For what it's worth I know you've worked on FHIR and probably know a lot of details I don't. Actually I'd be interested in talking to you about FHIR.
That said!
1) In the big picture isn't the US clearly paying more than other countries? I'm sure some of this is eg a janitor in the US costs more than a janitor elsewhere, but still...
2) Isn't the cap for the margin that insurance companies can take 20%? That is, they have to pay out 80% as claims take 20% for overhead
3) Doesn't insurance also induce more work done by everyone else who has to deal with them? So the margin the insurance company itself takes is not the only cost they add. Maybe they make providers do more paperwork, or let patients order tests etc that they would not if they were not spending other people's money, or some other reason. Say insurance pays out 80%, but 30% of documentation or actual work is not done by insurance but only exists because of them, now we're down to 56%.
I say this because literally yesterday, my wife, a pediatrician, after she spent the day seeing patients and got home to go through notes, had to leave a message with an insurance company: she saw they faxed her clinic on Saturday, when the clinic was closed, to cancel care for a patient with an ongoing chronic condition with no changes unless the insurance company got a reply in 48 hours (again, while the clinic was closed!). Now she has to schedule some kind of I don't even know what with them, to confirm the condition is the exact same, except she sees patients all day so it's a pain to schedule...
idk the fact that BCBS is a non profit and has no margin in some technical sense does not seem like a big consolation, something is rotten no?
(edit - the insurance company in the anecdote is not BCBS)
I've worked on a lot of healthcare interoperability standards, including HL7 FHIR. Those can be part of the solution in terms of making the system operate more efficiently and cutting administrative overhead. In many cases payer and provider organizations are still doing things manually that could be automated using existing standards. But they fail to do so due to lack of vision and insufficient technical resources. Literally everything that can be done with a fax can be done faster and better with X12 / NCPCP / DirectTrust standards that have been around for years and are widely supported by commercial EHRs.
It's true that no matter how you look at it, the USA spends a lot more per capita on healthcare relative to outcomes. But you have to be careful what outcome metric you look at. Like we're not doing great on life expectancy, but much of that is due to factors largely outside the healthcare system like violence, vehicle crashes, and lifestyle choices. And in other areas like 5-year cancer survival rates or new drug development we're at or near the top. Part of the problem in the USA is that we seem to be culturally incapable of admitting that rationing is needed, and that it simply isn't feasible to deliver excellent care to everyone, so political reform debates devolve into sound bites about "death panels".
The Affordable Care Act (Obamacare) set a minimum health plan medical loss ratio of 80%, or actually 85% for larger plans. And in practice most come in higher than that due to competitive pressures.
https://www.cms.gov/marketplace/private-health-insurance/med...
There's a huge amount of administrative overhead in dealing with health plans for things like claims and prior authorization. Much of that is imposed not so much by insurers themselves but by employers who want to hold down costs. Like a commercial insurer would be happy to sell a plan that would pay every claim immediately at 100% with no questions asked. It would be less work for them. But no one would buy it because costs would explode. Medicare and Medicaid plans also have prior authorization and peer review processes. Something like a quarter of all healthcare services are "low value care" which doesn't align with evidence-based clinical practice guidelines and may even harm the patient, so when health plans apply review processes the right way then ideally it's better for patients and holds down costs for everyone.
To be clear, I'm not here to defend commercial health insurance companies. They are part of the problem and some reforms in that area are sorely needed. But let's have an honest debate about it and stop pretending that eliminating them would solve the deeper systemic problems.
Admin inefficiencies between orgs definitely exist and maybe better interoperability and standards is the solution, but wouldn't there also be less of a problem in the first place if there were fewer different orgs all complicating workflows?
Also not saying you're wrong about many healthcare services being unnecessary or even harmful, and someone has to be the one to say no to patients asking for low value care which is definitely a real hard position to be in and a real problem. At the same time insurance companies aren't making a great case for themselves as the solution imo bring on the government death panels.