The Cost of Having Healthcare Choices
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The Cost of Having Healthcare Choices

Throughout our lives, each of us must make choices between unpleasant options. For example, our backyard deck is due for a major overhaul since many boards have rotted.  Should we hire a reputable carpenter to replace our deck, which can be very expensive? Or, should I perform the work myself, which may take longer and not look as great? Given my lack of carpentry experience, neither choice is desirable, yet a new deck must be built.

In healthcare, given the paucity of price and outcomes information, we frequently face unpleasant options between the providers (physicians and hospitals) we use and the health plan coverages available for purchase.  Both provide uneasy choices that test our abilities to become full-fledged ‘consumers.’

To become knowledgeable consumers, Americans want to have numerous options available before making a purchase. This is the nature of a market-based economy that allows transparency to keep vendors honest and accountable for their products and services. In a functional marketplace that allows for cost and quality transparency information, sellers are nudged to provide the best possible ‘product’ at the most competitive cost – a winning recipe for delivering ‘high value.’

Cost of Healthcare

According to a recent article, “Healthcare Costs are Bankrupting Us,” by H. Gilbert Welch and Elliott Fisher, among the 54 prescription drugs commonly-used by Americans age 65+, Medicare pays “nearly twice as much per dose as do the government systems in Canada, England and Norway.” Open heart surgery costs 70 percent more than the next highest country, while an appendectomy is over two times more. We pay five times as much in our hospitals than other developed countries. Why? According to the authors, we have a complicated insurance system that requires “an army of billing clerks – employed by hospitals and physicians on one side and private insurance companies on the other.” Because of this, U.S. employer-sponsored health costs continue to outpace other developed countries.

Similarly, another article written by Elisabeth Rosenthal, MD, “Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much,” paints the picture of a costly “coding war” between healthcare providers who hire legions of consultants to find ways to “upcode” procedures in medical bills. Not to be outdone, insurers hire their own coding consultants to protect their interests. Meanwhile, the patient gets lost in the complicated claims process – another reason why prices are not transparent to the public.

Cost of Health Insurance

As we all know, rising health insurance premiums have eaten into take-home pay over the years. In Iowa, the 2016 premium for family health coverage was $15,743, which is 186 percent higher than the family premium in 1999 ($5,508). This family premium is 28 percent of the Iowa household income (adjusted for inflation). In the next 10 years, using the average five-year premium growth rate in Iowa (7.7 percent), the family premium would climb to $33,056 – growing to 52 percent of the household income (assuming a 1.5 percent annual increase).

About two-thirds of the Iowa family premium is paid by the employer. Because of high-premium growth over the past decades, incomes of workers are suppressed. After paying for health premiums, take-home money is then used to pay for escalating health-plan deductibles, copayments and coinsurance. This financial tension contributes to personal bankruptcy and emotional stress – not to mention impairing the overall health and well-being of the workforce – a primary purpose for employers offering health coverage.

The Premium Dollar

In March, America’s Health Insurance Plans (AHIP), a national association of health insurers, released a simple chart showing where the premium dollar has been spent during 2014. This chart is based on national data for insured patients under age 65 for commercial and nonprofit health insurance companies. The breakdown of the premium dollar is as follows:

  • Prescription Drugs – 22.1 cents
  • Physician Services – 22.0 cents
  • Outpatient Services – 19.8 cents
  • Inpatient Services – 15.8 cents
  • Operating Costs – 17.8 cents
  • Net Margin – 2.7 cents

Aside from Medicare and Medicaid, which have lower operating costs compared to private (commercial) insurance, almost 80 cents of the premium dollar for private plans is used for medical expenses, while the remaining 20 cents flows to operating costs and net margin. The operating costs for private plans in the U.S. are about twice as high as the overhead costs in other less-complex healthcare systems around the world.

Medical Loss Ratio Status?

Prior to the passage of the Affordable Care Act (ACA) in 2010, many insurers who sold individual health policies admitted that between 55 – 65 cents of the premium dollar was spent on medical expenses, and the remaining amount was retained by the carrier. The ACA established the “medical loss ratio (MLR),” so that at least 85 percent was spent for medical services by large insurers and at least 80 percent was spent by smaller insurers. Of note, should the ACA be repealed, replaced or repaired, whether the MLR remains intact or not is yet another issue to be addressed.

When it comes to health insurance, Americans ‘appear’ to be willing to pay for the privilege of having choices among health insurance carriers and the multitude of plans offered by each carrier. But will having these choices really provide the added ‘value’ in the care we seek? In some cases, thanks largely to limited provider networks, we may (unknowingly) give up the freedom to choose among healthcare providers, such as physicians, hospitals and others. Will this undermine the competition we wish to have among our market providers?

As I ponder the unpleasant choices we have in healthcare, I must also focus on the backyard deck that awaits my attention.

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  1. Anne Kinzel says


    Nice factual summary of where we are with respect to costs. I am curious about “choice”. I work for a very large employer in Iowa. I have two choices when it comes to insurance carriers/TPAs.

    Who has all this “choice”? People in the individual market will soon have no choice at all in Iowa. We talk about “choice” so much, but what is the reality?

    • David Lind says

      Your comments are very well justified. You are correct, the choices for individual health plans in Iowa have dwindled down to most likely ‘zero’ if national political events continue to convey uncertainty. However, choices are more prevalent for the employer community – having access to multiple insurers and their respective plans. In this market, employers want choices. Choices for employers can also come in the form of plan financing options, such as self-insure vs. fully-insure – and a number of hybrid funding options between both. National research suggests that Americans want to have a healthy choice of carriers and plans, most likely to purchase the plan that is most affordable and meets their ability to assume out-of-pocket risks. But will having more carriers (and plans) keep the health costs down? I believe this discussion deserves more scrutiny because the root causes of rampant insurance premiums have been inadequately addressed to date. In Iowa, having no options is unacceptable in the individual market – primarily because the cost component has been largely ignored in all reform measures to date.

  2. Well written post! I like your insights about making choices. Sometimes I think in life there will be a time when we don’t have a choice but do it. This is I think what is happening with health insurance. It costs a lot but people do not really have a choice but to get one to ensure that the medical needs of their families will be provided when they need it.

  3. Anne Kinzel says

    In. Reading your comment a question comes to mind, do we want to choose our medical care or do we want to choose our insurance company. The reality is that more those of us who receive health insurance through work we get to use, but generally not choose the insurance company of third party administrator that our employer has contracted with. Then we have a network of general very limited choices. Bottom line, our compensation is paying for something we had no choice over.

    In a tax payer financed system we can set it up so that we have a choice of providers and in some instances, insurance carriers. If it’s done right we can have much more choice then we do now.

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The choices we have in seeking healthcare can be many, but how much is enough?