[rayiner]

Many countries rely on privately-managed health insurers (Germany, Switzerland, Netherlands, etc.).

> Edit: and I have an anecdote about this too. Last year I had an episode of AFib. I've been taking medication since then. So after almost 1 year taking a certain medication, my insurance rejected it, saying they wouldn't pay for it and that I had to switch to something else. Now, why is it OK for an insurance company to dictate what I can or cannot take, if my doctor prescribed me something? How on earth is it OK for insurance to dictate what treatments I can or cannot have? I feel like a piece of meat when I go to a clinic and they need to call my insurance to see if it is OK to give me a certain treatment. This is nuts.

Dictating what treatments you can and cannot have is how health systems all over the world control costs. Many systems do this much more aggressively than in the U.S. The U.K. NHS, for example, will only spend about 20-30,000 pounds per "quality-adjusted life year," or about double that for end-of-life drugs. In the U.S., it is routine to spend hundreds of thousands of dollars just to get a couple of extra years. (The historic practice in the U.S. was to have lifetime limits--typically in the several million dollar range, but even those are illegal under the ACA.)

[throwaway9d0291]

> Switzerland

I moved from the US to Switzerland. The systems can't be compared.

Yes Switzerland has private insurers but the industry is highly regulated:

- Costs of medications and procedures are regulated and capped.

- There's a mandatory level of insurance everyone must have. This covers basically everything except dental.

- The pricing of this mandatory insurance has a cap based on age (younger people pay less), location and deductible (the max deductible is 2500 CHF).

- The excess is capped at 700 CHF/yr (i.e. the max you ever pay in a year is premiums + deductible + 700).

- This mandatory insurance cannot be denied.

- This insurance costs ~230 CHF/month on the low end (from https://www.priminfo.admin.ch/de/praemien)

- (Not related to insurers): If you have very low income, you can receive government assistance with which you can pay for insurance.

As an Australian, the Swiss system feels much closer to the single payer end of the spectrum than the free for all of America.

[tptacek]

For what it's worth, the US system under the ACA has many of these (probably in large part because Switzerland has them, as our system is modeled in part on theirs). We don't do strong price controls, but we do mandatory insurance, with mandatory coverage levels, that can't be denied or repriced based on age, and public funding subsidizes a large fraction of the insured.

[pcwalton]

The difference is that Medicaid is a patchwork of various state systems rather than a no-questions-asked federal subsidy. Some states are hostile to Medicaid (e.g. Kentucky with its work requirements). Furthermore, the entire future of the ACA system is in doubt, because of executive sabotage, legislative attempts at repeal, and judicial overreach. All of that leads to people not being confident that they will be able to get the health insurance they need. That's why the Swiss system can fairly be described as universal health care, while the American system cannot.

[tptacek]

What reform could the US pass that would escape the criticism that Republicans might in the future choose to repeal it?

[pcwalton]

I don't know. I'm not sold on single payer either, mind you. The only long-term solution I can really see is for the Republicans to fail at repealing the ACA so many times, and for public opinion to be sufficiently against them, that they basically give up.

[rayiner]

But it’s not single payer, it’s still insurance, and there is still a “middle man,” which is what OP was complaining about. That still means, for example, that the medical industry itself is largely privatized, as opposed to say the UK where NHS is a government entity and doctors are public employees.

[ivanhoe]

30K pounds of medical services in the UK would cost you a lot more in the US, so it's hard to compare the two just by comparing those limits.