I keep paying my health insurance premium at my home country just because the health insurance in the US is completely broken. I feel that if you get seriously sick in the US you're in an almost sure path to financial insolvency.
My employer pays probably a shit ton of money for my health insurance and what I get is the most subpar, confusing, broken and sometimes blatantly extortive service ever.
I live in Austin and sometimes I think if I really need a major procedure it would be just simpler to drive to Mexico and get it done there. In fact, that's what many people in South Texas do, so there's your benchmark for how broken is healthcare in the US.
You don't even necessarily have the option to shop for service in the USA.
Earlier this year my family had a medical emergency that resulted in us being billed a truly staggering amount of money for services that were technically elective, somewhat unproven, and not necessarily even recommended by the standard of care, and for which the actual sticker price varies wildly from hospital to hospital. But, when an emergency happens, you don't get to shop for hospitals, and you more-or-less unthinkingly do what the care team recommends, because there's simply no opportunity to stop and do any sort of cost/benefit analysis. As luck would have it, we ended up at a hospital that both tends toward the more liberal end of the spectrum in terms of what they do, and tends toward the more expensive end of the price range.
Fortunately our financial hit won't be too bad, because we have decent employer-provided insurance, and that cushions the blow quite a bit. If there's a silver lining, it's that we hit our out of pocket expense limit in the first part of the year, so we basically get everything for free for the rest of the year. But that whole situation is also a big part of the problem. We're nominally in the driver's seat, but, in practice, we really aren't in charge. Because we don't have access to a lot of the information necessary to make informed decisions, but also because we've been insulated from some of the major factors that might motivate an informed decision.
Social criticism in the USA tends to revolve around the "theater" metaphor. We have security theater, we have hygiene theater. I would characterize the underlying principle of the USA's health care system as agency theater.
I definitely recommend it for dental work. You can easily find a dentist in Mexico that went to school in the US and has the same credentials. You'll save so much money.
I recommended a friend who needed heart surgery with less than great US health insurance go to India to have it done. US trained doctors, recuperated in accommodations equivalent to a five star resort. Cheap enough they could pay for it in cash.
I am downright surprised I haven't seen a YC startup that performs this sort of medical tourism brokerage to be honest. Take this business model! I'll be your first angel investment.
I love the idea, I imagine it's in a tricky legal area though. And perhaps the people that could pull it off are all profiting off of the US healthcare system well enough to not need to pursue this.
I know the insurance plan that Utah government employees are on will pay you to go to Mexico to get your prescriptions filled. Airfare, hotel, and medication costs are all covered. Free vacation just so the company doesn't have to pay the US prices for drugs.
Just remember that you might be displacing poor locals from getting the treatment instead. Poor countries have bigger shortage of good doctors and they prioritise foreign appointments due to getting paid more than the local prices.
Edit: This is true for India which is a top medical tourism place:
You have no way of knowing that demand for services in every single country with medical tourism outstrips supply of professionals. You just assumed it.
If it doesn't, which is just as likely (I think more, but I also don't know, and unlike you I won't pretend to know), then you're injecting money into the local economy, while getting medical/dental care at a lower price: win win.
The US has a uniquely onerous path of education and accreditation for medical professionals, with substantial supply-side limitation in the form of slots for medical school. Other places aren't so burdened.
I wonder if medical tourism provides a capitalist solution to the healthcare problem in the US. Could it be cheaper for a health insurance company to pay for flights to and from other countries along with procedures in those countries? There are a lot of non-emergency medical issues which can be serviced this way. In the long run, such insurance would drive down the price of traditional health insurance as well as the price of the procedures themselves locally.
Can confirm. I drove from Austin to Nuevo Laredo for dental work. Park up, walk across the bridge, get dental work for a fraction the of the US price and walk back. Most painful part of the process is going back though US border control.
This is an interesting idea. Is this an unintended consequence of binding health insurance to your employment?
According to the NYT: "During World War II, federal wage controls prevented employers from wooing workers with higher pay, so companies started offering health insurance as a way around the law. Of course, this form of nonmonetary compensation is still pay. When the war ended, the practice stuck."
I would much rather have a system where I was paid more and got to choose my health insurance provider. That way I could keep my insurance when I change jobs or if I wanted to freelance.
I run a company that helps software engineers find contract work, and the #1 question we get is "how much should I charge?". The #2 question is "what do I do for health insurance?"
It would seem like businesses brought this on themselves by offering benefits to get around compensation limits imposed by the government. Or you could say that this was caused by the government imposing limits on compensation. Super interesting to think that the root cause of our current problem could have been created 80 years ago.
Moving to a single payer system would unleash a lot of latent entreprenurial activity and free companies of all sizes from having to provide health insurance. Great documentary here on the business case for moving to single payer: http://fixithealthcare.com/
The real problem is that the current status is so bad, that those who are relatively better off (probably still bad) are scared of change because they've seen what "worse" looks like and a better system seems mostly aspirational.
There is a reason why ACA messaging from Democrats always included the fact that you could keep your existing insurance if you wanted.
> I think part of the problem in the US is that the current status is so bad, that everyone has a different proposed solution.
“Everyone has different solutions” as in the two parties, both corporatist through and through, are only willing to offer solutions that nip around the edges of the problem with ridiculously complex regulations that ultimately result in less competition and higher profits for healthcare conglomerates.
Single payer in the vein of “Medicare for All” is popular for voters of both parties. It’s just that our representatives represent us in name only.
> Single payer is also seen as too paternalistic by a large minority of the US, so there is that as well.
Again there’s a disconnect between the discourse you can see on corporate cable news and major newspapers and what people actually think and want.
That said, the corporate media and Dems/Rs have been very very successful in 50 years of messaging that everything the government does = bad, inefficient, rationing. And everything corporate = dynamic, efficient, desirable. Almost everything that can be privatized has been privatized via crony capitalism, but they can still say “govt has big budgets, shitty results” when it’s their privatization that is the exact reason for the decay.
I don't watch cable news. I know dozens of people who are vehemently opposed to single-payer. The reasons are paternalism and distrust of government to get things right.
To a certain extent, I agree with the second; I'm kind of glad that the current administration doesn't have control over my health care...
Good point. Health insurance is a form of golden handcuffs. The pain of switching health insurance providers has definitely deterred me from changing jobs before. Microsofts insurance in the early 2000's was so good, I stayed there long enough to become grossly underpaid. When I finally did leave, my salary increased by 50%!
There is really isn't much incentive for companies to stop offering health insurance as a benefit.
Another big bit is tax deductions. I believe when the employer provides healthcare, the amount they pay and the employee pays is 100% pre-tax.
If you pay for medical insurance yourself, it starts getting complicated[0]. They honestly just need to make it so any medical insurance payments should be 100% deductible, regardless of anything else. It would help level the playing field.
> I would much rather have a system where I was paid more and got to choose my health insurance provider. That way I could keep my insurance when I change jobs or if I wanted to freelance.
I would rather see employment and health insurance totally separated from each other.
But if people aren't open to that for whatever reason, one alternative would be a system where the employee freely picks any insurance plan, but the employer pays the premiums tax-free like they do now.
If you make it so the set of insurance choices is the same for all employers and for individuals paying their own way, then you could move around between employers or freelance.
Right now, big employers have bargaining power due to their size, so you'd lose that, but perhaps stronger competition (from everyone freely choosing) would make up for it.
It's not. That issue is tangential at best. If it was the crux of the issue here, you'd see many more companies going belly-up rather than pay for health insurance.
For this change, companies like Uber and Lyft will have to completely reorganize their internal systems, ranging from their relationships with drivers to their tooling for organizing their drivers.
They say things like "passengers would experience reduced service, especially in suburban and rural areas" when what they really mean is "lyft would have to pay drivers to be available in that area even when demand is low, and Lyft doesn't want to pay drivers to idle in low demand spaces". There are various solutions to this, but they would all cost Lyft and Uber money, and heaven forbid they not be able to pass those expenses onto others, such as drivers that would hang around those areas _without_ any compensation.
The real heart of the matter here is that 10 years ago Uber disrupted the taxi industry. Now that they're the incumbents, changes like these put Uber and Lyft in a position to be disrupted by newer companies that more easily adapt to regulatory changes, or possibly the taxi companies they disrupted a decade ago. What we're seeing now is Lyft taking drastic measures to try and enrage the public against these policies.
This is a kid throwing a tantrum because they aren't getting cake after refusing to their chores.
Health insurance is a major component. However, the broader theme is the offloading of risk from the company onto their workers, including not only health risk but also for example, accident risk.
Most rideshare drivers are not properly insured — while passengers are well-covered, the drivers and their vehicles are not. Because the drivers are contractors and must navigate the insurance system as individuals, many do not possess adequate knowledge and statistically speaking, a large number are guaranteed to make mistakes when purchasing coverage.
If drivers were employees, then accident coverage for drivers and their vehicles becomes the responsibility of the rideshare companies. There would be fewer bad outcomes for drivers, but because the rideshare companies would bear greater risk, their profits would be reduced.
A lot of these issues would go away if employers weren't responsible for providing healthcare group plans. But then again Europe also has similar drives to classify Uber/Lyft drivers as full time employees so they are entitled to other benefits and employment securities (but those don't exist in a very strong form in the USA anyways).
Employers are not required to provide health plans. The issue is that Uber provides _some_ employees with health plans while keeping their lower-paid workers classified as contractors, even if they work essentially full-time.
As soon as you're 50+ folks, you're required to provide health insurance. The US system is broken enough that you will do it before then too.
All founders I've talked with about it find it crazy that they're determining the healthcare choices for their team, and it's much worse when they are supporting a diverse team.
"""Fred has 3 kids and cares about their dental, Tim mostly cares about mental health, Alice runs ultramarathons, and Bob just got married. The main things we have in common are we like building cryptocurrency tech and work in similar time zones."""
Am I an employee of the bottle machine company if I deposit bottles I find? Do they owe me healthcare and a minimum wage if I took more than an hour to find so many bottles? How is uber any different?
I think you can employ W-2-style employees without providing them healthcare. It’s a perk, but not legally required to have a W-2 employee.
I think the heart of the issue is the entirely artificial split between the concept of employee and contractor. (Much like the arbitrary split between taxi and car service in nyc.)
Making everyone a contractor for every job, with the terms of the job specified in the contract, seems much more straightforward. I don’t think that the concept of “employment” needs to be one size fits all, like standard W-2 is today in the US.
It’s an artifact of tax law, the scam that is withholding (make most people not “feel” their taxes), and a dominant manufacturing economy model that no longer exists in the US.
Does that mean that when I remodel my house, I would have to negotiate on time and materials terms, lest the contractor accidentally underbid and end up with less than minimum wage?
I think the law rightfully distinguishes between truly negotiable contracts and take-it-or-leave-it terms offered by a party with more negotiating power.
Of course not. The prices someone sets are not related to the wages they're paid. You're paying a price; you're not paying a wage. The contractors are paid a wage by the business owner; if he pays them less than minimum wage it's illegal; if he pays them more, but does not recoup that cost on the job because he underbid it, that's a business loss.
Why do we treat these things differently? Why is the GC permitted to make bad business decisions and earn below minimum wage, but the people he employs are not?
Not just healthcare- but other beenfits like sick leave, etc. and collecting taxes like unemployment insurance. When you do this -you better not leave any loopholes because companies have proven they will use it. IF Uber was successful, other companies would start fractional hiring of employees. I only need Finance people 2 days/week- they can come in anytime they like, work as long as they want and can work at other companies too. We'll save on taxes and benefits and they will enjoy their freedom. Too bad the Govt will lose taxes and the workers their benefits.
I don't think that changing driers to employee status will necessarily give them health benefits. I'm not an expert, but while ERISA generally requires uniform benefit options for all employees in a similar class, the companies could chose to not schedule the drivers as full time employees, use contract labor services, raise the employee contribution to unaffordable level, etc. Many companies with large numbers of employees have large fractions of their employees without health insurance (Walmart, for instance).
This is why I think it was a mistake for the ACA to limit catastrophic care to people under 30 (unless you get a hardship waiver [0]). That policy makes the cheapest non-job insurance that a lot of people can get cost >$500/month, whereas a catastrophic plan costs a lot less (about $120/month when I had such a plan in 2016).
For a lot of people who drive Lyft, catastrophic care could be a good fit, e.g. people in between jobs who expect to have a company plan at their next full-time position. This wouldn't entirely close the gap towards providing gig workers with benefits, but it would have helped.
There's also people for whom Lyft is a second job -- I'm thinking of a ride with a Chicago public school teacher who drove on weekends and breaks -- and I don't think it makes sense to force Lyft to provide them with insurance.
Where do you see those numbers? ACA offers catastrophic plans to those under 30 and they're not nearly that expensive. I just did a quick check for someone with no subsidy in San Fransisco using the age of 25 and a catastrophic plan from Oscar showed up at $223.46/month. This includes zero subsidy. Using a $30k income and rerunning the numbers, a bronze plan form Kaiser with subsidy comes out at $47.83/month.
Look, I'm not happy about health care costs either, but ACA plans for young are really not that expensive. Further, plans prior to ACA offered terrible coverage. Yes, people got to say they had coverage, but the lifetime caps bankrupted people repeatedly. Eliminating the caps and mandating minimum essential coverage was absolutely essential to eliminating what really were scams of coverage. Further, even if you really want to get terrible coverage for less money, you can always use the loop hole and purchase coverage through a health care sharing ministry, which are even cheaper. Though, I strongly recommend against that because there's no guarantee that a bill will be covered.
OK, cool. Every state is different, so I'm always a bit curious as to how high premiums are set in different places. I just took a look at plans for those in NYC. For someone aged 35, it still looks like they're offering catastrophic plans. Fidelis has one at $178.75/month with no subsidy. For someone making $30k/year, the subsidy drops a bronze Fidelis plan to $16.59/month.
And, to be sure, coverage is still pretty bad. Just because someone has coverage doesn't mean they have the money to use coverage. Unless there's another subsidy, and there may be, that bronze Fidelis plan has a $8150 out of pocket max and it's unlikely someone making $30k/year is going to have that much money laying around. That said, at least the plan has a couple of free PCP visits.
Anyway, my intention here isn't to beat a dead horse. It's really important to me that people get health care coverage and costs are a barrier. I believe ACA plans to be far more affordable than people think them to be. I don't doubt that you saw a price in the realm you mentioned because they're out there, but often better pricing can be found and I end up doing these searches a lot.
You also would have to worry about housing payments. A very easy and progressive solution to this problem is that the government should construct housing that citizens can stay in.
While they are at it, they could also provide basic food.
That way, with your UBI, housing, and food you could live a dream life. We won't call them 'camps' though, but give them a hip millenial-approved name. Maybe 'launch centers'?
I think the heart of the issue is VC-backed startups trying their hardest to circumvent laws until they are big enough that enforcing the laws makes people mad.
What citizens want is fickle and entirely depends on framing and knowledge.
Citizens want goods for cheaper, obviously. But citizens also like the concept of people and companies doing "their fair share". For example a fair amount of people were outraged when it was revealed that official Walmart policy was to direct underpaid employees into Medicaid, EBT, etc. rather than just paying them to afford basic life expenses. And the gig economy if anything manages to be even more exploitative than that.
Citizens also want to be able to earn income as independent contractors, the way they have for decades in many other industries. But above all, citizens would like to be able to choose for themselves instead of having a few people with no idea of their experience tell them what they must do.
You mean like the way all citizens are entitled to choose their representatives that passed AB5 in the first place?
California has a strong history of voters holding politicians doing unpopular things accountable (see: Gray Davis) or doing things that override the will of politicians (see: Prop 13). There has not been strong voter organization against AB5, which speaks volumes about how much of a non-issue it is for voters.
In reality, most voters are ignorant and irrational while the state govt is especially dysfunctional, unrepresentative, and full of graft. That's why there are so many problems here in the first place. When CA gives more rights to illegal immigrants than tax-paying citizens, there's clearly something wrong.
America does not have a stories history of being labor friendly. It’s pretty much old European pissing competitions imported anew after WW2. Identity which the country had begun to schlep off between the Gilded Age and WW1. Refugees brought it back over.
The best part of all this is Adam Smith only ever mentions markets in the context of a free labor market, buoyed by government support of equality of condition.
But Smith and Aristotle, who wrote Democracy is likely the most moral government, are cast aside for James Madison who wrote the Senate ought to protect the rich from Democracy or the people will take all the aristocrats stuff.
This is all 2,000+ years old rhetoric. Human biology hasn’t evolved so fast in that time that such concerns of the past are rendered obsolete.
Were I rich right now, being educated enough to understand history, and looking at the relative income gap being larger than the french revolution, I'd be wanting to redistribute some wealth right now myself, lest it be taken by force. A 3% wealth tax seems "extreme" right now, but it will be preferable if the wedge making the poor fight each other breaks down.
The people who become obscenely wealthy in this country become so precisely because they have so little regard for others and almost no comprehension of the long-term impacts of massive inequality (either to the nation or their own physical security). And the system has become so perverse and adept at indoctrination that these people are heralded as heros when they drop a few crumbs from the table.
Aristotle considered democracy a deviant form of a polity. His views on democracy are more negative and complex than you're making it sound, which leads me to doubt what you're saying about the rest.
Forgive me for not satisfying you with a nuanced treatise on a casual forum. Aristotle’s ultimate conclusion was that “for the average person” Democracy was the moral government.
He was not of average status. His nuance and negativity was, to my mind, self preservation driven. Nonetheless, he understood the benefits of Democracy to what we’d call “Main Street” life as obvious. He dismissed on those grounds as well, given the threat to his status. He got what it meant as an idea and agreed it would be a moral win for the public.
Ultimately I’m not writing a biography here. This isn’t rocket science and there’s little new territory to really be walked.
America of a generation ago had high taxes flooding communities with money. Now that generation is wielding a nations wealth against the next generation.
America is a lot of control freaks policing each other for compliance to sound economics and calling it freedom.
Labor unions in the US are comparatively powerless next to countries with actual, functional unions that are quite capable of striking, and have little lobby.
No, the heart of the issue is definitely the dismal state of health care in the US.
Joe Biden, who many believe will be the next US president has stated "I am a union man, plain and simple". His whole political career has basically been bankrolled by labor unions. If that doesn't indicate the power labor unions have in the US, I don't know what else does.
Teachers Unions, UAW, and the AFLCIO are pretty much the strongest lobbies in America.
The campaign contributions of many other industry interest groups dwarfs those other interests, and that is evidently obvious when looking at the policies of the Democratic party, which would not even be a center left moderate party in most EU countries with actually strong labor interests.
I don’t understand, why is that surprising? After all the reason behind this bill is to prevent unfair labor conditions. It is literally the job of labor unions to push forward and lobby for bills like these.
I think you are guilty of bad faith reasoning here. First you state that “big labor unions want more power” and your evidence for that claim is “Labor unions push for bills that prevent bad labor practices”.
Instead of accusing me of acting in bad faith, how about you do some research instead of mudslinging on the internet. I have provided evidence. You have provided none.
To help point you in the right direction, why are the United Auto Workers acting in California when there are no unionized auto workers in California? These unions are always seeking to increase there member base because the more members they have the more powerful they are as an entity.
It is bad faith because the evidence you provide is accusing the unions of working towards their expressed interest, to protect the workers from bad labor practices.
Unions also have a notion of solidarity. What is good for workers in California is usually good for workers in New York. That is why you will often see unions acting across state (and industry) boundaries, in solidarity with other unions and non-union workers.
Unsure why this is getting downvoted. Anyone who actually follows the money in this debate knows that the unions are very heavily financially invested in this and donate tons of money to the politicians that support anything that increases their power and influence.
If unions were truly invested in the best interest of workers instead of the best interest of the union, they would value the desires of the 4/5 of drivers that want independent work as much as the 1/5 of drivers that want to be employees with benefits.
It is being downvoted because it is making an unsound claim without any backing.
Most likely there is not a single explanation, usually issues like these are more complicated then that. There is no consensus on whether unions are more powerful in the US then elsewhere, I’m sure you can easily find examples—or spin the narrative—to back either case. And finally there is no evidence for some ulterior motive of driver’s unions, nor even a convincing narrative. Quite the contrary there is both evidence and a somewhat convincing narrative for why the ride-share companies would want to keep their workers from unionizing and asking for full-time worker’s benefits.
This is an unfair critique. The whole point is that the drivers will get regular employment (as opposed to being contracted) and will be able to unionize under any driver’s union (or create a new union, or even some other more generic union).
My employer pays probably a shit ton of money for my health insurance and what I get is the most subpar, confusing, broken and sometimes blatantly extortive service ever.
I live in Austin and sometimes I think if I really need a major procedure it would be just simpler to drive to Mexico and get it done there. In fact, that's what many people in South Texas do, so there's your benchmark for how broken is healthcare in the US.