[thisisnotauser]

This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection for these exploitative middlemen when the necessary solution was to blow up the entire industry with a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.

Not every system becomes more efficient with profit incentives, and this really seems like just such a case.

[epistasis]

The ACA was the best compromise that could be struck at the time, with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.

This is the dirty part of the political process: people sacrifice better outcomes for all, merely for the pursuit of more power in the future. And those who want better outcomes for all must somehow gather a coalition that can achieve those outcomes.

Nobody, least of all the architects of the ACA, thought it was the best possible system. It was merely the best system that could get through the democratic process of our government.

Which means we need iterative design on these programs. It's not pass once and done forever. We need maintenance legislation for bug fixes and feature improvements. However, every culture war battle that we fight can be used to distract from actual reform, like a nefarious form of bike-shedding.

[toast0]

I wish we'd just say ok, people like Medicare, let's drop the age of enrollment by 1 year every year for ten years and see how that goes. If that works out, drop the age of enrollment by 2 years every year for the next ten years. Then figure it out from there. Could start as a paid option rather than just lowering the age when you get coverage based on work history, too.

Maybe something for children too, start with making Medicaid or something automatic for the first N months of life, and increase it every year too.

[soks86]

We'd still be waiting for healthcare with this kind of plan.

Before the ACA it simply was not a choice to be an independent professional and have health insurance.

If people could understand why it is unacceptable to force independent professionals and entrepreneurs to give up healthcare they would see the ACA was necessary in whatever form it could be passed.

[franktankbank]

You don't need to have insurance for the vast majority of care, yet it gets used as such. Let's drop that nonsense, it tangles up the billing process.

[mistrial9]

when you fall from a bicycle in traffic and need more than ten stitches, you probably want clean conditions and high skill people ready. Ordinary daily care is done by ordinary daily care people because there is so much of it to do. It is fairly rare to need ten stitches from a bicycle accident. This is an example of people in ordinary good health. When you get to chronic care and elder care, things change again.

this call for "less reliance on insurance" lacks context and is overly-simplistic IMHO

[franktankbank]

Doctors can't exist without insurance? Hell we don't need doctors to diagnose strep etc. My argument is to remove insurance from the common. I've never crashed a bike requiring 10+ stitches probably never will, but might be a good reason for to carry insurance for it. However I don't want it plugging up the bill flow when I go to get antibiotics for a routine illness.

[lotsofpulp]

This is the point of High Deductible Health Plans with access to HSA contributions.

[jordanb]

Obama started from the idea that the private insurance industry would continue to exist (and grow!) and therefore anything that would eat into their business was out.

Medicaid expansion was allowed only because it was insuring people the the private companies didn't want as customers.

[prepend]

Everyone I know on Medicare does not like it and would prefer something else.

I think people like Medicare like they like Comcast. They have it, it performs a service they want, they hate everything about it, and would never leave.

[jordanb]

> Everyone I know on Medicare does not like it and would prefer something else.

I have UnitedHealtcare through my employer. I don't like it and would prefer something else.

[prepend]

I’ve actually never met anyone who pays for their healthcare who likes it. Over the years I’ve used United, Aetna, KP, BCBS and didn’t like any of them. I switch when I can.

[epistasis]

There are very very serious financial problems with going down this route. Private insurance pays for a lot of Medicare, because Medicare reimbursement rates do not cover the costs of Medicare patients in many parts of the country.

One of the better sources of information I have seen on this is actually a YouTube video, something I don't normally recommend, but getting a wholistic viewpoint is somewhat difficult otherwise:

https://www.youtube.com/watch?v=QqrpFICtqpQ

We could increase the medicare contribution cap (samething like only the first $175k of income has medicare tax applied to it), but I'm not sure that's going to fill the massive gap. Perhaps increasing the rate would also work.

There could be some good things about this process, I just want to bring up that it's not a magic bullet because we will run into access problems unless we also solve the funding side of things. And when there are access problems, the people who lose access will be those with the least to pay.

[pxmpxm]

Some 30% of NY state and ~48% CA population is already on medicaid. Are you gonna make a whole middle-america flyover town work an extra shift to pay for that plan?

[projectazorian]

Both of those states are net contributors to the federal budget, unlike many "middle-america" flyover states.

BTW, your stats are way off, CA is at 33-34% Medicaid utilization. Below several red states.

[pxmpxm]

Mixed up the numbers, 37% was the number of the article I was thinking of. https://www.wsj.com/opinion/biden-welfare-spending-transfer-...

In any case, I don't see how the state net revenue balance is relevant as a justification for this - all that's saying is california has fatter tail on the income distribution. You don't "own" those rich people, as the high-tax states are coming to find out with the mass exodus to florida.

Definitionally 4/10 of california residents cannot be in poverty.

[fumeux_fume]

As silly as agile government sounds, if it forces our legislators to take part in the misery of a daily standup, I'm all for it.

[epistasis]

Legislation is literally the code of society.

[JumpCrisscross]

Sort of. It’s more akin to design guidelines.

[epistasis]

By "literally" I mean that the name for it is the Code of Law, with a civil code, and a criminal code. And this usage of "code" predates computer programming by many centuries!

[6510]

is it safe?

[joquarky]

So let's put it in a code versioning system.

[gatlin]

> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.

This is a fiction people repeat with no citation. A large portion of the population wants m4a when it is explained to them. This "system" failure was specifically our elected reps - bipartisanly - ignoring the needs and wants of the people at the behest of their donors. The democratic process failure was when the two parties solidified.

It wasn't pitchfork wielding illiterate rubes (or whatever undoubtedly out of touch "data driven" parody of what an average person is we're operating with) trying to deny a Black man his legacy, it was that Black man's party collectively wanting to be reelected that gave us the "Buy Insurance Or We Fine You Through Taxes" Act.

[jtmarl1n]

You say the comment you replied to cited no sources while making an assertion you disagree with. Then, you go on to do the very same thing.

[jordanb]

> The ACA was the best compromise that could be struck at the time,

That's not he way the ACA went down. Obama had this idea that the best way to reform an industry was to have it write its own reform legislation and pretty much let the industry have first draft.

> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.

The ACA was initially popular but it became increasingly unpopular during the months of horse trading, the explosion in length of the law, the jettisoning of most of the good parts (drug price controls, public option, etc), retention and expansion of industry giveaways (tax penalties), and yes, relentless Republican opposition and propaganda against it.

But even the latter was Obama's fault for not being prepared to anticipate and deal. He actually spend the first several months pushing for a "bipartisan" deal with Republicans that gave them room to delay and attack.

> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.

Obama had a filibuster-proof supermajority in congress. Yes, Republicans were going to oppose his agenda, but he didn't need them. For some dumb reason he loaded a gun, pointed it at himself and handed it to them.

There were lots of comparisons to Medicare/Medicaid being made at the time. That law was a fraction the size of ACA, the implementation phase was like a year instead of a decade for the ACA, and its effect on the public was immediate and profound.

The failure of the Obama administration was the failure of technocracy. Obama thought he could have "experts" develop the ultimate "win-win" policy. What you ended up instead was a bunch of naked self-dealing by craven opportunists who either worked for the industries they were regulating or intended to do so in the future. People saw through this and it lead directly the the rise of Trump

[jjav]

> This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection...

Both are true! The ACA is a literal life-saver and bankrupcy-avoider for a significant percentage of the population. So it is a huge win for the common person.

At the same time, yes, it perpetuates the corrupt insurance system, which is bad. But at least makes it more widely available, which is good.

> Not every system becomes more efficient with profit incentives, and this really seems like just such a case.

Health care can only ever get worse with profit incentives. The best way would be to eject all the profiteering out of the system so that only the people who provide actual care (doctors, nurses, medical technicians,etc) get paid. Remove all profit from the hangers-on that do nothing useful (insurance middlemen).

The path to get there is obvious, but politically quite impossible in the US (and only in the US, since every other country has it figured out.)

[JumpCrisscross]

> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven

We can solve pharmaceuticals without bringing in the miasma of the broader healthcare debate.

Three things:

1. Let Medicare directly negotiate pricing on all drugs;

2. Make it easier for generics producers, including foreign manufacturers, to sell into America; and

3. Reform PBMs [1]. Transparency on pricing. Spun out of monoliths.

While we’re at it, maybe someone can figure out how to cut the $1bn it costs to get a drug to approval to something lower.

[1] https://www.congress.gov/bill/118th-congress/senate-bill/297...

[jacksnipe]

It made a massive difference in the day to day lives of the most affected people — the chronically ill.

I cannot emphasize enough how much of a death sentence being chronically ill before the ACA was. No protection for preexisting conditions meant one unfortunate incident could cost you your job could cost your your healthcare could cost you your ability to get back on solid footing to get another job.

[Webstir]

Love how people try to rationalize these vultures. The elite and their PMC toadies are just corrupt. That’s it. The united states is corrupt to it’s core because we allowed the elite to run things.

[indymike]

> we allowed the elite to run things

I'm pretty sure that being elite is a symptom of running things, not the cause of running things.

[JumpCrisscross]

> because we allowed the elite to run things

By definition, a society’s elites always run things…

[forgetfreeman]

True. How's that worked out so far?

[JumpCrisscross]

> How's that worked out so far?

Pretty damn well in the long run!

[voakbasda]

Worked great for the French too, right up to the Revolution.

[JumpCrisscross]

> Worked great for the French too, right up to the Revolution

Each of the French Revolution’s successive governments had their own sets of elites. (La Révolution itself had its elites.) Arguing against elites as a category is arguing against hierarchical sociology. It’s inchoate. We don’t have an example of a society without elites; we barely have examples of social animals without hierarchies. (Zebra herds.)

And speaking of the French Revolution, the elites ex post facto were not only mostly the same as before, they escaped with so much money and wealth that it’s actually debated if they increased their wealth share through the chaos [1].

[1] https://www.jstor.org/stable/650023

[forgetfreeman]

You ever lick a boot clean off the foot wearing it?

[SoftTalker]

As if a "public option" would not have a middle tier that evaluated, and then approved or denied claims?

[Auracle]

That doesn’t matter when it’s subsidized by the government. When people talk for a public option all they’re really talking about is one option, because no company would be able to compete.

[ljf]

We have free at point of need healthcare here in the UK, and still have a lot of choice in private healthcare if you want it.

In the nearest city to me there are 3 major private hospitals, and if you head into London there are loads of them.

Private is still able to compete and to be profitable. Just no one needs to die from preventable diseases.

(not saying NHS is perfect, it is a shadow of what it should be right now)

[ajb]

Sort of. My understanding is that private hospitals largely opt out of most of the difficult stuff, because the NHS is there to take it on. So they're good if you're waiting around for a hip replacement but not so much for other things.

[tialaramex]

Right, essentially every private hospital's response if, say, a patient they're giving a boob job suddenly becomes unresponsive is to... call the NHS. Yeah, the medical staff will be better than your neighbour or some random passing guy in the street when it comes to knowing how to put you in recovery position or attempt CPR but those hospitals won't have a crash protocol beyond too bad call the NHS.

I spent eight hours at an Accident & Emergency department at my city's hospital a couple of weeks ago (Those electric scooters look easy enough, I have a driving license, I watch the training video, then at midnight I thought I'd try one, signed it out, crashed into a lamp post within seconds, broke my hand and busted my head open. Oops. Signed the scooter back in, walked to the Urgent Care, it shuts late at night, walked towards hospital, saw a cop - "Hey, I can't see my head, I can feel the wound, is it bad?" "You should get a taxi to A&E. I'll call you one"). There is no private emergency care, private cosmetic surgery sure, and lots of private non-urgent care, like knee replacement or whatever - but no emergency care.

[conductr]

Nothing in this article was a byproduct of ACA and it all predated it. But also in no way did it reduce costs, that’s a lie. Who even says that? Unless you’re only considering very specific benefits like birth control. Overall it increased costs, even when Medicare of any government program announces a reduction or sequestration the industry just raises prices everywhere else to offset. I’ve been in those decisions when I worked in the industry. We never let it flow through to bottom line, we always found a way.

[Eddy_Viscosity2]

The middlemen would never allow a public option and they have enough money to stop it happening. US policy is the will of the rich not the people.

[DarkNova6]

Profit-chasing never makes systems more efficient. It’s competition.

[throwawayqqq11]

> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.

Much like amazon did in the early days.

When the problem is incentive structures -- of profit seeking corporations or compensation seeking individuals -- what options do you have? (IMO its only regulatory enforcement with democratic oversight and transparenct.)

I think we as a society still have to figure out ways to restructure sprawling institutions and i dont like it when people only put the blame on public or private ones while ignoring the other.

[neuralRiot]

>Not every system becomes more efficient with profit incentives

Maybe it does but not for the right people.

[renewiltord]

Public option would lead to pure fraud like in the ABMT treatment for breast cancer. Asking for trouble. Especially in the US where people believe that no one should trade grandma for a dollar.

In the UK, they fortunately have a notion of money spent for QALYs earned (adjusted to boost life extension at end of life) but in the US everyone believes that we should spend arbitrary amounts of money on people and if we don't, we should pay their relatives extraordinary amounts to compensate for the fact that we didn't spend a few aircraft carriers worth of money on them.

Put simply, so long as US ethics remains "there is no sum of money that is too high to save an arbitrary person's life", we have to oppose the public option.

[krapht]

I'd like to see proof that Medicare does not evaluate QALY and spends unlimited money in general.

[renewiltord]

The percentage of the federal budget that is spent on dialysis and the life of the patient preceding when they're put on dialysis.

Even without that, when Cuomo in NY said he wouldn't trade grandma for a dollar, there was thunderous applause across the US. And many here argued that the economy isn't as important as any life lost. That's enough to cement it for me.

[roenxi]

Typical US profit margins are somewhere in the area of 8%. If dropping healthcare costs by 8% is what people are arguing over then I've been badly mislead about the problems with the US healthcare system.

There is a real issue with regulatory capture. Making the system purely public is not going to result in the regulators suddenly purging their souls of all corruption. It'll still be a disaster just without any pretence of an alternative. There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.

[foolswisdom]

That's nominal profit margins. It doesn't take into account the way that different parts of these conglomerates take money from one pocket and put it in the other (e.g. insurance and Healthcare providers), which means it doesn't show up in the profits for your first pocket. This is why the fact that Healthcare platforms are vertical monopolies (not just horizontal monopies) is important to this conversation.

(separately, profit capping rules means that once a monopoly is cemented, once a company has moved as much as it can from one pocket to the other, there's an internal incentive to spend money on bureaucracy).

[roenxi]

Because the regulations encourage vertical monopolies. Replacing that with a state mandated vertical monopoly unconstrained by market forces isn't going to help. In fact it'll probably make the situation worse. There is no reason for there to be monopolies in healthcare and if they are emerging that strongly suggests misregulation. Giving the regulators more power in that sort of situation is the opposite of helping.

[ThePowerOfFuet]

Are you seriously arguing against single-payer healthcare?

[roenxi]

Which part of the argument strikes you as frivolous?

[ThePowerOfFuet]

Not frivolous, but outright incorrect.

[lotsofpulp]

>That's nominal profit margins. It doesn't take into account the way that different parts of these conglomerates take money from one pocket and put it in the other (e.g. insurance and Healthcare providers), which means it doesn't show up in the profits for your first pocket.

This is nonsense. UNH’s profit margin is all net income divided by all revenue.

https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...

Same with Elevance, CVS, Cigna, Humana, Centene, and Molina. There is a reason all these businesses aren’t at the top of the market cap rankings. Not even in the top 100.

UNH is up there due to sheer size and the fact that they sell high profit margin software and healthcare. Otherwise, you will not get rich starting a managed care organization. Even Warren Buffet, Jeff Bezos, and Jamie Dimon ran away with their tail between their legs:

https://en.wikipedia.org/wiki/Haven_Healthcare

[rqtwteye]

The profit margins are not the only thing. There are tens or hundreds of thousands of people working on billing jobs at doctors and insurances that shouldn’t exist.

[Auracle]

And you think a government run system would be more efficient? It’s still going to have people in each side verifying claims, preauthorizing stuff, etc. To do otherwise invites massive fraud.

[ljf]

Government run systems are alot cheaper all across Europe. So yes.

Unless you are saying there is something exception about the US and profit extractions?

[Auracle]

They're cheaper because of price controls on medications and salaries.

That's just straight up not going to happen in the US. We could have easily tackled medication prices by tying them to an average of some select other countries, but we haven't.

People would throw an absolute fit if our government tried to lower the salaries of doctors, and especially nurses.

The US is also just a very large country, population-wise. German has around 84 million people, so barely more than twice the population of California. I'd be a lot more likely to support government run healthcare if it was done by the states. The larger a system gets, the more inefficiencies sneak in - and, as a bonus, people could move to other states if the healthcare in their own wasn't up to par.

[rqtwteye]

Government run is not the only alternative. We should start at standardizing and simplifying things. Less variations in insurance plans. Standard data exchange. Same pricing for same procedures. Price transparency. It doesn't make any sense that a drug or procedure costs less in cash than through insurance.

[ForTheKidz]

> There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.

I trust the market to provide healthcare about as much as I expect america to suddenly blast off to join the moon. And i trust vc/finance a hell of a lot less than that.

[roenxi]

Do you feel the Trump & Musk dynamic duo are going to do a better job of handling it? They're cut from similar cloth.

[ForTheKidz]

No, of course not, this is just more extreme of the same behavior.

[slt2021]

high cost of healthcare can be solved overnight: just mandate insurance companies to pay for healthcare for foreign hospitals (at rates not exceeding US rates).

so that Americans could travel overseas and get healthcare expenses reimbursed over there.

watch prices drop...

[rickydroll]

Does that include airfare and living expenses? I figured out that if I needed two crowns, it would be cheaper to fly to Estonia and use my friend's dentist than to go to a US dentist.

On prescriptions, reimbursement for drugs bought from cost plus would also help drive down pharma prices