[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?

[epistasis]

Absolutely not. It regularly performs invalid rights on unallocated memory and even kills people.

[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