[maxerickson]

The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland. Standardized, subsidized insurance with some mechanisms to increase subscription.

The problem is that it also mixed employer mandates and Medicaid with that stuff. In principle Medicaid is good, providing care to low income people, including millions of children. The problem is that it is a huge off the books tax scheme, mandating care that it doesn't fund. And with guaranteed issue individual insurance available, employer requirements should have been reduced, not increased.

[AsyncAwait]

> The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland.

It did not, because it still kept private insurance companies in control and still made it impossible to negotiate drug prices. It seems better than what came before it, but I'd argue it may have even done some damage, (in terms of the debate towards universal health care), since its failures are now ascribed to 'socialised healthcare' by its opponents and equated to a single payer system, whereas in reality it is in may ways the polar opposite.

[maxerickson]

Germany has private insurance companies and all US insurance companies negotiate drug prices. Even the specific drug prices that the talking point says Medicare should be able to negotiate are negotiated (by the private companies that administer that part of Medicare...).

Most Germans are covered by "sickness funds" but those with higher incomes have the option of buying private insurance. And the sickness funds aren't really single payer, spending is negotiated regionally, not at the national level.

[AsyncAwait]

> Germany has private insurance companies

Yeah, practically every country does, if you want it. The problem in the US is that it is practically the only option for many, not a choice.

> and all US insurance companies negotiate drug prices

But that's the problem, it should not be done by private companies, but by a state/national body with more power.

> Even the specific drug prices that the talking point says Medicare should be able to negotiate are negotiated (by the private companies that administer that part of Medicare...).

Yeah, private companies...

> Most Germans are covered by "sickness funds" but those with higher incomes have the option of buying private insurance.

I am not saying anything about the option of buying private insurance, I am saying it should not be a requirement for basic coverage.

> And the sickness funds aren't really single payer, spending is negotiated regionally, not at the national level.

That is semantics, the principle is the same.

[krrrh]

In Germany private insurance is the only option for self-employed. It is precisely a mandated requirement for basic coverage. The two "public options" are not available to freelancers, and anyway the public options are more akin to competing non-profit insurance companies than state-administered health care like in France, the U.K., or Canada.

Buying insurance is also a pain because unlike in the US under ACA, German insurance companies are able to charge higher premiums for pre-existing conditions up to a mandated Basispreis (approximately 3x a healthy person's rate - somewhere north of 600€ per month). Pre-existing conditions can include a hospital visit with a null diagnosis.

There's a lot more to it, but I get frustrated when people talk about European-style health care as if it means something concrete, when there are such a wide range of policies across Europe.

[maxerickson]

Abusive drug pricing would go away nearly instantly if the Medicaid formula considered the lowest effective price paid (by accounting for rebates when calculating Average Manufacturer Price).

It's really only patented drugs where it matters, most generics in the US are all but free (the exceptions to that pattern mostly have few users).

[refurb]

What? AMP accounts for rebates.

Add in the Medicaid rebate and Medicaid pays almost the lowest price in the US for drugs. I think the VA is the only org paying a little less than that.

[ahupp]

The Swiss system has mandatory private insurance. It's very ACA-like.

Drug costs are 10% of health expenditures in the US. Not sure this is a critical issue for controlling costs.

[Chathamization]

> The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland.

In Germany you're automatically enrolled in public insurance unless you opt out and choose private insurance, no? That's completely different from the ACA, which has no automatic enrollments (if you're application gets stuck at the exchanges, good luck), no option to keep public insurance (if you're on Medicaid and you're income rises, you might have a month long gap between being kicked off Medicaid and getting a new health plan), pushes people into employer provided plans, and generally has a host of problems and complications that lead to 10.9% of Americans still be uninsured (and those who are insured still facing massive problems with healthcare costs).

[maxerickson]

I said "look more like". I even listed the things I thought were similar.

Automatic enrollment is rather obviously going to be more effective than a tax penalty, but the tax penalty is at least a mechanism designed to increase subscription.

There are a bunch of bad compromises in the ACA, but the comment I replied to was mystified that the US apparently isn't even trying things that have worked elsewhere, which is just wrong.

[Chathamization]

> There are a bunch of bad compromises in the ACA, but the comment I replied to was mystified that the US apparently isn't even trying things that have worked elsewhere, which is just wrong.

I'd say that they are right. The ACA is completely different from the German system. I mean, I could argue that the Republican healthcare plan is similar to the German healthcare system since it would have a public Government run system (Medicare and Medicaid) and subsidized private insurance (vouchers), but that's not a particularly compelling argument. When two systems are completely different, talking about a couple of ways they're slightly similar if you squint and don't look at the details doesn't seem particularly useful.

[maxerickson]

I guess I think that guaranteed issue of a plan with minimum standard coverage is a lot more important than the details of how payments flow through a system.

I'm certainly more concerned about the possible repeal of the federal insurance standards, the "essential health benefits" than I am eager for a public option to start competing with insurers (which I don't think insurers are doing a whole lot to either control or drive medical costs). I wouldn't mind a public option, I just don't expect it to matter much.

[Noos]

The ACA is a huge failure.

it massively increased everyone's premiums and deductible, and made it more or less impossible for many poor people to afford private insurance. If you ask many americans here how much they pay per month and how large their deductible is, you'll realize Obamacare actually wound up being absurdly expensive catastrophic insurance instead of universal coverage.