If something is unsustainable then eventually it will stop. US healthcare costs have been increasing at faster than the rate of inflation to the extent that it now consumes about 18% of GDP. The majority of people are on employer sponsored group health plans and employers have absorbed most of the cost increases but they're reaching a breaking point. I predict that more employers will simply drop medical benefits and choose to pay the penalty instead, forcing employees to purchase their own health plans on state ACA exchanges.
ACA plans are going up even more on average than employer based plans, at the same time subsidies are being reduced.
The ACA exchanges are possibly doomed long term. People on that skew mid to lower income (but higher than medicaid), and many won't be able to afford the higher premiums - so they will drop off. So then there is the death spiral situation.
I'd prefer that if it was replaced by a system where the business pays/subsidizes YOUR ACA plan. Changing health plans when you change jobs is a huge headache.
A better solution to untie employment from health insurance would be to make premiums tax deductible. That way you would no longer be financially penalized for opting out of employer provided coverage. The cost would be no different than the pre-tax dollars the employer used to pay.
True but it would also be more of a hassle and would be subject to things like putting it in competition with the standard deduction, which doesn't seem to have happened with employer withholdings.
You just described insurance as a whole. If you truly just want catastrophic coverage, get a dirt cheap catastrophic coverage plan from the marketplace and pay for meds and basic care out of pocket, you'll probably save money.
Your employer will not pass any savings on to employees. When has that EVER happened in modern history?
You will be taking a shadow pay cut instead. Or soooo much worse, they will cut your healthcare benefits, and instead pay you the balance of your portion of the premium, which isn't even close to what health benefits cost, and they will angrily expect you to thank them for the privilege.
Then the market would adjust and offer a rebate for not requiring insurance. You can make any claims against that but then you'd have to say something akin to "there is no market for employees". The money that my employer pays in premiums as indicated on my w2 must be going to the insurer surely, even if they are self-insured? If its going to a pool that my employer just gets to keep then why is that tax deductible and why would I trust them with my health insurance?
On the face of it, +1 and yes please, but only if we also see a push to get more/better ACA plans on the market. In some states the pickings are quite slim; last time I browsed ACA plans there were no PPO plans, for example.
I would also accept Medicare For All if we're shooting big here :)
That would be awesome, especially if we could get rid of the yearly Open Enrollment period. We could finally dump insurance providers that don't provide good service or who have bad networks without having to change jobs.
I can't speak to smaller employers who actually use the insurance capability, but larger employers (e.g. 500+ employees) are almost certainly self-insured. They bring the money for the loss pool and use the insurance company for claims service and network.
On it's face it might seem like this isn't related to your complaint, but one of the consequences of self-insurance is that the employer essentially has a dial that they can turn that influences what level of service you get from the provider. If the pool is okay, then your employer might spring for additional benefits like free telehealth. If the pool is marginal, they might force you into a pharmacy plan. And if the pool is completely hosed, then the provider can get aggressive about requiring documentation to bring pool spend back in line.
Exactly right. Many consumers naively blame their health insurance company when they have trouble with a denied claim or prior authorization. What they don't realize is that in most cases the "insurance" company isn't actually providing insurance (bearing financial risk) at all and is simply acting as a third-party administrator for a self-funded employer. It's ultimately the employer that decides what to cover (within legal limits). Insurance companies are happy to offer plans that pay 100% of every claim for everything no questions asked if that's what an employer wants.
Yes and no (and I worked for a company that built software for administrating all that).
You are right, the insurers in a sense don't care about specifics - you can say "everyone gets 52 massage visits a year covered 100%" and they'll do that for you.
But when you talk about TPAs, realize too that those self-funded employers obviously haven't done the actuarial work, so they'll by and large follow an insurer plan because that's had a lot of effort put into balance, optimization and such. Otherwise it's like "I don't know, how much -should- we pay for X?"
Sure, I understand that. Health insurers and TPAs all have standard offerings that they'll sell off the shelf to any customer that wants one. But the point is that they're happy to build a custom product with better benefits for any large customer that asks. When consumers aren't happy with their coverage it's pointless and counterproductive to complain about "greedy" insurance companies: any major improvements will have to come from employers or government. (I suspect that some large employers are secretly happy to take advantage of public ignorance and let insurers take the blame for everything.)
Of course if we take a step back it's crazy that the current system of tax incentives and penalties essentially forces most large employers to do some level of healthcare actuarial work. There's a whole niche industry of consultants who assist self-funded employers with this. But we'd all be better off if access to affordable health coverage wasn't tied to employment.
Even more reasons for insurance companies to not exist.
Not only does what you describe introduce additional middle-man costs that aren't being spent on actual care, but it also obscures the overall health of the public, by creating a number of private health pools that are administered separately.
If we had a single payer system, we'd have much better data on spend vs outcomes and would be able to direct the flow of care much better.
And in the years it would take for a new system to shake out of this disruption and chaos, most people would be unable to access healthcare for basically anything.
Isn't that just great?
I too would love to disconnect healthcare from employment, but good god is this the wrong way to do it. But the current administration has shown for over 20 years that it is utterly incapable of building a solution, so they will just keep tearing down what little of this system is effective while pocketing billions.
If you had 20k extra in your pocket to cover regular shit and 10k to pay for a private health insurance covering catastrophic shit all the while regular hospital expenses went down (cough diagnosis, broken bones, etc etc) I think that would be a good thing. Right now you can see the effects of taking insurance out of the system by going to private practice that doesn't accept insurance. These fuckers way overstepped, not only are you paying several 10K for insurance you pay more when you go for minor issues.
"employers have absorbed most of the cost increases "
Health insurance is part of the total compensation so it's employees who have absorbed the cost by lower salary and higher deductibles, co-pays and whatever other ways insurers find to reduce their own cost.
That thinking only applies to non-essential markets. The whole reason we're in this mess is that insurers (and government/lobbyists) realized that people will never stop getting sick or hurt and that people will pay literally anything for medical care because the alternative is gruesome, horrifying, painful death.
The market simply cannot correct for this. It's just not possible. As fewer people can afford care, prices will go up to offset lost profit. The only organic correction that can happen is if so many people die that the entire economy collapses.
So yes, we'll see a decrease in hiring, a decrease in the number of insured and/or healthy workers, and absolutely nothing will change. The public simply cannot squeeze insurance into lowering prices, nor can businesses. Only legislation can fix this problem.
But since that seems to be ever more unlikely, the best solution is probably for the people to storm the insurance companies and put the CEOs on pikes for all of the death and destruction they've inflicted on our entire society. Democracy has utterly failed us and the only reasonable option left is incredible violence. That's the sad, sorry state that american society is left in today.
Commercial health plans already have very low profit margins, enforced by the ACA minimum medical loss ratio and competitive pressures. There's nothing much to squeeze there. If you analyze the actual cashflows, most of the money is ultimately going to things like provider wages, facilities operations, prescription drugs, and medical devices. Regardless of whether bills are paid by employers, consumers, or government, any attempt to reduce overall healthcare system costs will have to focus on those areas.
And it's horrifying that you would advocate for violence on this issue so I flagged your comment.
The USA really needs to implement Medicare For All or a similar plan. The amount of bureacracy that would be simplified or just go away is staggering. The savings would be huge. Getting healthcare would be easier not just for patients but for doctors as well! Doctors' primary concern is providing the best treatment for their patients, but they usually have no idea how much such treatment would cost. Patients often don't know if they'll be totally covered or if they'll be financially ruined until they make a separate phone call to some customer support rep (who also probably doesn't really know). It's nuts. Under a Medicare For All system, coverage would be standardized for everyone, and doctors would have much better understandings of whether an MRI or X drug would be covered or not.
Likewise, employers won't have to carry this burden. Companies that hire employees across multiple states have to navigate a patchwork of state/region based health insurance policies. Whenever there is a wrinkle in health insurance paperwork, an HR person has to to hunt down the issue and coordinate between an employee and the health insurance.
My gosh. I switched employers within a month of having a major medical event, and it was just the worst. The hospital was claiming I didn't have insurance, but I did (through COBRA, which is a whole other shit show that should and would go away), so I had to have multiple phone calls with the HR dept of the employer that I had just left. It's pretty awkward!
How often do we get to say that the government option reduces bureacracy.
That's not to mention the increasing potential for innovation! I know personally I left a fulfilling but somewhat unstable freelance lifestyle to get a job that offers health insurance after I had kids. I would like to pursue something else independently, and I can tolerate the financial risks, but I simply cannot tolerate the high costs of health insurance for myself and the rest of my family (or worse, the risks that come with having no insurance at all). If my family had health insurance, I'd leave my day job and chase other more exciting, fulfilling prospects. If that was a successful venture, maybe I could afford to hire a few employees because I wouldn't have to cover their health insurance.
Medicare For All should be a slam dunk. The only thing standing in the way is the health insurance industry, which is rolling in money. Get rid of them.
It was surreal to see the lengths that bought corpo Dems and their media went to sink the Bernie Sanders campaigns twice, making it extremely clear they preferred Trump over Bernie.
The whole system is broken. It's overdue to launch our own publicly owned instance of what they built in Taiwan to sidestep political gridlock:
The whole idea of making employer-sponsored health insurance tax-free but not out of pocket medical expenses is a problem in need of fixing. As things currently stand, you can only write off medical expenses that exceed 7.5% if your adjusted gross income, and only if you use itemized deductions rather than the standard deduction.
This public-private healthcare system as it currently exists in America combines glacially-slow subpar public services with the rent-seeking behavior of private insurance.
More than any other group, it screws small business owners, i.e. the people the politicians usually claim to run for office on behalf of.
Imagine if businesses did not have to worry about their employee's healthcare. Instead they could focus on the business at hand. Maybe this is just a crazy idea.
I completely agree. While it's counter intuitive, many businesses want to maintain control of employee's healthcare. Some companies look at it as a way to compete by offering better benefits than their competitors. A lot of companies like controlling healthcare because it keeps employees tied to their employer. If you temporarily lose your insurance when you switch a job, all of the sudden switching doesn't look as good. When you get to really larger companies, then they have the ability to self-insure, which means they can control the costs a hell of a lot more.
Of course, since many companies prefer less regulation, the last thing they'd want to do is hand over the keys to what they do for the healthcare for their employees over to the government. With things how they are now, they can always cut or pair back their plans if they want to cut costs. That lever would be gone with single payer.
Like many things, the system is set up to benefit those in charge rather than those who it's meant to serve. You can look just about anywhere outside the US and see that universal healthcare is a much better system, but better for who? Not much of a benefit for those who make the decisions, so we keep the flawed system we have.
>> Some companies look at it as a way to compete by offering better benefits than their competitors.
Do they really? I've see only select hedge funds actually advertise their health plans. Even that is usually that "we pay 100% of premiums." Most plans are impossible to assess until you actually get to the job and see the tiers available and support available. The devil is in the details -- network coverage for your specific state, co-insurance, co-pays, deductibles, % premium paid, support like QoS/tier.
Competition based on benefits really comes in at the low end and the top end of employment.
If you're a tradesperson, just having insurance coverage is a big thing. It doesn't matter if it's not great, it's better than nothing. Leaving a job with insurance for one without insurance is likely going to cost you thousands of dollars out of pocket for the same coverage.
At the top end, companies will have plans that cover so many things at very high percentages, meaning that your out of pocket for health insurance will be surprisingly small. Less competitive companies simply can't offer that.
It's only in the middle where the details of a plan matter, and those are going to be the hardest details to find.
Someone has to pay for healthcare. If not the employer directly, then they’ll pay for it through higher wages. Are you suggesting employees stop paying for healthcare altogether?
Healthcare thru employment began as a perk for employees. Everyone else just paid out of pocket for regular care. And yes, it was priced into wages.
Even today, most people will pay several hundred dollars a month for insurance; the employer will pay several hundred dollars and the plan will still have a $2K or so deductible. That's a lot of money that most people make no use of at all.
Not necessarily: I gain the ability to switch insurances (imagine, for example, a "free market" where insurance has to compete…), job losses or changes don't affect my insurance, etc. Actual competitive pressure and lower switching costs should, in theory, drive the price down.
Also, IIRC, insurance premiums paid with post-tax dollars are deductible, so they're not really post-tax. However, that deduction is part of the itemized deduction — while currently most people are not itemizing (as they do not have enough itemized deductions to hit the "it is worth it" threshold), my napkin math says that throwing HC premiums in there — since HC is so damn expensive — tips the scale / breaks the threshold for basically any normal income level.
But this is also an "imagine if" thread. Imagine if we made healthcare premiums outright deductible to alleviate the problem you've identified?
I also was buying out of pocket while employed for awhile. Unless you have a qualifying event you can only switch insurance at the beginning of the year, at least from the insurance options I was able to find that fit my family.
I honestly didn't even realize the thing about the standard deductible until I had already done it. I was shocked to find I couldn't deduct it because I'd have to use the itemized deduction which would have been lower. I just assumed my insurance could have been deducted like it was when I bought it through my employer... how wrong I was.
But yes I would absolutely prefer the "imagine if" scenario.
It's not a compelling argument for society, but it's a compelling argument for the individual at the instantaneous moment of making that microeconomic decision.
But you're right, this taxation intertwine is another tangle that shouldn't exist. Too much energy is spent by everyone trying to optimize take home pay, coverage etc.; and lower wage workers who just don't have the mental cycles to do any thinking get shafted.
The US pays more per capita for healthcare than any developed nation. We should redirect those funds to more taxes to pay for Medicare for all. Costs will go down and your healthcare will no longer be tied to your employment. As a bonus, everyone gets healthcare.
Don't be naive. Medicare reimbursement rates are artificially fixed below the market rate in order to hold down the federal budget. This kind of works right now because Medicare ends up with a hidden cross subsidy from commercial health plans with higher rates (often explicitly set as a fixed multiple of the Medicare rate). If we put everyone on "Medicare For All" then those subsidies will disappear and queues will get much longer. So not everyone "gets" healthcare if they have to wait a year for an elective procedure.
Also, original Medicare Part A/B doesn't cover certain types of healthcare at all such as prescription drugs. So not everyone on Medicare "gets" healthcare today. That's why many Medicare beneficiaries choose to pay out of pocket for Drug Coverage (Part D), Medicare Advantage, and/or Medicare Supplement (Medigap) insurance.
Sure but that’s not gonna happen. Workers mostly ever only get things taken away these days. It wouldn’t mean that money is available somewhere else all of a sudden to pay for healthcare.
If Congress could decide to agree on something, they announce taxes are being raised by X% to provide Medicare for all next year. Next year, employers stop providing healthcare via insurance companies and everyone signs up for medicare. Done.
One of the huge fights about ACA from the left was so-called "Cadillac Plans": Unions negotiated excellent medical insurance coverage in lieu of wages for their members. If you suddenly axed employer-provided coverage, nearly every union in the US would want to renegotiate contracts to account for that.
Everyone needs healthcare, and offering the benefit is mostly untaxed, so it's just a way of offering a higher compensation than the competition that doesn't. End result is most every professional full time job offers it, because taxed can't compete with untaxed.
Tying health insurance (via tax benefits) to employment was a explicit decision by the US government to make people work, but it also makes people stay in worse jobs longer out of fear.
Don't pretend what the US does amounts to genuine care.
The philosophy behind a business caring for employees and implementations of slavery are two fundamentally different topics, only confused when buying into US propaganda.
80 years ago, in the context of the war economy of WW2
How is that relevant? Democrats have been pushing for Medicare for all or some other fully socialized system since the Kennedys, while republicans have shown zero ability to do anything but ban you from buying cheaper drugs
Pretending this is "gubermint bad" is just ignorant. It also just, wasn't the government's explicit doing. The government froze wages during a literally existential war. Look at Russia right now for why that's generally a good idea. Companies responded by offering non-wage payments of various sorts.
The US built a significant fraction of ALL war material for the allies in WW2. They did this through significant amounts of command economy. Building a Liberty transport ship every other day was done by centralized planning, NOT the free market. See the US's current difficulties buying 155mm howitzer rounds for examples of how the "free market" is worthless at dealing with real wartime production concerns. We didn't build 50k tanks by waiting for the free market to collect a payday. We didn't build more aircraft carriers than the rest of the world combined by relying on the free market.
So why haven't republicans fixed this in the near 70 years of political dominance they've had in the US? Democrats have consistently pushed for solving this shitty situation for decades, but have never gotten the votes needed to even get into government.
What I don't see are businesses advocating for someone to take this work off their hands.
I gotta wonder how much hassle this is if it doesn't cause them to advocate for alternatives. Rather lobbying efforts and such seem to focus on other things.
Businesses should get out of health insurance and also things like 401k. Give the same tax benefits to everybody. I am totally convinced that cost would go down if employees could choose health plans for their own needs instead of the employer choosing what's best for the employer.
Crazy! Imagine if human beings did not have to worry about losing access to healthcare for themselves and their children because their company went bankrupt or they got laid off. So Crazy!
The craziest thing to me is paying less even accounting for insurance for simple seasonal illnesses. Do I have strep? Go to hospital and pay $400 to find out yes/no and then get prescription covered by insurance at opaquely priced pharmacy of your choice. Go to private practice pay $25 and get yes/no and then you can freelance prescription.
They don't have to, it's a perk I'm sure that many (me included) rather have their employer pay/take care of, than to do it out of pocket with higher salary.
American mindset. In some countries it's just provided to everyone equally.
And no, we don't have the wait times Americans are afraid of. I can visit a doctor the same day and get treatment. My friends back in the US are desperately trying to find appointments with everything filled months down the line. America has the worst of all systems combined.
Solve that problem first and maybe I'll change my mind. Otherwise I'm being honest in my situation. IME employer provided insurance is way better than what I can find on my own.
Not crazy. Caring about the business without caring about the people who literally are and empower the business is simply dehumanization.
It's been done to death. Literally.
Edit: People seem to think I'm proposing businesses keep operating how they are. I'm suggesting businesses that truly care need people running them who know how to care, not the normalized psychopathy that's become corporate culture. I'm not suggesting current or past harmful relationships with businesses continue or that even those businesses should continue.
Crazy. The whole notion of employer sponsored health insurance is a historical accident and never made any logical sense. I don't want my employer to care about me at that level and prefer a straightforward transactional relationship.
Should business also care about their employee's diets and fitness regimes? There are things that are outside of the purview of a business and the healthcare of their employees, outside of the direct impact of the business's work environment on the employee's health, should not be part of it.
Another way to say it, there is more to health than how an employer affects a person's life, and those things are none of the business' business.
Yes, businesses would be better off if they cared about wellbeing to such a degree. That doesn't mean control employees, though.
It means to actually care about the quality of food the employees have access to and the quality of culture surrounding them. It means caring about the environments people live in. It means recognizing people LEARN to make harming choices through harm (individual, familial, social, collective, cultural, systemic...etc) so recognizing repair is needed & pursuing that. This is what lobbying would be about without dehumanization.
Don't get lost in the fascist fantasies of what it means to care.
I don't want my employer to be involved in any of that though. Otherwise we'll be having a lot more conversations with people who are completely unqualified to make any determinations about things like my mental health.
If you think health insurance is expensive now, wait until it's free!
In all seriousness, if a private business with all the incentive in the world can't figure out how to lower healthcare costs, I don't see how punting to the government would somehow be better.
Everyone that proposes a single payer can't explain who makes less money. Will we save money by the doctors getting paid less? The drug companies? Where do these savings come from?
Even if you're able to do everything the health insurance company does and capture 100% of their margin with equal efficiency, you'll capture a profit margin of around 2-6%.
The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
> if a private business with all the incentive in the world can't figure out how to lower healthcare costs
What if their incentives aren't to lower cost? Insurance companies make more when the obfusicate pricing and payout less. That's the opposite of incentive, it's a way to cover up your profits.
> Everyone that proposes a single payer can't explain who makes less money.
If you think the healthcare industry is just doctor-insurance-you, then you're nuts. Look up pharmacy benefit managers. They're basically third parties that are in place to jack up prices.
> Even if you're able to do everything the health insurance company does and capture 100% of their margin with equal efficiency, you'll capture a profit margin of around 2-6%.
Insurance companies have had their profits capped via the ACA for more than a decade now. Where they're making their money is by using more third parties in the middle to jack up pricing and increase costs so that A) their 2-6% is bigger, and B) their "investments" in the third parties are not regulated by the ACA so they can get their massive profits their.
> The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
Its a very serious argument, you're just happy to dismiss it for some reason. If the entire developed world uses a different system than us, gets better results and for less money, then you'd have to be insane to insist that mimic those systems is not a serious alternative.
Single payer is cheaper. The US spends more per capita than any other developed nation and is not even capable of providing health care to all of its citizens.
Move to single payer, kill the medical insurance industry, and save these costs:
The health insurance industry employs approximately 605,000-912,000 people directly. The top 10 companies generate over $1.5 trillion in combined revenue annually. Conservative estimates suggest these companies spend $45-90 billion annually on employee salaries.
> The US spends more per capita than any other developed nation and is not even capable of providing health care to all of its citizens.
US has medicare and medicaid. It actually spends more than most other countries. I guess they need to spend more to save money?
Again throwing around stats about health insurance industry is not an argument. That money gets spent on something unless you think there is some grand cabal of health insurance companies to do make-work and hire people and set money on fire for no reason. Why doesn't some greedy capitalist start a health insurance company, set slightly less money on fire and provide great healthcare?
Yes, exactly. We spend more far more and get less because we do not have a single payer system like the rest of the world. We are lining the pockets of healthcare execs and unnecessarily employing hundreds of thousands of people at insurance companies and private companies to manage employee benefits.
What do you think is so unique about the US that it is incapable of having similar pricing and quality of care compared to the rest of the developed world?
"The US spends more in public spending on healthcare than other countries" isn't some great gotcha, it's proof that healthcare access in the US is vastly more expensive than in those companies.
Some great quotes from your own link about US healthcare:
> The underlying challenges in fixing U.S. healthcare may be multi-faceted and complex, but the overall diagnosis is clear: costs are out of control.
> In other words, costs seem to be out of whack across the board in the United States, regardless of whether it is private or public care being discussed.
> Spending keeps rising, but the effect of that spending seems to have decreasing marginal returns on life expectancy – a metric that is an important indicator for the overall effectiveness of any health system.
> It’s clear that Americans aren’t getting bang for their buck when it comes to medical treatment – so how is it to be fixed?
Your own link comprehensively and thoroughly disputes your original assertion:
> If you think health insurance is expensive now, wait until it's free!
> The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
Given that all those countries pay less for the healthcare they provide AND have better morbidity and life expectancy outcomes, I dunno, that sounds "better" to me, but apparently you have a different definition?
What you have is a really simplistic model of how private enterprise actually works. And what you need to understand is that economics is primarily driven by incentives, both for the individual and for the company. The only way to get different behavior out of actors in the economy is to offer different incentives, either naturally or by government fiat. Let me give you an example.
The health insurance company's bottom line profits are determined entirely by the volume of cash that they funnel to healthcare. Their profit margins are capped by law to X% of this volume. So the only way they grow year over year is to increase the amount of cash they hoover up and direct to healthcare providers. Because the stock market demands year over year growth, they are incentivized naturally and by fiat to increase the volume of cash that flows through their network. This volume of cash is directly spent on healthcare. So you can see pretty easily that the incentive structures in our society are geared toward raising costs steadily.
If you couple that with private equity buying up healthcare providers and globbing them together, then you can see that there's a whole market system being built to make healthcare more expensive so that health insurance providers can absorb more costs and therefore increase their year over year profits. PE companies increase the negotiating power with insurance companies, and costs increase. And when costs increase, the insurance company's profit increases proportionally year over year.
So what you're saying about private companies doesn't make any sense. There doesn't even have to be collusion, although United Healthcare, an insurance provider, owns Optum, a healthcare provider, and I suspect there is a lot of collusion in relationships like that. The incentives are perfectly aligned to create this situation.
That's not quite how the actual incentives work. Most commercial insurers (both for-profit and non-profit) are increasingly adopting the "payvider" business model pioneered by Kaiser Permanente. As health plans pressured network providers to cut rates, the providers responded with M&A activity (some financed by PE) to gain more negotiating power. In some regions there are only a couple large health systems left that dominate the local market. Like in the SF Bay Area, health plans are pretty much forced to have Sutter Health in their networks in order to maintain adequate coverage. So now the only lever that health plans have left to control costs for their customers (i.e. large employers) is to hire clinicians directly as employees and cut out the middleman. UnitedHealth Group has been particularly aggressive about this strategy but all of their major competitors are taking similar approaches.
> if a private business with all the incentive in the world can't figure out how to lower healthcare costs
Of course they can. But why on earth would they? Health insurers are mandated by law to not exceed certain profit margins, so the only/best way to make more money is not by increasing volume and lowering margin, it's by increasing costs for your target captive market. That flows down the chain, you increase the allowed costs, so providers increase to meet that (why wouldn't they?) and the only person left hurting is the policy holder (and their employer, paying some portion of it).
> unpersuasive. It's not a serious argument
Your argument amounts to "this doesn't make sense, why wouldn't companies look to lower costs" when lowering costs in the health insurance mathematically equals lowering your profits.
What's not a serious argument is this constant belief that America is unique. "We're bigger than other countries", "our population density is different", all these things.
But you're going to need to do better than a pithy "it's not a serious argument" with no substance behind it when acknowledging that the entirety of the developed world hasn't "solved" healthcare but does a better job at making it equitable and accesible to more, at a lower cost, with oftentimes better outcomes (looked at our mortality rates around childbirth, lately?). It's not about the quality of care, it's about a system that revolves around making more money, not patient care. Another simple example, my insurer, Aetna, simply refuses to authorize 90-day (or rather, anything beyond 30-day) prescriptions from any pharmacy except the pharmacy they wholly own. Why? That doesn't provide patient benefit. There's no discount - the charged amount for the 90-day script is 3x the cost of the 30-day. It provides a worse experience for the patient, removing flexibility for them. It doesn't change their pharmacy network - they're still serving pharmacies all over, just for a subset of patient needs.
No, it's just about money. Again, there's near no incentive in the current US healthcare market to compete on price. And that's why US healthcare is ~20% of GDP, double, if not triple the cost of other developed nations.
Okay, and how much did insurers pay back in rebates to companies large enough to have their own pools? Assuredly that has also grown.
People in this thread ask why don’t businesses lobby for public health. Wrong: why doesn’t Apple lobby for public health? Follow the money. It’s so naive to think it’s solely about providers. Who anyways, when there is fraud, they are defrauding CMS, not UNH.
Huh? What rebates do you mean? Most large employers like Apple are already self funded and the health plans merely act as third-party administrators, assembling networks and processing transactions. The ACA does include a minimum medical loss ratio so health plans that come in under the limit are forced to issue premium refunds to customers.
There is plenty of waste, fraud, and abuse committed by providers against all payers including Medicare, Medicaid, and commercial health plans. Most providers are honest and follow the rules in good faith but there are a few bad apples who attempt to exploit all payers.
"The ACA does include a minimum medical loss ratio so health plans that come in under the limit are forced to issue premium refunds to customers."
The loss ratio seems to be a good incentive for insurance to pay more to hospitals in order toincrease their own cut of the premiums they are taking in.
Sure, that's part of it and the minimum medical loss ratio does create some perverse incentives. But in most markets there are intense competitive pressures between health plans which motivates them to negotiate lower rates with network providers. Your employer would be happy to switch from Aetna to Humana (or whatever) next year if it cuts their employee healthcare costs by 3%.
Of course. Those employers are (mostly) not running charities so they'll always attempt to shift as many healthcare costs to employees as they can without triggering tax penalties, or hurting recruiting and retention. This is one reason why society would be better off with eliminating special tax advantages for employer-sponsored health plans. Having employers act as payers and intermediaries reduces consumer choice and hides the true cost of health coverage.
> Most large employers like Apple are already self funded and the health plans merely act as third-party administrators, assembling networks and processing transactions.
Ha ha, “merely act as third-party administrators.” Dude, does United Health or Apple deny your claims?
Anyway, it’s a simple question. Why doesn’t Apple lobby for public health?
If there's a UnitedHealthcare plan for Apple employees (and I don't know which company Apple currently uses) then Apple sets the policy for what is and isn't covered. UHC simply enforces the policy set by Apple so blaming UHC in that scenario is simply naive and displays a total misunderstanding of how the healthcare financing system actually works. UHC would be happy to offer a custom plan for Apple employees that pays 100% of every claim with no questions asked if Apple wanted it — it would be less work for UHC and they would merely pass the costs on to Apple (plus a very small profit margin).
The largest employers do have a financial incentive to maintain the current broken system. Despite the hassles, their economies of scale in running self-funded employee health plans give them a cost advantage over smaller competitors. I suspect that's part of the reason why they don't lobby for reforms but I'm not privy to internal Apple decisions.
> If there's a UnitedHealthcare plan for Apple employees (and I don't know which company Apple currently uses) then Apple sets the policy for what is and isn't covered. UHC simply enforces the policy set by Apple so blaming UHC in that scenario is simply naive and displays a total misunderstanding of how the healthcare financing system actually works.
The reality though is that the employer generally doesn't want to pay 100% of all claims, all the time.
So they're left with "well, what do we pay, how much, and how can we use the insurer's negotiated pricing, etc., etc." and they ask UHC to provide plans that largely match UHC's plans, rules and the like, potentially with one or two little carve outs or exceptions, because UHC is the one that has done the math to make sure that balances cost/benefit for Apple. So a lot of time, they just "pass through" plans.
Which is why most self-funded plans look "suspiciously similar" to what you might find elsewhere in the market.
I wrote software for a healthcare claims benefit management company that drove insurance for direct insureres and TPAs for 12 years.
Okay. So you’re saying tax dodging giant corporations like to save money?
Why does it have to be so complicated? The government HAS to pay for treatments that are FDA approved. UNH and Apple, working together, do not. Furthermore, Apple doesn’t have to cover everyone, the government would! It’s that simple!
For people reading this thread: Apple gets paid a rebate at the end of the year by United. The employee whose paycheck has a cut out for “health plan” does not. It’s that simple. Apple gets to pay the employees less when it chooses United. Apple has not lost many antitrust cases, but it has lost them for paying employees less! This is their MO! Your cheaper ACA plans do not pay rebates for unused services. The government, which pays for the health costs of the people whose claims are denied, does not pay you a rebate. Your auto insurance sometimes “pays” you a “rebate,” if for some idiosyncratic reason Gavin Newsom decides that’s how it should work. So generally, Apple is not lobbying for public health because the status quo lets them save a TON of money by overcharging their own employees for “health plans.”
I don’t think you should throw around “total misunderstanding” like that either. You don’t know me, or know how much I know about this stuff. Not every generalization is Wrong. It can be wrong, but not Wrong. And anyway, you have a problem with my generalizations, and then you say “total misunderstanding,” which is itself a generalization. It’s bad faith. I am choosing rhetorically to generalize, in a way that aligns very well with the truth, and you are choosing meaningless specificity that may be ever so slightly more truthful, but doesn’t align with the emotions - the anger against giant corporations, the government, etc. - at all. We’re both being intellectually honest, but only one of us is co-opted. That is my feedback to you.
No, you're not being intellectually honest. You're lying and making things up. I don't know whether that's due to ignorance or bad faith. And I don't give a damn about your condescending "feedback": save it for someone who cares.
There is no credible allegation here that Apple has dodged US federal or state tax laws.
Government sponsored health plans such as Medicare aren't legally required to pay for all FDA approved treatments (and much of what they do pay for are procedures which aren't subject to FDA approval at all). Commercial health plans offered by UHC and their competitors cover everything that is medically necessary (and they often cover more than Medicare does), but as with everything in healthcare the precise definition of that term gets a bit fuzzy in some edge cases.
Okay well, I think you know a lot about this stuff, and it’s worth thinking very deeply about these questions:
- why does Apple prefer the status quo? How do they “make more money”? Why do they use UNH? They make software, if it’s so simple as you say, administer plans, why don’t they do it themselves? Btw, Apple Health as in Health IT does exist! So does Google’s Health (IT)?
- how can health IT be the second worst performing VC sector (only Ed tech is worse), but UNH is worth whatever it is, hundreds of billions? What is UNH’s actual product? It’s not “being a middleman” - that’s health IT…
- why do doctors think Kaiser sucks? Like how does Kaiser make money?
- do we have “death panels” in this country? What do they look like?
These are all related.
In general, I don’t think health IT has the answers to rising costs. That’s the POV I’m hearing. It’s likely that greater adoption of health IT has accelerated, not slowed, the growth of costs in a way that has not improved outcomes per dollar. That’s an orthodox opinion.
In my experience, the intellectual leap for a lot of engineers working in enterprise sales heavy sectors is two realizations: (1) that just because something happens, doesn’t mean it makes sense (2) and just because you give people what they ask for, such as in the context of health IT fulfilling dull consulting services asks, doesn’t mean that what people are asking for makes sense or is a net positive, maybe by any metric.
And anyway, most experts agree that the middlemen in the healthcare sector, like pharmacy benefit managers and insurers, are responsible for a significant part of the cost difference per outcome here compared to Europe. To me, it is unsurprising that middlemen in general cause costs to rise for very little actual gains, even if in their POV, they are fulfilling some requirement by regulations or whatever. You know, they’re stuck in the “I did what someone asked and paid for, and therefore it makes sense” mindset.
Want this to stop? Make GLP-1 available on every street corner and get the majority of Americans who are overweight or obese to start taking it en mass.
One of the few things I'm happy about republicans being in power for is the current grey market situation with GLP-1s. I have a feeling that a democratic FDA would try to come down hard on the current situation. Rich people and girls who are pissed at their body know how easy it is to get these drugs with no oversight. Thank god for it and may it never get harder to access these substances.
The idea that those who take "the easy way out" are "giving up" is asinine.
There is no moral, social, ethical, or related good from doing "hard work". Physical exercise is wasteful compared to other things that can be done with ones time. Significantly reducing the amount of time needed to be wasted on such activities as the only way to reduce the poison damage of our food on is ontologically good.
Go listen to Bertrand Russel[1] if you don't believe me. Ultra smart, ultra hard working people realized that they had to dedicate entire books to defend being lazy because of how many puritanical pearl clutchers exist who get physically angry at the idea that you can have something good without "earning" it.
> Physical exercise is wasteful compared to other things that can be done with ones time
The human body is meant to move much more than society in 2025 compels it to move. There are countless studies on health, mental health, longevity and quality of life that refute your statement.
That's such a naive and uniformed take. While there are certain benefits to GLP-1 agonists and they are medically indicated in some cases, there are a host of benefits that come from frequent hard physical exercise that go way beyond weight loss. You won't be "ultra smart" in middle age when you have reduced blood flow to your brain due to a sedentary lifestyle. And you can't fix that with a pill or injection.
You've got to be mad thinking that hooking people on medication for life is better than people learning self-control and discipline. This isn't the only area in which those things matter for health outcomes, and for life outcomes.
It does give big pharma a lifelong revenue stream though, so I suppose it's good for them.
I put it in the same category of playing a video-game every day. It can be cool and fun for the people doing it, but a dystopia if you were forced to do it for your health; it's not for everyone.
GLP-1 will help but not completely solve the current obesity epidemic. My source is me being more than 6 month long durations, at maximum dosage, of both semaglutide and tirzepatide. While it's resulted in a solid amount, there is a cap to what it can do where diet/exercise have to take over.
If something is unsustainable then eventually it will stop. US healthcare costs have been increasing at faster than the rate of inflation to the extent that it now consumes about 18% of GDP. The majority of people are on employer sponsored group health plans and employers have absorbed most of the cost increases but they're reaching a breaking point. I predict that more employers will simply drop medical benefits and choose to pay the penalty instead, forcing employees to purchase their own health plans on state ACA exchanges.
https://www.kff.org/affordable-care-act/employer-responsibil...
ACA plans are going up even more on average than employer based plans, at the same time subsidies are being reduced.
The ACA exchanges are possibly doomed long term. People on that skew mid to lower income (but higher than medicaid), and many won't be able to afford the higher premiums - so they will drop off. So then there is the death spiral situation.
That's the insurers putting their finger on the scale so they can hold out for their employment health insurance scam.
I'd prefer that if it was replaced by a system where the business pays/subsidizes YOUR ACA plan. Changing health plans when you change jobs is a huge headache.
A better solution to untie employment from health insurance would be to make premiums tax deductible. That way you would no longer be financially penalized for opting out of employer provided coverage. The cost would be no different than the pre-tax dollars the employer used to pay.
True but it would also be more of a hassle and would be subject to things like putting it in competition with the standard deduction, which doesn't seem to have happened with employer withholdings.
I'd prefer it be unrelated and they can just pay me a fucking salary without deducting several tens-of-thousands "for my benefit".
Don't opt in to the health insurance from your employer then.
I'm obligated to purchase a 30K lottery ticket and lose year over year on the chance I get cancer.
You just described insurance as a whole. If you truly just want catastrophic coverage, get a dirt cheap catastrophic coverage plan from the marketplace and pay for meds and basic care out of pocket, you'll probably save money.
Your employer will not pass any savings on to employees. When has that EVER happened in modern history?
You will be taking a shadow pay cut instead. Or soooo much worse, they will cut your healthcare benefits, and instead pay you the balance of your portion of the premium, which isn't even close to what health benefits cost, and they will angrily expect you to thank them for the privilege.
Then the market would adjust and offer a rebate for not requiring insurance. You can make any claims against that but then you'd have to say something akin to "there is no market for employees". The money that my employer pays in premiums as indicated on my w2 must be going to the insurer surely, even if they are self-insured? If its going to a pool that my employer just gets to keep then why is that tax deductible and why would I trust them with my health insurance?
On the face of it, +1 and yes please, but only if we also see a push to get more/better ACA plans on the market. In some states the pickings are quite slim; last time I browsed ACA plans there were no PPO plans, for example.
I would also accept Medicare For All if we're shooting big here :)
That would be awesome, especially if we could get rid of the yearly Open Enrollment period. We could finally dump insurance providers that don't provide good service or who have bad networks without having to change jobs.
I can't speak to smaller employers who actually use the insurance capability, but larger employers (e.g. 500+ employees) are almost certainly self-insured. They bring the money for the loss pool and use the insurance company for claims service and network.
On it's face it might seem like this isn't related to your complaint, but one of the consequences of self-insurance is that the employer essentially has a dial that they can turn that influences what level of service you get from the provider. If the pool is okay, then your employer might spring for additional benefits like free telehealth. If the pool is marginal, they might force you into a pharmacy plan. And if the pool is completely hosed, then the provider can get aggressive about requiring documentation to bring pool spend back in line.
Exactly right. Many consumers naively blame their health insurance company when they have trouble with a denied claim or prior authorization. What they don't realize is that in most cases the "insurance" company isn't actually providing insurance (bearing financial risk) at all and is simply acting as a third-party administrator for a self-funded employer. It's ultimately the employer that decides what to cover (within legal limits). Insurance companies are happy to offer plans that pay 100% of every claim for everything no questions asked if that's what an employer wants.
Yes and no (and I worked for a company that built software for administrating all that).
You are right, the insurers in a sense don't care about specifics - you can say "everyone gets 52 massage visits a year covered 100%" and they'll do that for you.
But when you talk about TPAs, realize too that those self-funded employers obviously haven't done the actuarial work, so they'll by and large follow an insurer plan because that's had a lot of effort put into balance, optimization and such. Otherwise it's like "I don't know, how much -should- we pay for X?"
Sure, I understand that. Health insurers and TPAs all have standard offerings that they'll sell off the shelf to any customer that wants one. But the point is that they're happy to build a custom product with better benefits for any large customer that asks. When consumers aren't happy with their coverage it's pointless and counterproductive to complain about "greedy" insurance companies: any major improvements will have to come from employers or government. (I suspect that some large employers are secretly happy to take advantage of public ignorance and let insurers take the blame for everything.)
Of course if we take a step back it's crazy that the current system of tax incentives and penalties essentially forces most large employers to do some level of healthcare actuarial work. There's a whole niche industry of consultants who assist self-funded employers with this. But we'd all be better off if access to affordable health coverage wasn't tied to employment.
Even more reasons for insurance companies to not exist.
Not only does what you describe introduce additional middle-man costs that aren't being spent on actual care, but it also obscures the overall health of the public, by creating a number of private health pools that are administered separately.
If we had a single payer system, we'd have much better data on spend vs outcomes and would be able to direct the flow of care much better.
And in the years it would take for a new system to shake out of this disruption and chaos, most people would be unable to access healthcare for basically anything.
Isn't that just great?
I too would love to disconnect healthcare from employment, but good god is this the wrong way to do it. But the current administration has shown for over 20 years that it is utterly incapable of building a solution, so they will just keep tearing down what little of this system is effective while pocketing billions.
If you had 20k extra in your pocket to cover regular shit and 10k to pay for a private health insurance covering catastrophic shit all the while regular hospital expenses went down (cough diagnosis, broken bones, etc etc) I think that would be a good thing. Right now you can see the effects of taking insurance out of the system by going to private practice that doesn't accept insurance. These fuckers way overstepped, not only are you paying several 10K for insurance you pay more when you go for minor issues.
"employers have absorbed most of the cost increases "
Health insurance is part of the total compensation so it's employees who have absorbed the cost by lower salary and higher deductibles, co-pays and whatever other ways insurers find to reduce their own cost.
That thinking only applies to non-essential markets. The whole reason we're in this mess is that insurers (and government/lobbyists) realized that people will never stop getting sick or hurt and that people will pay literally anything for medical care because the alternative is gruesome, horrifying, painful death.
The market simply cannot correct for this. It's just not possible. As fewer people can afford care, prices will go up to offset lost profit. The only organic correction that can happen is if so many people die that the entire economy collapses.
So yes, we'll see a decrease in hiring, a decrease in the number of insured and/or healthy workers, and absolutely nothing will change. The public simply cannot squeeze insurance into lowering prices, nor can businesses. Only legislation can fix this problem.
But since that seems to be ever more unlikely, the best solution is probably for the people to storm the insurance companies and put the CEOs on pikes for all of the death and destruction they've inflicted on our entire society. Democracy has utterly failed us and the only reasonable option left is incredible violence. That's the sad, sorry state that american society is left in today.
Commercial health plans already have very low profit margins, enforced by the ACA minimum medical loss ratio and competitive pressures. There's nothing much to squeeze there. If you analyze the actual cashflows, most of the money is ultimately going to things like provider wages, facilities operations, prescription drugs, and medical devices. Regardless of whether bills are paid by employers, consumers, or government, any attempt to reduce overall healthcare system costs will have to focus on those areas.
And it's horrifying that you would advocate for violence on this issue so I flagged your comment.
I don't see advocacy, I see a regretful prediction (one that I think is quite possible). The horror is being caught in this system.
The USA really needs to implement Medicare For All or a similar plan. The amount of bureacracy that would be simplified or just go away is staggering. The savings would be huge. Getting healthcare would be easier not just for patients but for doctors as well! Doctors' primary concern is providing the best treatment for their patients, but they usually have no idea how much such treatment would cost. Patients often don't know if they'll be totally covered or if they'll be financially ruined until they make a separate phone call to some customer support rep (who also probably doesn't really know). It's nuts. Under a Medicare For All system, coverage would be standardized for everyone, and doctors would have much better understandings of whether an MRI or X drug would be covered or not.
Likewise, employers won't have to carry this burden. Companies that hire employees across multiple states have to navigate a patchwork of state/region based health insurance policies. Whenever there is a wrinkle in health insurance paperwork, an HR person has to to hunt down the issue and coordinate between an employee and the health insurance.
My gosh. I switched employers within a month of having a major medical event, and it was just the worst. The hospital was claiming I didn't have insurance, but I did (through COBRA, which is a whole other shit show that should and would go away), so I had to have multiple phone calls with the HR dept of the employer that I had just left. It's pretty awkward!
How often do we get to say that the government option reduces bureacracy.
That's not to mention the increasing potential for innovation! I know personally I left a fulfilling but somewhat unstable freelance lifestyle to get a job that offers health insurance after I had kids. I would like to pursue something else independently, and I can tolerate the financial risks, but I simply cannot tolerate the high costs of health insurance for myself and the rest of my family (or worse, the risks that come with having no insurance at all). If my family had health insurance, I'd leave my day job and chase other more exciting, fulfilling prospects. If that was a successful venture, maybe I could afford to hire a few employees because I wouldn't have to cover their health insurance.
Medicare For All should be a slam dunk. The only thing standing in the way is the health insurance industry, which is rolling in money. Get rid of them.
It was surreal to see the lengths that bought corpo Dems and their media went to sink the Bernie Sanders campaigns twice, making it extremely clear they preferred Trump over Bernie.
The whole system is broken. It's overdue to launch our own publicly owned instance of what they built in Taiwan to sidestep political gridlock:
https://www.theguardian.com/world/article/2024/aug/17/audrey...
https://www.plurality.net/
Nationalize health care. All health care should be owned by the state and operated not for profit.
The profit motive and health care outcomes are fundamentally at odds.
Nationalize health insurance maybe as a start.
Medicare For All, as put forward by Bernie Sanders, would do this. It basically just expands the existing Medicare structure to cover everyone.
No, also nationalize for-profit hospitals which prioritize ten cents in profit over a person's actual life.
I think you are wrong. Insurance as run today requires so much extra provider staff that it negates its own benefits.
I don't think Hospitals are the folks running away with all the monies here.
https://www.cbsnews.com/news/steward-health-care-hospital-ba...
The whole idea of making employer-sponsored health insurance tax-free but not out of pocket medical expenses is a problem in need of fixing. As things currently stand, you can only write off medical expenses that exceed 7.5% if your adjusted gross income, and only if you use itemized deductions rather than the standard deduction.
This public-private healthcare system as it currently exists in America combines glacially-slow subpar public services with the rent-seeking behavior of private insurance.
More than any other group, it screws small business owners, i.e. the people the politicians usually claim to run for office on behalf of.
Works when/where archive.is is unavailable:
https://www.msn.com/en-us/money/insurance/health-insurance-c...
Text-only, no Javascript:
https://assets.msn.com/content/view/v2/Detail/en-in/AA1Mg1Fv...
https://archive.is/WvHZo
Imagine if businesses did not have to worry about their employee's healthcare. Instead they could focus on the business at hand. Maybe this is just a crazy idea.
I completely agree. While it's counter intuitive, many businesses want to maintain control of employee's healthcare. Some companies look at it as a way to compete by offering better benefits than their competitors. A lot of companies like controlling healthcare because it keeps employees tied to their employer. If you temporarily lose your insurance when you switch a job, all of the sudden switching doesn't look as good. When you get to really larger companies, then they have the ability to self-insure, which means they can control the costs a hell of a lot more.
Of course, since many companies prefer less regulation, the last thing they'd want to do is hand over the keys to what they do for the healthcare for their employees over to the government. With things how they are now, they can always cut or pair back their plans if they want to cut costs. That lever would be gone with single payer.
Like many things, the system is set up to benefit those in charge rather than those who it's meant to serve. You can look just about anywhere outside the US and see that universal healthcare is a much better system, but better for who? Not much of a benefit for those who make the decisions, so we keep the flawed system we have.
>> Some companies look at it as a way to compete by offering better benefits than their competitors.
Do they really? I've see only select hedge funds actually advertise their health plans. Even that is usually that "we pay 100% of premiums." Most plans are impossible to assess until you actually get to the job and see the tiers available and support available. The devil is in the details -- network coverage for your specific state, co-insurance, co-pays, deductibles, % premium paid, support like QoS/tier.
Competition based on benefits really comes in at the low end and the top end of employment.
If you're a tradesperson, just having insurance coverage is a big thing. It doesn't matter if it's not great, it's better than nothing. Leaving a job with insurance for one without insurance is likely going to cost you thousands of dollars out of pocket for the same coverage.
At the top end, companies will have plans that cover so many things at very high percentages, meaning that your out of pocket for health insurance will be surprisingly small. Less competitive companies simply can't offer that.
It's only in the middle where the details of a plan matter, and those are going to be the hardest details to find.
Someone has to pay for healthcare. If not the employer directly, then they’ll pay for it through higher wages. Are you suggesting employees stop paying for healthcare altogether?
Healthcare thru employment began as a perk for employees. Everyone else just paid out of pocket for regular care. And yes, it was priced into wages.
Even today, most people will pay several hundred dollars a month for insurance; the employer will pay several hundred dollars and the plan will still have a $2K or so deductible. That's a lot of money that most people make no use of at all.
If you pay out of pocket it is post-tax. If your employer pays it is barely at all taxed.
If you accept higher wages to pay it for yourself, it's a bad deal, either to the employer or to you or possibly to both.
> it's a bad deal,
Not necessarily: I gain the ability to switch insurances (imagine, for example, a "free market" where insurance has to compete…), job losses or changes don't affect my insurance, etc. Actual competitive pressure and lower switching costs should, in theory, drive the price down.
Also, IIRC, insurance premiums paid with post-tax dollars are deductible, so they're not really post-tax. However, that deduction is part of the itemized deduction — while currently most people are not itemizing (as they do not have enough itemized deductions to hit the "it is worth it" threshold), my napkin math says that throwing HC premiums in there — since HC is so damn expensive — tips the scale / breaks the threshold for basically any normal income level.
But this is also an "imagine if" thread. Imagine if we made healthcare premiums outright deductible to alleviate the problem you've identified?
I also was buying out of pocket while employed for awhile. Unless you have a qualifying event you can only switch insurance at the beginning of the year, at least from the insurance options I was able to find that fit my family.
I honestly didn't even realize the thing about the standard deductible until I had already done it. I was shocked to find I couldn't deduct it because I'd have to use the itemized deduction which would have been lower. I just assumed my insurance could have been deducted like it was when I bought it through my employer... how wrong I was.
But yes I would absolutely prefer the "imagine if" scenario.
You should think of a tax deduction less as "free money" and more as "behavior the government wants to subsidize."
"This is a better paradigm because the government has decided to subsidize it" isn't a particularly compelling argument.
It's not a compelling argument for society, but it's a compelling argument for the individual at the instantaneous moment of making that microeconomic decision.
Not if it is an HSA like setup which is pre tax.
But you're right, this taxation intertwine is another tangle that shouldn't exist. Too much energy is spent by everyone trying to optimize take home pay, coverage etc.; and lower wage workers who just don't have the mental cycles to do any thinking get shafted.
The US pays more per capita for healthcare than any developed nation. We should redirect those funds to more taxes to pay for Medicare for all. Costs will go down and your healthcare will no longer be tied to your employment. As a bonus, everyone gets healthcare.
Don't be naive. Medicare reimbursement rates are artificially fixed below the market rate in order to hold down the federal budget. This kind of works right now because Medicare ends up with a hidden cross subsidy from commercial health plans with higher rates (often explicitly set as a fixed multiple of the Medicare rate). If we put everyone on "Medicare For All" then those subsidies will disappear and queues will get much longer. So not everyone "gets" healthcare if they have to wait a year for an elective procedure.
Also, original Medicare Part A/B doesn't cover certain types of healthcare at all such as prescription drugs. So not everyone on Medicare "gets" healthcare today. That's why many Medicare beneficiaries choose to pay out of pocket for Drug Coverage (Part D), Medicare Advantage, and/or Medicare Supplement (Medigap) insurance.
But what about billions in profit for healthcare insurance companies and their business model to collect money and deny benefits?
Sure but that’s not gonna happen. Workers mostly ever only get things taken away these days. It wouldn’t mean that money is available somewhere else all of a sudden to pay for healthcare.
If Congress could decide to agree on something, they announce taxes are being raised by X% to provide Medicare for all next year. Next year, employers stop providing healthcare via insurance companies and everyone signs up for medicare. Done.
One of the huge fights about ACA from the left was so-called "Cadillac Plans": Unions negotiated excellent medical insurance coverage in lieu of wages for their members. If you suddenly axed employer-provided coverage, nearly every union in the US would want to renegotiate contracts to account for that.
Everyone needs healthcare, and offering the benefit is mostly untaxed, so it's just a way of offering a higher compensation than the competition that doesn't. End result is most every professional full time job offers it, because taxed can't compete with untaxed.
You've explained the current situation without acknowledging any of its downsides, good job.
This is how they keep the cogs trapped in the machine
Tying health insurance (via tax benefits) to employment was a explicit decision by the US government to make people work, but it also makes people stay in worse jobs longer out of fear.
Don't pretend what the US does amounts to genuine care.
The philosophy behind a business caring for employees and implementations of slavery are two fundamentally different topics, only confused when buying into US propaganda.
Sure.
80 years ago, in the context of the war economy of WW2
How is that relevant? Democrats have been pushing for Medicare for all or some other fully socialized system since the Kennedys, while republicans have shown zero ability to do anything but ban you from buying cheaper drugs
Pretending this is "gubermint bad" is just ignorant. It also just, wasn't the government's explicit doing. The government froze wages during a literally existential war. Look at Russia right now for why that's generally a good idea. Companies responded by offering non-wage payments of various sorts.
The US built a significant fraction of ALL war material for the allies in WW2. They did this through significant amounts of command economy. Building a Liberty transport ship every other day was done by centralized planning, NOT the free market. See the US's current difficulties buying 155mm howitzer rounds for examples of how the "free market" is worthless at dealing with real wartime production concerns. We didn't build 50k tanks by waiting for the free market to collect a payday. We didn't build more aircraft carriers than the rest of the world combined by relying on the free market.
So why haven't republicans fixed this in the near 70 years of political dominance they've had in the US? Democrats have consistently pushed for solving this shitty situation for decades, but have never gotten the votes needed to even get into government.
What I don't see are businesses advocating for someone to take this work off their hands.
I gotta wonder how much hassle this is if it doesn't cause them to advocate for alternatives. Rather lobbying efforts and such seem to focus on other things.
Businesses should get out of health insurance and also things like 401k. Give the same tax benefits to everybody. I am totally convinced that cost would go down if employees could choose health plans for their own needs instead of the employer choosing what's best for the employer.
I would like them to, but they also don't seem to want out.
How much hassle this is to them seems up in the air to me.
Crazy! Imagine if human beings did not have to worry about losing access to healthcare for themselves and their children because their company went bankrupt or they got laid off. So Crazy!
The craziest thing to me is paying less even accounting for insurance for simple seasonal illnesses. Do I have strep? Go to hospital and pay $400 to find out yes/no and then get prescription covered by insurance at opaquely priced pharmacy of your choice. Go to private practice pay $25 and get yes/no and then you can freelance prescription.
I don't worry about it. I just pay it 100% for my employees.
They don't have to, it's a perk I'm sure that many (me included) rather have their employer pay/take care of, than to do it out of pocket with higher salary.
American mindset. In some countries it's just provided to everyone equally.
And no, we don't have the wait times Americans are afraid of. I can visit a doctor the same day and get treatment. My friends back in the US are desperately trying to find appointments with everything filled months down the line. America has the worst of all systems combined.
Solve that problem first and maybe I'll change my mind. Otherwise I'm being honest in my situation. IME employer provided insurance is way better than what I can find on my own.
Not crazy. Caring about the business without caring about the people who literally are and empower the business is simply dehumanization.
It's been done to death. Literally.
Edit: People seem to think I'm proposing businesses keep operating how they are. I'm suggesting businesses that truly care need people running them who know how to care, not the normalized psychopathy that's become corporate culture. I'm not suggesting current or past harmful relationships with businesses continue or that even those businesses should continue.
Crazy. The whole notion of employer sponsored health insurance is a historical accident and never made any logical sense. I don't want my employer to care about me at that level and prefer a straightforward transactional relationship.
Dumb take, business is "spending" 30k plus to "help out" but not allowing any choice of options to employees and an opaque choice by joyce in HR.
I'm not suggesting implementing dumb care. Genuine care isn't fascistic and doesn't sacrifice people's wellbeing (which includes autonomy).
If my employer wants me to have good healthcare they can pay a salary that allows for it.
Yes. They can also lobby for all kinds of systemic changes (and already do, but usually away from care)
I mean this nicely but I don't really think you are making any sort of coherent argument.
Should business also care about their employee's diets and fitness regimes? There are things that are outside of the purview of a business and the healthcare of their employees, outside of the direct impact of the business's work environment on the employee's health, should not be part of it.
Another way to say it, there is more to health than how an employer affects a person's life, and those things are none of the business' business.
Yes, businesses would be better off if they cared about wellbeing to such a degree. That doesn't mean control employees, though.
It means to actually care about the quality of food the employees have access to and the quality of culture surrounding them. It means caring about the environments people live in. It means recognizing people LEARN to make harming choices through harm (individual, familial, social, collective, cultural, systemic...etc) so recognizing repair is needed & pursuing that. This is what lobbying would be about without dehumanization.
Don't get lost in the fascist fantasies of what it means to care.
I don't want my employer to be involved in any of that though. Otherwise we'll be having a lot more conversations with people who are completely unqualified to make any determinations about things like my mental health.
Classic neo liberalism. Works for whoever owns the capital, yes, terrible for workers.
If you think health insurance is expensive now, wait until it's free!
In all seriousness, if a private business with all the incentive in the world can't figure out how to lower healthcare costs, I don't see how punting to the government would somehow be better.
Everyone that proposes a single payer can't explain who makes less money. Will we save money by the doctors getting paid less? The drug companies? Where do these savings come from?
Even if you're able to do everything the health insurance company does and capture 100% of their margin with equal efficiency, you'll capture a profit margin of around 2-6%.
The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
> if a private business with all the incentive in the world can't figure out how to lower healthcare costs
What if their incentives aren't to lower cost? Insurance companies make more when the obfusicate pricing and payout less. That's the opposite of incentive, it's a way to cover up your profits.
> Everyone that proposes a single payer can't explain who makes less money.
If you think the healthcare industry is just doctor-insurance-you, then you're nuts. Look up pharmacy benefit managers. They're basically third parties that are in place to jack up prices.
> Even if you're able to do everything the health insurance company does and capture 100% of their margin with equal efficiency, you'll capture a profit margin of around 2-6%.
Insurance companies have had their profits capped via the ACA for more than a decade now. Where they're making their money is by using more third parties in the middle to jack up pricing and increase costs so that A) their 2-6% is bigger, and B) their "investments" in the third parties are not regulated by the ACA so they can get their massive profits their.
> The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
Its a very serious argument, you're just happy to dismiss it for some reason. If the entire developed world uses a different system than us, gets better results and for less money, then you'd have to be insane to insist that mimic those systems is not a serious alternative.
Single payer is cheaper. The US spends more per capita than any other developed nation and is not even capable of providing health care to all of its citizens.
Move to single payer, kill the medical insurance industry, and save these costs:
The health insurance industry employs approximately 605,000-912,000 people directly. The top 10 companies generate over $1.5 trillion in combined revenue annually. Conservative estimates suggest these companies spend $45-90 billion annually on employee salaries.
> The US spends more per capita than any other developed nation and is not even capable of providing health care to all of its citizens.
US has medicare and medicaid. It actually spends more than most other countries. I guess they need to spend more to save money?
Again throwing around stats about health insurance industry is not an argument. That money gets spent on something unless you think there is some grand cabal of health insurance companies to do make-work and hire people and set money on fire for no reason. Why doesn't some greedy capitalist start a health insurance company, set slightly less money on fire and provide great healthcare?
https://www.visualcapitalist.com/u-s-spends-public-money-hea...
Yes, exactly. We spend more far more and get less because we do not have a single payer system like the rest of the world. We are lining the pockets of healthcare execs and unnecessarily employing hundreds of thousands of people at insurance companies and private companies to manage employee benefits.
How does removing competition and choice reduce costs?
What do you think is so unique about the US that it is incapable of having similar pricing and quality of care compared to the rest of the developed world?
"The US spends more in public spending on healthcare than other countries" isn't some great gotcha, it's proof that healthcare access in the US is vastly more expensive than in those companies.
Some great quotes from your own link about US healthcare:
> The underlying challenges in fixing U.S. healthcare may be multi-faceted and complex, but the overall diagnosis is clear: costs are out of control.
> In other words, costs seem to be out of whack across the board in the United States, regardless of whether it is private or public care being discussed.
> Spending keeps rising, but the effect of that spending seems to have decreasing marginal returns on life expectancy – a metric that is an important indicator for the overall effectiveness of any health system.
> It’s clear that Americans aren’t getting bang for their buck when it comes to medical treatment – so how is it to be fixed?
Your own link comprehensively and thoroughly disputes your original assertion:
> If you think health insurance is expensive now, wait until it's free!
> The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better
Given that all those countries pay less for the healthcare they provide AND have better morbidity and life expectancy outcomes, I dunno, that sounds "better" to me, but apparently you have a different definition?
What you have is a really simplistic model of how private enterprise actually works. And what you need to understand is that economics is primarily driven by incentives, both for the individual and for the company. The only way to get different behavior out of actors in the economy is to offer different incentives, either naturally or by government fiat. Let me give you an example.
The health insurance company's bottom line profits are determined entirely by the volume of cash that they funnel to healthcare. Their profit margins are capped by law to X% of this volume. So the only way they grow year over year is to increase the amount of cash they hoover up and direct to healthcare providers. Because the stock market demands year over year growth, they are incentivized naturally and by fiat to increase the volume of cash that flows through their network. This volume of cash is directly spent on healthcare. So you can see pretty easily that the incentive structures in our society are geared toward raising costs steadily.
If you couple that with private equity buying up healthcare providers and globbing them together, then you can see that there's a whole market system being built to make healthcare more expensive so that health insurance providers can absorb more costs and therefore increase their year over year profits. PE companies increase the negotiating power with insurance companies, and costs increase. And when costs increase, the insurance company's profit increases proportionally year over year.
So what you're saying about private companies doesn't make any sense. There doesn't even have to be collusion, although United Healthcare, an insurance provider, owns Optum, a healthcare provider, and I suspect there is a lot of collusion in relationships like that. The incentives are perfectly aligned to create this situation.
That's not quite how the actual incentives work. Most commercial insurers (both for-profit and non-profit) are increasingly adopting the "payvider" business model pioneered by Kaiser Permanente. As health plans pressured network providers to cut rates, the providers responded with M&A activity (some financed by PE) to gain more negotiating power. In some regions there are only a couple large health systems left that dominate the local market. Like in the SF Bay Area, health plans are pretty much forced to have Sutter Health in their networks in order to maintain adequate coverage. So now the only lever that health plans have left to control costs for their customers (i.e. large employers) is to hire clinicians directly as employees and cut out the middleman. UnitedHealth Group has been particularly aggressive about this strategy but all of their major competitors are taking similar approaches.
"The only argument I hear is "other countries do it", which is just unpersuasive. It's not a serious argument. Propose something better"
What's unserious about this?
> if a private business with all the incentive in the world can't figure out how to lower healthcare costs
Of course they can. But why on earth would they? Health insurers are mandated by law to not exceed certain profit margins, so the only/best way to make more money is not by increasing volume and lowering margin, it's by increasing costs for your target captive market. That flows down the chain, you increase the allowed costs, so providers increase to meet that (why wouldn't they?) and the only person left hurting is the policy holder (and their employer, paying some portion of it).
> unpersuasive. It's not a serious argument
Your argument amounts to "this doesn't make sense, why wouldn't companies look to lower costs" when lowering costs in the health insurance mathematically equals lowering your profits.
What's not a serious argument is this constant belief that America is unique. "We're bigger than other countries", "our population density is different", all these things.
But you're going to need to do better than a pithy "it's not a serious argument" with no substance behind it when acknowledging that the entirety of the developed world hasn't "solved" healthcare but does a better job at making it equitable and accesible to more, at a lower cost, with oftentimes better outcomes (looked at our mortality rates around childbirth, lately?). It's not about the quality of care, it's about a system that revolves around making more money, not patient care. Another simple example, my insurer, Aetna, simply refuses to authorize 90-day (or rather, anything beyond 30-day) prescriptions from any pharmacy except the pharmacy they wholly own. Why? That doesn't provide patient benefit. There's no discount - the charged amount for the 90-day script is 3x the cost of the 30-day. It provides a worse experience for the patient, removing flexibility for them. It doesn't change their pharmacy network - they're still serving pharmacies all over, just for a subset of patient needs.
No, it's just about money. Again, there's near no incentive in the current US healthcare market to compete on price. And that's why US healthcare is ~20% of GDP, double, if not triple the cost of other developed nations.
The Medicare-for-all solution increasingly seems to be the most economical.
Okay, and how much did insurers pay back in rebates to companies large enough to have their own pools? Assuredly that has also grown.
People in this thread ask why don’t businesses lobby for public health. Wrong: why doesn’t Apple lobby for public health? Follow the money. It’s so naive to think it’s solely about providers. Who anyways, when there is fraud, they are defrauding CMS, not UNH.
Huh? What rebates do you mean? Most large employers like Apple are already self funded and the health plans merely act as third-party administrators, assembling networks and processing transactions. The ACA does include a minimum medical loss ratio so health plans that come in under the limit are forced to issue premium refunds to customers.
There is plenty of waste, fraud, and abuse committed by providers against all payers including Medicare, Medicaid, and commercial health plans. Most providers are honest and follow the rules in good faith but there are a few bad apples who attempt to exploit all payers.
"The ACA does include a minimum medical loss ratio so health plans that come in under the limit are forced to issue premium refunds to customers."
The loss ratio seems to be a good incentive for insurance to pay more to hospitals in order toincrease their own cut of the premiums they are taking in.
Sure, that's part of it and the minimum medical loss ratio does create some perverse incentives. But in most markets there are intense competitive pressures between health plans which motivates them to negotiate lower rates with network providers. Your employer would be happy to switch from Aetna to Humana (or whatever) next year if it cuts their employee healthcare costs by 3%.
It seems they have decided it’s easier to save money by jacking up deductibles and copays.
Of course. Those employers are (mostly) not running charities so they'll always attempt to shift as many healthcare costs to employees as they can without triggering tax penalties, or hurting recruiting and retention. This is one reason why society would be better off with eliminating special tax advantages for employer-sponsored health plans. Having employers act as payers and intermediaries reduces consumer choice and hides the true cost of health coverage.
> Most large employers like Apple are already self funded and the health plans merely act as third-party administrators, assembling networks and processing transactions.
Ha ha, “merely act as third-party administrators.” Dude, does United Health or Apple deny your claims?
Anyway, it’s a simple question. Why doesn’t Apple lobby for public health?
If there's a UnitedHealthcare plan for Apple employees (and I don't know which company Apple currently uses) then Apple sets the policy for what is and isn't covered. UHC simply enforces the policy set by Apple so blaming UHC in that scenario is simply naive and displays a total misunderstanding of how the healthcare financing system actually works. UHC would be happy to offer a custom plan for Apple employees that pays 100% of every claim with no questions asked if Apple wanted it — it would be less work for UHC and they would merely pass the costs on to Apple (plus a very small profit margin).
The largest employers do have a financial incentive to maintain the current broken system. Despite the hassles, their economies of scale in running self-funded employee health plans give them a cost advantage over smaller competitors. I suspect that's part of the reason why they don't lobby for reforms but I'm not privy to internal Apple decisions.
> If there's a UnitedHealthcare plan for Apple employees (and I don't know which company Apple currently uses) then Apple sets the policy for what is and isn't covered. UHC simply enforces the policy set by Apple so blaming UHC in that scenario is simply naive and displays a total misunderstanding of how the healthcare financing system actually works.
The reality though is that the employer generally doesn't want to pay 100% of all claims, all the time.
So they're left with "well, what do we pay, how much, and how can we use the insurer's negotiated pricing, etc., etc." and they ask UHC to provide plans that largely match UHC's plans, rules and the like, potentially with one or two little carve outs or exceptions, because UHC is the one that has done the math to make sure that balances cost/benefit for Apple. So a lot of time, they just "pass through" plans.
Which is why most self-funded plans look "suspiciously similar" to what you might find elsewhere in the market.
I wrote software for a healthcare claims benefit management company that drove insurance for direct insureres and TPAs for 12 years.
Okay. So you’re saying tax dodging giant corporations like to save money?
Why does it have to be so complicated? The government HAS to pay for treatments that are FDA approved. UNH and Apple, working together, do not. Furthermore, Apple doesn’t have to cover everyone, the government would! It’s that simple!
For people reading this thread: Apple gets paid a rebate at the end of the year by United. The employee whose paycheck has a cut out for “health plan” does not. It’s that simple. Apple gets to pay the employees less when it chooses United. Apple has not lost many antitrust cases, but it has lost them for paying employees less! This is their MO! Your cheaper ACA plans do not pay rebates for unused services. The government, which pays for the health costs of the people whose claims are denied, does not pay you a rebate. Your auto insurance sometimes “pays” you a “rebate,” if for some idiosyncratic reason Gavin Newsom decides that’s how it should work. So generally, Apple is not lobbying for public health because the status quo lets them save a TON of money by overcharging their own employees for “health plans.”
I don’t think you should throw around “total misunderstanding” like that either. You don’t know me, or know how much I know about this stuff. Not every generalization is Wrong. It can be wrong, but not Wrong. And anyway, you have a problem with my generalizations, and then you say “total misunderstanding,” which is itself a generalization. It’s bad faith. I am choosing rhetorically to generalize, in a way that aligns very well with the truth, and you are choosing meaningless specificity that may be ever so slightly more truthful, but doesn’t align with the emotions - the anger against giant corporations, the government, etc. - at all. We’re both being intellectually honest, but only one of us is co-opted. That is my feedback to you.
No, you're not being intellectually honest. You're lying and making things up. I don't know whether that's due to ignorance or bad faith. And I don't give a damn about your condescending "feedback": save it for someone who cares.
There is no credible allegation here that Apple has dodged US federal or state tax laws.
Government sponsored health plans such as Medicare aren't legally required to pay for all FDA approved treatments (and much of what they do pay for are procedures which aren't subject to FDA approval at all). Commercial health plans offered by UHC and their competitors cover everything that is medically necessary (and they often cover more than Medicare does), but as with everything in healthcare the precise definition of that term gets a bit fuzzy in some edge cases.
Okay well, I think you know a lot about this stuff, and it’s worth thinking very deeply about these questions:
- why does Apple prefer the status quo? How do they “make more money”? Why do they use UNH? They make software, if it’s so simple as you say, administer plans, why don’t they do it themselves? Btw, Apple Health as in Health IT does exist! So does Google’s Health (IT)?
- how can health IT be the second worst performing VC sector (only Ed tech is worse), but UNH is worth whatever it is, hundreds of billions? What is UNH’s actual product? It’s not “being a middleman” - that’s health IT…
- why do doctors think Kaiser sucks? Like how does Kaiser make money?
- do we have “death panels” in this country? What do they look like?
These are all related.
In general, I don’t think health IT has the answers to rising costs. That’s the POV I’m hearing. It’s likely that greater adoption of health IT has accelerated, not slowed, the growth of costs in a way that has not improved outcomes per dollar. That’s an orthodox opinion.
In my experience, the intellectual leap for a lot of engineers working in enterprise sales heavy sectors is two realizations: (1) that just because something happens, doesn’t mean it makes sense (2) and just because you give people what they ask for, such as in the context of health IT fulfilling dull consulting services asks, doesn’t mean that what people are asking for makes sense or is a net positive, maybe by any metric.
And anyway, most experts agree that the middlemen in the healthcare sector, like pharmacy benefit managers and insurers, are responsible for a significant part of the cost difference per outcome here compared to Europe. To me, it is unsurprising that middlemen in general cause costs to rise for very little actual gains, even if in their POV, they are fulfilling some requirement by regulations or whatever. You know, they’re stuck in the “I did what someone asked and paid for, and therefore it makes sense” mindset.
Want this to stop? Make GLP-1 available on every street corner and get the majority of Americans who are overweight or obese to start taking it en mass.
One of the few things I'm happy about republicans being in power for is the current grey market situation with GLP-1s. I have a feeling that a democratic FDA would try to come down hard on the current situation. Rich people and girls who are pissed at their body know how easy it is to get these drugs with no oversight. Thank god for it and may it never get harder to access these substances.
What a sad state of affairs. That’s what giving up looks like in my opinion. Which is fine but that’s what it is.
The idea that those who take "the easy way out" are "giving up" is asinine.
There is no moral, social, ethical, or related good from doing "hard work". Physical exercise is wasteful compared to other things that can be done with ones time. Significantly reducing the amount of time needed to be wasted on such activities as the only way to reduce the poison damage of our food on is ontologically good.
Go listen to Bertrand Russel[1] if you don't believe me. Ultra smart, ultra hard working people realized that they had to dedicate entire books to defend being lazy because of how many puritanical pearl clutchers exist who get physically angry at the idea that you can have something good without "earning" it.
[1] https://en.wikipedia.org/wiki/In_Praise_of_Idleness_and_Othe...
> Physical exercise is wasteful compared to other things that can be done with ones time
The human body is meant to move much more than society in 2025 compels it to move. There are countless studies on health, mental health, longevity and quality of life that refute your statement.
That's such a naive and uniformed take. While there are certain benefits to GLP-1 agonists and they are medically indicated in some cases, there are a host of benefits that come from frequent hard physical exercise that go way beyond weight loss. You won't be "ultra smart" in middle age when you have reduced blood flow to your brain due to a sedentary lifestyle. And you can't fix that with a pill or injection.
You've got to be mad thinking that hooking people on medication for life is better than people learning self-control and discipline. This isn't the only area in which those things matter for health outcomes, and for life outcomes.
It does give big pharma a lifelong revenue stream though, so I suppose it's good for them.
I put it in the same category of playing a video-game every day. It can be cool and fun for the people doing it, but a dystopia if you were forced to do it for your health; it's not for everyone.
Take childhood obesity as a single case-study. Add ozempic and all you've done is covered up childhood abuse.
GLP-1 will help but not completely solve the current obesity epidemic. My source is me being more than 6 month long durations, at maximum dosage, of both semaglutide and tirzepatide. While it's resulted in a solid amount, there is a cap to what it can do where diet/exercise have to take over.
Wildly myopic pump of glp-1 stock