It doesn't require collusion, just misaligned incentives.

"Perversely, with the MLR requirement capping profit margins and administrative costs, insurers are discouraged from containing health plans’ premium increases. Economists have noted that the MLR requirement effectively turns health insurers into “cost-plus” businesses: If insurers’ predicted premiums are less than the actual medical care spending on claims, it can lead to higher MLRs and less profits, within MLR restrictions. Professor Scott Harrington warned early on that MLR requirements could reduce insurers’ motivation to control premium increases. Prior research has found that the MLR requirement is associated with stronger financial performance for insurers, since they can raise premiums to cover higher claims and still comply with the MLR threshold."

After the ACA passed it's really hard for insurers to differentiate on policies because so much is mandated. They're essentially all identical products that are going to have similar prices.

The insurance company that provides your ACA plans gets money from the government for doing so. How much money they get is tied to a few things (not an exhaustive list):

1. On average, how healthy is your group of ACA plan holders? If the group has a bunch of chronic conditions, they get more subsidy money to offset the increased care costs. Going to the PCP allows them to have official medical evidence of those conditions.

2. The government gives these plans quality ratings to help people compare them to each other. These ratings are partially based on how often patients get their annual screenings and patient satisfaction. A gift card for a PCP visit accomplishes both aims.

There are also more practical concerns. Preventative care is cheaper than an acute incident for the company. You'd rather catch an arrhythmia at a PCP appointment than pay for the cost of a heart attack.

You must have very little income.

I had an ACA "marketplace" plan back for my family back in 2017 when I was self-employed. My premiums were >$15K / year for a >$10K deductible and no tax credits (because of my income).

Could you elaborate?

There are all sorts of perverse incentives in play. Many plans won't pay for weight loss drugs (obviously GLP-1s, but even beyond that) but will happily pay for gastric bypass, for one simple example.

> things like spurious denials drive up costs for them and for the providers

Spurious denials? Or improperly filed claims?

How would spurious denials drive up the cost of medical service?

By definition a free market in healthcare requires forcing some people to die from a treatable injury or condition to discover the optimal price. That's part of the definition.

The buyer and sellers are frequently wrong. The buyer isn’t the patient, it’s the employer. The insurer is either charging a premium for risk or servicing work for a self-pay employer.

The biggest buyer is the Federal government and by law they are required to get the best deal, the government also restricts the supply of providers. It’s not a capitalist system at all. It’s a weird hybrid command economy with a consolidating cartel of providers and administrators.

Because the American Medical Association artificially restricts residency spots in hospitals. There's really not much more to it. This explains the proliferation of NPs, PA-Cs, etc acting as GPs. In reality, we simply need more doctors, so we should uncap the # of spots.

Because human labor is supply side constrained.

There's only so many doctors, only so many MRI machines, so many valve stents, so many syringes.

Everything on earth is supply constrained.

The fact that a single person is "in charge" of the government, with the other two branches largely deferring all power to that one person, is a recent aberration from the norm in the USA. I'm for a single-payer health system that is administered by a well-checked regulatory apparatus and institutions that are not subject to wild policy swings at the whim of a single king-like leader.

Public healthcare in the US can work. Most seniors on traditional Medicare like it. Make that available to more people, and bob's your uncle.

I propose allowing buy into medicare at 5 years before regular eligibility. And a long phase in of lowering the eligibility age. Drop it by 6 months every year for 10 years, then 1 year every year for 10 years, then 2 years every year until everyone with work credits is eligible.

At the same time, start covering all kids up to some age with Medicaid (after all, kids tend to have no income, so if eligibility was based on their own income instead of household income, they'd qualify). First year, kids get covered until 6 months, next year until 1 year, etc.

When the Medicare and Medicaid ages meet, we have universal health care. It would take a long time to get there on my schedule, but it would be gradual, so everyone could adapt. And if future legislation could adjust the timeline as needed.

Also, clearly someone needs to add more residency slots.

There are so many more options than a 4 year administration being hostile to the people it's supposed to represent. Corruption will undermine any collective action amongst honest collaborators regardless of what color their party flag is.

Also, having a baseline of public care and then private as an option on top doesn't sound like the boogeyman this is pitching it as to me. That seems like a great way to reduce the scope of what the state needs to be in charge of.

If the take is that government cannot possibly work for the people no matter what then yeah, all policy is bad.

Before we go pushing money into private insurance, we need to define why. We need to understand why the public ones are inadequate and who/what drove those decisions.

A public health care system should be independent of politics. Unfortunately, as the latest administration has shown, even if you designed it to be independent, such as the CFPB, it doesn't matter with an autocrat in charge. On the other hand, private industry does not have all that good a reputation for not effing with your healthcare.

I don't think it's odd for a middleman to have some functions in a market (as long as they aren't actually producing anything) but also the definition of a middleman is unimportant to me. I am just highlighting how he glides over a lot in this article (some of which are actually common progressive critiques of the insurance system) and I don't come away from it sympathetic to medical insurance companies at all.

Is she really underpaid? The average pediatric critical care physician in the US makes $262K-$440K a year according to Glassdoor.

This is twice what the same role pays in most European countries. Unless she is well below that range for some reason, she is likely overpaid.

Everybody in healthcare, from the nurses to the hospital CEOs, makes far far more in the US than they would in a country with socialized medicine.

Because you wanted to pay more? Or are you saying it is cheaper in the US? If the latter, could you be more specific?

I pay the maximum possible in Germany for my health insurance and from what I understand I still pay less for healthcare than I would in the US.

I've lived for many years each in the UK, Australia and the US. I've worked as a healthcare provider for many years in the US.

I would dearly love to know what "costs" of healthcare you are looking at when you say the US is preferable enough to actually move to/be in/stay in the US.

Because when I can have higher end insurance from my employer, and still be out $9K for a kidney stone after insurance, I'm not seeing it. That is an outlier, for me, I'll acknowledge, but it's still nearly five digits that had to come out of my pocket after my employer paid thousands, I paid premiums, for insurance (that is insurance-in-name-only).