Legitimately made me laugh for a good minute picturing the scene. First, my favorite MOAT (movie of all time) is 12 Angry Men. And second, I'm picturing the 82-year old slowly convincing the risk pool that out-of-network costs should be covered.
But at the same time, I think there is some dignity in recognizing that we all exist - in what feels like an oppressive and insurmountable healthcare system - and that we actually do have a choice. It might feel impractical, but I think it is morally sound
Wow, what a great article. I know a ton about healthcare but this piece really hammered it home.
Also, I was about to "correct" you on your assertion that 2/3rds of employer sponsored plans are self-funded. A quick Google search says its actually 67%! I never knew that.
It's time to fix American healthcare. We need to remove the middlemen and...they are all middlemen...
Very well captured - but I would take it one step further. Many keep referring to our Casino Healthcare as "broken," but it's not. It's working exactly as designed and we (desperately) need a different design. We can keep tweaking around the edges (with a bouillabaisse of acronyms - VBC, ACO, ACA, PBM, BPCI, CJR, PCMH, APM - and even Advanced APM) but we're just rearranging deck chairs and we won't make real progress on systemic reform until we end the accidental design of Employer Sponsored Insurance (ESI). http://hc4.us/esi20
Thank you for sharing this amazing diagram, Andrew. I have been up in arms about the mess that is our health care system for years, and I'm going to study this in detail.
1) Clicking on your link for the 1999 average family premium took me to the 2024 KFF report. (Perhaps this was a mistake in your link, or perhaps somewhere in that 2024 report there is the 1999 number.) But, I was able to find the 1999 report (here: https://www.kff.org/wp-content/uploads/2013/04/the-1999-employer-health-benefits-annual-survey.pdf ) and confirm your $5,791 number within a table there.
2) I am curious if the employer-plan cost rise is partly caused by an increasing cross-subsidy to Medicare and Medicaid between 1999 and 2024. (I do not know, quantitatively, about an increased cross subsidy. I only learned that there was some increasing pattern on the cross subsidy since the late 1970s in a happenstance fashion, exploring the Maryland almost-same-rate all-payers system, where some documentation I was able to find asserted that Medicare and Medicaid having to pay more in Maryland than elsewhere was much less of an issue in the late 1970s, when the system started, due to much lower cross-subsidy proportion, so the federal government agreed. (The documentation I could find on Marylnad within my post here https://normspier828307.substack.com/p/understanding-the-lower-medicare , if interested.)
1.) Thanks for checking! Yes, when I put this together, I saw the two pages but in my mind, I was going for a 25-year window. Glad to see good-faith fact checking - I appreciate that!
2.) As for the Medicaid/Medicare cross-subsidy, you'll love my other diagram here https://healthisotherpeople.substack.com/i/175943797/what-have-we-created which really lines up with your thesis around the hidden subsidization. One thing that I liked about your (really excellent, and intellectually honest) post is the callout about Maryland's All Payer model - without going into all the research of it, I believe it does keep the prices more reasonable. But there are demographic and socioeconomic impacts as well, which is always the trade-off between cost, quality, and access.
I at once completely agree with the core point and am picturing doing 12 Angry Men with 50+ colleagues every time we hire someone
Legitimately made me laugh for a good minute picturing the scene. First, my favorite MOAT (movie of all time) is 12 Angry Men. And second, I'm picturing the 82-year old slowly convincing the risk pool that out-of-network costs should be covered.
"I know this man better than anyone here"
https://www.yarn.co/yarn-clip/b8a1247d-5e27-4b3d-8260-4abacf0fea74/gif
But at the same time, I think there is some dignity in recognizing that we all exist - in what feels like an oppressive and insurmountable healthcare system - and that we actually do have a choice. It might feel impractical, but I think it is morally sound
Hey — I came across your writing and really liked how you think.
I’m exploring something similar from a different angle — writing about human behavior through a system design lens (like debugging internal patterns).
Just started publishing on Substack. If you ever get a moment to read, I’d genuinely value your perspective.
Also happy to support your work — feels like there’s an interesting overlap here.
your charts are so good man. great post
Wow, what a great article. I know a ton about healthcare but this piece really hammered it home.
Also, I was about to "correct" you on your assertion that 2/3rds of employer sponsored plans are self-funded. A quick Google search says its actually 67%! I never knew that.
It's time to fix American healthcare. We need to remove the middlemen and...they are all middlemen...
Very well captured - but I would take it one step further. Many keep referring to our Casino Healthcare as "broken," but it's not. It's working exactly as designed and we (desperately) need a different design. We can keep tweaking around the edges (with a bouillabaisse of acronyms - VBC, ACO, ACA, PBM, BPCI, CJR, PCMH, APM - and even Advanced APM) but we're just rearranging deck chairs and we won't make real progress on systemic reform until we end the accidental design of Employer Sponsored Insurance (ESI). http://hc4.us/esi20
Thank you for sharing this amazing diagram, Andrew. I have been up in arms about the mess that is our health care system for years, and I'm going to study this in detail.
Really glad you like it - feel free to ask any questions that come up here as well!
1) Clicking on your link for the 1999 average family premium took me to the 2024 KFF report. (Perhaps this was a mistake in your link, or perhaps somewhere in that 2024 report there is the 1999 number.) But, I was able to find the 1999 report (here: https://www.kff.org/wp-content/uploads/2013/04/the-1999-employer-health-benefits-annual-survey.pdf ) and confirm your $5,791 number within a table there.
2) I am curious if the employer-plan cost rise is partly caused by an increasing cross-subsidy to Medicare and Medicaid between 1999 and 2024. (I do not know, quantitatively, about an increased cross subsidy. I only learned that there was some increasing pattern on the cross subsidy since the late 1970s in a happenstance fashion, exploring the Maryland almost-same-rate all-payers system, where some documentation I was able to find asserted that Medicare and Medicaid having to pay more in Maryland than elsewhere was much less of an issue in the late 1970s, when the system started, due to much lower cross-subsidy proportion, so the federal government agreed. (The documentation I could find on Marylnad within my post here https://normspier828307.substack.com/p/understanding-the-lower-medicare , if interested.)
1.) Thanks for checking! Yes, when I put this together, I saw the two pages but in my mind, I was going for a 25-year window. Glad to see good-faith fact checking - I appreciate that!
2.) As for the Medicaid/Medicare cross-subsidy, you'll love my other diagram here https://healthisotherpeople.substack.com/i/175943797/what-have-we-created which really lines up with your thesis around the hidden subsidization. One thing that I liked about your (really excellent, and intellectually honest) post is the callout about Maryland's All Payer model - without going into all the research of it, I believe it does keep the prices more reasonable. But there are demographic and socioeconomic impacts as well, which is always the trade-off between cost, quality, and access.