100%. America's healthcare system is a disgrace - it serves the executives and shareholders of the gargantuan health insurers rather than patients, who often turn to substandard "temporary" or "association" plans, or even "ministry" plans, thinking they are getting the same coverage for less cost, only to learn their lesson the hard way.
There is another cost effective model in the U.S. I have managed a union health plan for 15 years and approaching retirement. The plan covers about 6000 lives with comprehensive low deductible (ranging from $5 to $115) as well as dental and vision. But we are not for profit and self administered (we do not use a contracted third party administrator. Our administrative costs are 4% to 8% of total spend. Our contribution rates (a/k/a premiums) are just under 1/2 the national average per participant cost. Nearly 100% of the contribution is paid by employers and most employers do pay 100%. We have very modest offices, pay modest salaries, and have kept annual increases between 0% and 4% for last ten years. As this article notes, we are not driven by profit - we are driven by pressure from employers and the union to keep costs as low as possible while still offering a comprehensive set of benefits.
Yes we rent networks for physicians and ancillary - but use reference based pricing for hospitals and surgery centers. We also have implemented higher level bill review on claims. So we do incur network fees and we do pay "shared savings" fees. But we put a cap on the payment of shared savings for larger claims. So we do pay for these but we find that our net is very favorable.
The arbitrage between payers and providers as the payers have made claims processing and the repeated denial and clarification steps a resistance to defer cash flow out is the main reason Hospital providers are struggling to have positive margins. The game is to constantly change and make more obscure the rules and hurdles so that money stays in the bank as long as possible. It is the ultimate process tax on healthcare spending and sadly deflects directly to patients experience in seeking care.
Cont get me started on the delays that PBM’s (now largely owned directly or indirectly by Insurers) do the same thing with drugs. The friction created is harming patients in a large number of cases.
And the dirty little secret, The insurers pay so much in lobbying and political donations (bribes) to Congress and senate that there is no incentive to make wholesale changes or even investigate the way the game is being rigged against providers and patients.
Mr. T. R. Reid's article leaves out one HUGE difference in American healthcare. The document (a Provider Contract) that defines what we are owed in care and coverage is being deliberately hidden from us to grow the earnings of the so-called health insurance industry. And, it isn't insurance either, so we don't owe what they fail to pay. - - Ignore me if you you choose, but you can't dispute the above because it's clear Contract Law. Frank Lobb & www.killAbill.com
If all unions around the country demanded single payer, we would have it. It would also take healthcare off the table as a bargaining tool. I don't know what they don't get about it.
I’ve assigned T.R. Reid’s work in my undergrad course on comparative health systems for years—his framing helps students grasp not just how other countries organize care, but why the U.S. feels so uniquely broken by comparison. This piece is yet another clear-eyed breakdown of the profit logic at the core of our system. I’ve been exploring these themes more lately over on my own Substack as well—grateful for writing like this that keeps pushing the conversation.
Thank you so much for this explanation of the 20% medical loss ratio our insurance companies are allowed, vs the actual cost of doing business overhead of 4-11% seen in other systems- including our own Medicare/Medicaid.
The whole idea that the INSCOs profit is based on denial of services is explicated right here.
Yes. And laws were changed under Reagan to encourage non-profit mutual companies to convert to for-profit corporations. The industry has been generally re-purposed accordingly.
It is no longer about providing protection against medical expenses or providing preventive care. The purpose of a for-profit corporation is to pay competitive dividends to shareholders while growing in financial value. They compete with other investments. That's their thing now.
There are still some non-profit carriers, but the practices of the industry have been bent. Democrats are the best hope at changing this, but too many are stuck insisting on single-payer. Politically, it is a total mess.
“It is no longer about providing protection against medical expenses or providing preventive care” doesn’t square with reality, Greg.
Incentives are offered in various forms for making SURE you get your preventative care.
These items are tracked in a fashion that goes way beyond what could have been even hoped for in the days of RR.
Never forget, between the spin and the politics is where reality lays.
The reality is that healthy people are cheaper, which is why so much is spent trying to get people to quit smoking, lose weight, get their ‘maintenance” checkups etc., etc.
It’s called value based benefits, and it’s a real thing.
Even today, I received an email warming me up to reduce my 2026 healthcare premiums by participating in a VBB program leading into open enrollment.
I write with the perspective of fifty years as a retail insurance agency. My thinking is reality-based, not investor driven. I am an independent agent and not an employee of any insurance company. We are the people charged with explaining all this to consumers. Go fish, Jerry.
Ok, well speaking as a 20 year software developer in the space, it is painfully obvious that your ability to “explain” these products, services and solutions is woefully limited.
Maybe you could take a class or something?
Because if you’re failing to encourage your clients to engage with VBB and a host of other health preventive and cost saving measures, you suck at it.
More selective and partial information from the spin doctors at Health care un-covered.
In this case, they fail to inform you about scale, on PURPOSE, in order to try and make their paid for point.
The scale we're talking about is population.
When you have a smaller scale, the concept of government assisted, or government run healthcare becomes much more tenable. Unfortunately, when a scale the size of the USA is reached, the model becomes untenable without continually increasing tax hikes saddling future generations with 40%+ tax rates in perpetuity (once you hit 40%, 50% is not far behind).
To be even clearer, what the wannabe politicos that run this stack are doing is failing to inform you of the scale involved in the so called "model" democracies that they reference.
Allow me, below is the population of the "model democracies" with their avg tax rate in parenthesis.
Sweden - 10.59m (25% National, 32% Municipal)
Canada - 41.29m (32% National)
UK - 68.5m (45% National)
Germany - 84.72m (45% National)
Japan - 123.89m (55% National)
USA - 340.1m (30% National)
Do you notice the trend relationship between population and tax rate for those with Nationalized healthcare?
Imagine trying this at the scale of the USA which is roughly 3x bigger than the nearest example, Japan.
A 50% tax rate for the USA in this case might even be low, it's literally never been tried; and for good reason.
Now you know what these guys at Health care un-covered do.
They feed you partial information on purpose and try to spin it into a salient point, which some seem to swallow hook, line and sinker.
It's intentional, by design and not to be trusted.
100%. America's healthcare system is a disgrace - it serves the executives and shareholders of the gargantuan health insurers rather than patients, who often turn to substandard "temporary" or "association" plans, or even "ministry" plans, thinking they are getting the same coverage for less cost, only to learn their lesson the hard way.
TR Ried's reporting on health care is impeccable!
Healing solution …
Get Republicans on board with Medicare for All Acts currently reintroduced into this 119th Congress
There is another cost effective model in the U.S. I have managed a union health plan for 15 years and approaching retirement. The plan covers about 6000 lives with comprehensive low deductible (ranging from $5 to $115) as well as dental and vision. But we are not for profit and self administered (we do not use a contracted third party administrator. Our administrative costs are 4% to 8% of total spend. Our contribution rates (a/k/a premiums) are just under 1/2 the national average per participant cost. Nearly 100% of the contribution is paid by employers and most employers do pay 100%. We have very modest offices, pay modest salaries, and have kept annual increases between 0% and 4% for last ten years. As this article notes, we are not driven by profit - we are driven by pressure from employers and the union to keep costs as low as possible while still offering a comprehensive set of benefits.
Does this plan use networks?
Yes we rent networks for physicians and ancillary - but use reference based pricing for hospitals and surgery centers. We also have implemented higher level bill review on claims. So we do incur network fees and we do pay "shared savings" fees. But we put a cap on the payment of shared savings for larger claims. So we do pay for these but we find that our net is very favorable.
I’m out
I’ll make it even simpler. It doesn’t work because it’s not real insurance.
The arbitrage between payers and providers as the payers have made claims processing and the repeated denial and clarification steps a resistance to defer cash flow out is the main reason Hospital providers are struggling to have positive margins. The game is to constantly change and make more obscure the rules and hurdles so that money stays in the bank as long as possible. It is the ultimate process tax on healthcare spending and sadly deflects directly to patients experience in seeking care.
Cont get me started on the delays that PBM’s (now largely owned directly or indirectly by Insurers) do the same thing with drugs. The friction created is harming patients in a large number of cases.
And the dirty little secret, The insurers pay so much in lobbying and political donations (bribes) to Congress and senate that there is no incentive to make wholesale changes or even investigate the way the game is being rigged against providers and patients.
Mr. T. R. Reid's article leaves out one HUGE difference in American healthcare. The document (a Provider Contract) that defines what we are owed in care and coverage is being deliberately hidden from us to grow the earnings of the so-called health insurance industry. And, it isn't insurance either, so we don't owe what they fail to pay. - - Ignore me if you you choose, but you can't dispute the above because it's clear Contract Law. Frank Lobb & www.killAbill.com
If all unions around the country demanded single payer, we would have it. It would also take healthcare off the table as a bargaining tool. I don't know what they don't get about it.
I’ve assigned T.R. Reid’s work in my undergrad course on comparative health systems for years—his framing helps students grasp not just how other countries organize care, but why the U.S. feels so uniquely broken by comparison. This piece is yet another clear-eyed breakdown of the profit logic at the core of our system. I’ve been exploring these themes more lately over on my own Substack as well—grateful for writing like this that keeps pushing the conversation.
Thank you so much for this explanation of the 20% medical loss ratio our insurance companies are allowed, vs the actual cost of doing business overhead of 4-11% seen in other systems- including our own Medicare/Medicaid.
The whole idea that the INSCOs profit is based on denial of services is explicated right here.
Love this essay👊🏼
The moron strikes again!
Here you go pumpkin, here’s some real data for you:
• UnitedHealthcare:
• Q2 2024: 85.1%
• Full Year 2024: Reported at 85.5%
• 2025 Projection: Expected MLR of 86.5% at the midpoint
• Note: The increase in 2024 was partly attributed to changes in CMS-HCC risk adjustment models (V28) and elevated utilization trends.
• Cigna:
• Q2 2024: 82.3%
• Full Year 2024 Projection: Expected to be between 81.7% and 82.5%, trending toward the higher end due to increased use of specialty drugs
• Q3 2023: 80.5%, which was better than expectations due to favorable ratios in the US Commercial business
• Note: Cigna’s lower MLR reflects its limited exposure to Medicare Advantage (MA) and focus on employer-sponsored plans.
• CVS Health (Aetna):
• Q2 2024: 89.6%
• Full Year 2024 Projection: Expected to be between 90.6% and 90.8%, driven by elevated Medicare Advantage utilization and higher Medicaid acuity
• Q3 2023: 85.7%
• Note: Aetna’s higher MLR is largely due to challenges in Medicare Advantage, including increased utilization and star rating pressures.
• Humana:
• Q2 2024: Not explicitly reported, but the insurance segment benefit ratio was noted to be high due to Medicare Advantage pressures
• Full Year 2024 Projection: Expected MLR between 90.1% and 90.5%
• Q3 2023: Insurance segment benefit ratio was 87.5%, with a projected Q4 2023 ratio of 89.5%
• Note: Humana’s high MLR is driven by its heavy Medicare Advantage focus, increased inpatient, and star rating declines.
Your mansplaining just supports the article’s premise.
Incel
“Mansplaining”? 😂😂
Now that’s comedy when a 1/2 wit refers to data as “mansplaining”.
Btw - 2008 called and they want their phrase back
Yes. And laws were changed under Reagan to encourage non-profit mutual companies to convert to for-profit corporations. The industry has been generally re-purposed accordingly.
It is no longer about providing protection against medical expenses or providing preventive care. The purpose of a for-profit corporation is to pay competitive dividends to shareholders while growing in financial value. They compete with other investments. That's their thing now.
There are still some non-profit carriers, but the practices of the industry have been bent. Democrats are the best hope at changing this, but too many are stuck insisting on single-payer. Politically, it is a total mess.
Greg -Jerry Myers is big into moronsplaining, so just ignore him.
Only in your case, but thanks for outing yourself. 😉
“It is no longer about providing protection against medical expenses or providing preventive care” doesn’t square with reality, Greg.
Incentives are offered in various forms for making SURE you get your preventative care.
These items are tracked in a fashion that goes way beyond what could have been even hoped for in the days of RR.
Never forget, between the spin and the politics is where reality lays.
The reality is that healthy people are cheaper, which is why so much is spent trying to get people to quit smoking, lose weight, get their ‘maintenance” checkups etc., etc.
It’s called value based benefits, and it’s a real thing.
Even today, I received an email warming me up to reduce my 2026 healthcare premiums by participating in a VBB program leading into open enrollment.
So, yeah, it’s not quite what you’re thinking.
I write with the perspective of fifty years as a retail insurance agency. My thinking is reality-based, not investor driven. I am an independent agent and not an employee of any insurance company. We are the people charged with explaining all this to consumers. Go fish, Jerry.
Ok, well speaking as a 20 year software developer in the space, it is painfully obvious that your ability to “explain” these products, services and solutions is woefully limited.
Maybe you could take a class or something?
Because if you’re failing to encourage your clients to engage with VBB and a host of other health preventive and cost saving measures, you suck at it.
Might be time to hang it up big guy.
It’s the cost, Jerry. GFY.
CA Insurance License 0488272
LOL - I’m sorry, was that a sentence containing information???
WHAT, is the cost?
COST: verb
(of an object or action) require the payment of (a specified sum of money) before it can be acquired or done.
e.g. Health insurance, which pays both of us. Take care.
Might work to get employers, unions, retirement systems and etc. out of our healthcare.
Unbelievable!
More selective and partial information from the spin doctors at Health care un-covered.
In this case, they fail to inform you about scale, on PURPOSE, in order to try and make their paid for point.
The scale we're talking about is population.
When you have a smaller scale, the concept of government assisted, or government run healthcare becomes much more tenable. Unfortunately, when a scale the size of the USA is reached, the model becomes untenable without continually increasing tax hikes saddling future generations with 40%+ tax rates in perpetuity (once you hit 40%, 50% is not far behind).
To be even clearer, what the wannabe politicos that run this stack are doing is failing to inform you of the scale involved in the so called "model" democracies that they reference.
Allow me, below is the population of the "model democracies" with their avg tax rate in parenthesis.
Sweden - 10.59m (25% National, 32% Municipal)
Canada - 41.29m (32% National)
UK - 68.5m (45% National)
Germany - 84.72m (45% National)
Japan - 123.89m (55% National)
USA - 340.1m (30% National)
Do you notice the trend relationship between population and tax rate for those with Nationalized healthcare?
Imagine trying this at the scale of the USA which is roughly 3x bigger than the nearest example, Japan.
A 50% tax rate for the USA in this case might even be low, it's literally never been tried; and for good reason.
Now you know what these guys at Health care un-covered do.
They feed you partial information on purpose and try to spin it into a salient point, which some seem to swallow hook, line and sinker.
It's intentional, by design and not to be trusted.
You're welcome :)
White supremacist ideology is why the US doesn't have universal healthcare but pays for Israel's. Oh, that includes free abortive care.