The murder of UnitedHealthcare CEO Brian Thompson has revealed a simmering anger with the American healthcare system in the spotlight. William Brangham discussed more with Wendell Potter. He spent decades working for the health insurance company, Cigna, before leaving and dedicating his career to reform.
Those people generally have really good insurance
That’s one of the key issues of tying health insurance to employment: it creates a backwards system where the affluent pay basically nothing for care and those who make little pay a great deal
There’s a weird curve at the bottom because of government services like Medicaid, with these you also pay very little to nothing, but in most states you have to basically be destitute to qualify
It’s one of the most frustrating things about being someone who takes insurance as a career. The people I see who make $30-40k or less? They have 4-10,000 deductibles and pay 10-30% coinsurance after, on top of hundreds of dollars of premiums coming out of their check (that percentage wise take up a huge chunk of each pay). Their out of pocket max is also very high so their medical spending has to be pretty crazy to get to the point where they just don’t have to pay anymore
But the people who make 100k? 150? 200+? They almost always have nice PPOs. They pay $5-30 per visit. They have lower out of pocket max (though tbf still fairly high, it’s insurance) so their copays can go away (but this is uncommon, tbf). They pay more out of their check but not as much as you’d think because it’s usually more heavily subsidized by their employer (“nicer benefits for essential staff”) and given their substantially higher income it’s often much less percentage wise of their net earnings.
So someone says “go see a therapist”. If you’re making 40k a year with avg benefits that might mean you’re now on the hook for $120 a week for weeks or months (or more!) because of your high deductible plan, until you finally hit that deductible. If you’re young and healthy and don’t utilize much you may never hit it just going to therapy. Even if you do you’re still on the hook for 12-36 dollars a meeting after that. Meanwhile the 150k a year tech bro or banker goes and pays $10 a week.
It’s not always like this of course. Sometimes low earners get bad PPOs with high copays that feel criminal ($75 per meeting). Sometimes high earners do high deductible plans because they realize the accounting makes more sense for their medical spending. Or sometimes they work for a company that cheaps out on benefits even though it pays a few people very lucrative salaries. Etc
But it’s also one of the hard issues to solve as a result. In an ideal world the people who have more resources would pay more and the people who have less would pay less. The sliding scale payment system where the wealthy subsidize those who have less. But people are greedy and don’t want to give away their money. And guess who has more political power and also tends to vote more?
I used to live in ri, paid 420 a month for a half decent dental and health plan from BCBS. I moved to Vermont, went to look up insurance cost and since I make a godly 53k a year BEFORE taxes, I don’t qualify for any assistance. A catastrophic plan here is 450 a month. A mid silver plan is 1k a month. I literally cannot afford to have health insurance anymore, and so I have been priced out. Now that I don’t have coverage I just hope I never get sick or hurt again. I broke my arm bad and it was 30k between surgery and ambulance and emergency room (in ri and my health insurance covered it), if something like that happened now id just have to bury myself in debt. If I’m not mistaken medical debt is one of the leading causes of bankruptcy in the USA.
Which one are you?
EDIT: This was a sincere question, and no judgements of any kind were intended.
Does it matter?
A fat doctor smoking a cigarettes is still right when he tells you to lose weight and quit smoking
But for the record I make about 50-60k a year and have high deductible insurance. I could potentially make substantially more but I don’t because I have a large number of sliding scale slots to subsidize the care of people who have financial need, at my expense, because the system is bullshit
I have colleagues who do not do this and work the same amount of hours as me and easily clear 70-80k thanks to a combination of no sliding scale and much more draconian no show penalties assuring they always get paid even when someone doesn’t attend (some charge as much as $100 for missed appointments)
Some colleagues curate the insurance panels they’re on so they maximize payment amounts. Some eschew insurance altogether and only take out of pocket payments, usually far more than what any insurance would pay (over $150 an hour). These tend to make over six figures
But even if I was in the latter categories that wouldn’t change that it was correct (although it would make a hypocrite tbf ig). Insurance is a collectivist concept for the greater good and cannot work without someone subsidizing someone else, typically the young subsidizing the old. The only way you escape the need is being healthy forever (unlikely) or being obscenely wealthy (far more unlikely)
No judgements whatsoever, I was just curious. And TBH your situation is very interesting and illustrative of the problem, whilst also being clearly awful and kind of confusing. I would bet any non-americas reading it would be completely lost. I actually had to explain our insurance system to a new co-worker in India because I suddenly work in the fucking insurance industry due to a recent merger. I pulled zero punches, and fully let loose with how completely bonkers this system is. The dude is super cool though. We do have the high-deductible options, but I just could not math those out to make any sense whatsoever.
Often the high deductible options do financially make sense if you are in a place where spending the deductible each year isn’t a burden. They can even be advantageous if you are healthy; in that scenario they are essentially “hedging your bets”. You can save a substantial amount over a ppo if your utilization is low and typically if you just spend to the deductible the cost is about the same.
It’s the coinsurance afterward that can be a killer, especially if you have a chronic illness that requires a lot of expensive stuff. A PPO caps everything at a copay amount (which, tbf, can sometimes be quite high), but coinsurance can be 10-30% sometimes (maybe higher but that’s the highest I’ve seen). And if you have cancer, or some other nasty thing that requires expensive scans, medications, bloodwork, etc, paying 10-30% of the bill is still a shitload of cash. Thankfully there’s still an out of pocket max but that’s often quite high
And tbh I took your statement as judgey. I’m glad it wasn’t, thanks for clarifying. But that’s one of the issues with such a system. My colleagues who don’t do what I do are absolutely judged. But at the same time I do not judge them (usually, lol). This is not a sustainable setup. It is not sustainable to ask individual practitioners to take on the financial burden. It harms the relationship between practitioner and client, it’s destructive and can breed resentment. It results in quality of life issues for practitioners like wildly unpredictable pay. I could go on.
Ideally we would just be paid an actual salary, an actual living wage, with benefits, to work with a set number of clients, but with the current system this is functionally impossible. If we had a single payer system this would be easily feasible, all healthcare staff could be government employees basically. Good luck getting most doctors to support this though. They love padding billing under the current system
Just as an FYI, sometimes mental health gets special coverage. So I have one of those high deductible plans but a few therapist visits are 100% percent covered before normal insurance math kicks in. I’ve been told this is a fairly frequent feature of employer coverage for whatever reason.
This is true and mental health is a pain in the ass specifically because of it.
This is probably what’s called an EAP, employee assistance program. Basically your employer benefits provider provisions a few sessions paid in full. Great for you, kind of a pain in the ass for me. It’s more paperwork, the coding is weird, and the payments are lower (sometimes by a lot, like 40% lower). Not your fault at all obviously and entirely an insurance problem. Just another thing that makes working within this system an absolute nightmare.
However, sometimes this is called a “carve out”. This is different and less of a direct pain but causes so much confusion. This is where your works benefits provider decides that insurance company a charges too much for mental health coverage so they don’t purchase that portion and instead “carve it out” and replace it with insurance company b. This can result in you having specific copays for mental health even if you have high deductible (or even a separate deductible) because it’s essentially a secondary insurance (though technically it’s not considered as such and you would generally never even know the name of the company handling the carve out)
This is SUPER confusing for consumers because when you get your benefits package they hand you a card that says Aetna or Cigna or whatever. Then you see my psychologytoday profile and I advertise I’m in network with Aetna, Cigna, etc. great! we do a consultation, feels good, you send me your info, then I go “ooh, so sorry, turns out I don’t take your specific Aetna plan”. Because your Aetna plan takes mental health coverage and subcontracts it to another company who I have never paneled with.
Sometimes this is because I have never even heard of the company (paneling with an insurance co is weird, sometimes it takes a week, sometimes it takes 10 months), sometimes it’s because their reimbursement rates are a joke (one literally pays $24/hr which doesn’t even cover my overheads), etc. This isn’t entirely on the insurer though as it’s the employer that cuts coverage benefits to do this, although the insurer rising costs year after year is definitely a factor in why an employer would do that tbf