[diogenescynic]

Quality of care is shit. Doctors barely care about their patients. It’s all a racket. Most areas seem to have a local monopoly that takes over the local hospitals. Obamacare has done nothing to really change anything meaningfully.

[DavidPeiffer]

Obamacare is a mixed bag, but I don't think I'd go back to a pre-obamacare era if I had a choice. So many people stayed at jobs for longer than ideal because they had pre-existing conditions that wouldn't be covered under a new insurance plan.

The consolidation of the last 20 years has been a real black mark on the system. It was supposed to improve outcomes by making all the records easily available in one system. Instead we've seen the independent doctors office largely go by the wayside and local competition decrease.

Not all outcomes are comparable or worse though. The outcomes most improved seem to be net worth of executives.

[fellowniusmonk]

Pre ACA was absolutely insane. Literally any change would have been better. The artificially limited and abusive process of training doctors is still completely broken. The training pipeline is pure protectionism. The rise of nurse practitioners and the creep of doctor like responsibilities for nurses is a sign of the complete failure of our doctor training pipeline.

Approximately each year we have 1 doctor finishing residency for every 120 births, compare that to Portugal which has 1 new doctor for every 57 births.

Horrible individual, family and economy destroying things from pre-ACA:

1. Because I wasn't born with a perfect body I was literally forced to work for a company until ACA because I was uninsurable. I started my first successful startup immediately after ACA became law with an idea I had fully fleshed out a decade prior. It's a horrid drag on the economy to introduce infinite health (and bankruptcy) risk to any attempt to be an entrepreneur.

2. If you WERE ever eligible for private insurance and every stopped paying for it (because you had insurance through your company) you were unable to quit that job and go back to private coverage, if you tried you would be denied if you weren't in perfect health. Fully contiguous coverage would still get you fully denied for "pre-existing conditions". Coverage was not guaranteed to transfer between states.

3. My family was bankrupted and financially destroyed because my mother was diagnosed with cancer during a short interstitial period where the company my father was working for suddenly went out of business and keeping cobra would have cost 15k a month so they didn't. It was so messed up she qualified for state medicare but that meant that my families income couldn't be above ~15k, my parents only option for my dad to get a normal paying job was to divorce (which they refused to do on religious grounds), this meant that I had to enter the workforce full-time to pay for my family to have a roof and food over their heads at 15.

Even though so much of the brunt of this was put on my childhood shoulders I was able to make it out ok all things considered because I am a complete bastard of a person, my siblings who were less resilient were absolutely destroyed, we were all in the top 10% of intelligence based on standardized testing.

The pre ACA system was a kafkaesque nightmare that was completely different state to state so many people found themselves unable to move states for work because coverage and eligibility was effectively unparsable between states for the laymen.

[DavidPeiffer]

I'm sorry you went through that. My analysis was short largely because I was still in high school when it passed. I knew it was a nightmare prior, but didn't have any direct experiences.

The beat of the drum has long been "repeal the ACA" for a political party. It rallies people to undo a sweeping change the other party put in place, but it has never materialized. So many parts of the ACA poll very popular, a complete repeal without a really good alternative (which has also never materialized beyond "a concept of a plan") would be a surefire way to immediately lose political standing.

And perhaps most sad of all of this is ACA didn't even remove health insurance from its tie to employers. There are still massive inefficiencies for people who hit a deductible or max out pocket early in the year. They'll either need to pay through the nose for COBRA through the year end, or switch jobs and start over with the deductible and max out of pocket, which for large swaths of the population is simply not a reasonable option. Switching near the start of the plan year is optimal, but definitely less efficient overall.

In 2020 I learned health insurance premiums from your paycheck are taken pre-tax, however you cannot deduct COBRA premiums. It really rubs salt in the wound for people who have been laid off.

[fellowniusmonk]

Yes, I mean I was young and a republican at the time but even I was pissed that Joe Liberman voted single payer down.

My perspective at the time which was naive/wrong was that we should either deregulate completely (which was a foolish perspective from my youth) or switch to single payer like France's system where doctors stay independent (unlike the UK's NHS at the time) and we just shoot the health insurance industry.

It was very obvious to anyone who had regular dealings with our system that it was opaque, cruel, insane and a premium cost for an inferior experience.

Not to mention the history of insurance companies losing lawsuits because as a "cost saving tactic" they would deny claims by default so people would die before procedures were approved.

From a cost efficacy and perverse incentives perspective it was clear that things had to change but that the ACA as it was passed would be easy to pick away at and sabotage by insurance industry and health provider conglomerates, and that is exactly what has happened.

Still the protections in place are FAR better than what we had.

It was very common at the time to hear even Republicans refer to themselves as "wage slaves" because of how beholden the populace was to corporate insurance and how it effected career choices.