim.

As a result people like me carry 100% of the burden now.

Either socialize medicine for all or scrap ACA in my humble opinion.

 

[FelixDeCat]

His was one of those plans that wasn't real the moment you needed to use it. The ACA banned those plans.

It was very real. And in the late 90s was a bargain. By 2008 it had a premium of 25 a month and a 1500 deductible.

 

[[DHT]Osiris]

It was very real. And in the late 90s was a bargain. By 2008 it had a premium of 25 a month and a 1500 deductible.

I bet 3 decades ago you weren't trying to use that plan the way you would be today.

 

[Brainonska511]

I bet 3 decades ago you weren't trying to use that plan the way you would be today.

And it could also be a case of retrospective bias. Like when asking people what they used to pay for groceries or (insert another item about the past where nostalgia goggles blind the truth).

 

[FelixDeCat]

How much was your employer paying in premiums?

I dunno.

 

[nOOky]

I've always had employer provided health insurance, and the ACA did nothing to impact my costs except to lower them. Insurance had always been going up every year before the ACA. The fact that the ACA made many common preventative medicine steps covered has made our eye exams and colonoscopies etc. free. Before a roto rooter of the colon was around $1,500 out of pocket, now it's covered.

In my past before the ACA I had 3 years where I hit the max out of pocket which was $4,000 a year and also prescriptions were not a part of that so around $14,000 total out of pocket for a-fib. It took me a bunch of overtime every year to pay those bills off.

In 2012 some insurers were sending people with a-fib to Europe to have ablations done, and paying all of the costs for a week off work and transportation and other amenities it was still cheaper than having it done in the USA. My first ablation for a-fib cost $76,000 for a day and half hospital stay.