[mindslight]

Talking about the "middle" is the wrong way of framing it. The problem is that the Democratic party sandbags any meaningful reforms, as they're still beholden to that same Epstein class when it comes time to campaign. For example the Democrats' grand attempt at healthcare reform included making it mandatory to patronize the "insurance" cartel! Is it possible for regulatory capture to be any more brazen?

So people get frustrated with the hamfisted top-down plans tailored for those deeply wed to the system, tire of the hypocrisy, and then either stay home or vote for the alternative that doesn't even bother promising to try and constructively fix anything. It's a game of bad cop worse cop. We desperately need ranked pairs voting.

[tzs]

Several countries with universal healthcare use the "you have to buy private insurance" model, such as the Netherlands and Switzerland. There doesn't seem to be anything inherently wrong with that system.

ACA has survived 12 years and enabled a lot of people to obtain health insurance that would not have been able to otherwise, with Republicans wanting to kill it that entire time but failing to do so. Do you think there was any other system Democrats could have passed instead that would have lasted that long?

[mindslight]

> Do you think there was any other system Democrats could have passed instead that would have lasted that long?

You're buying into the paradigm wherein sandbagging it was necessary for pragmatic reasons, and justifying within that. While this is true to an extent, it doesn't really change my overall point.

I do get that the ACA was a significant piece of legislation that has helped many people. And if you want to talk system design, such a mandate might make sense in a system with much much more regulatory bandwidth than ours, where it's not just forcing people into a corrupt system. But as it stands, they didn't even address the antitrust issues of bundling healthcare plans with employment or price fixing between insurers and providers. So I stand by my characterization of the dynamic as brazen regulatory capture.

[bubblewand]

Switzerland has a “public option”, price controls, and IIRC private insurers have to be non-profits (and possibly that designation means more in their system than the US, I dunno about that).

[Steltek]

ACA mandates that ~80% of insurance co. revenue must go back towards medical service. So not "non-profit" per se but there is some kind of restriction there.

[bubblewand]

1) Not for "self-funded"—many plans are managed by big insurance companies, but funded by employers. No restrictions there.

2) Not for plans that are (IIRC) two years old or newer. I'd be shocked if there aren't a bunch of shenanigans going on with this loophole.

[mindslight]

also 3) many "insurance" companies are in the provider game, meaning they can preferentially shuffle surplus to their other arm

(2) and (3) were part of what I meant by a lack of regulatory bandwidth in another comment. There are rules that could be enforced to promptly impose steep penalties for a company that tries to skirt them. But they just aren't, so after one company starts doing it the rest inevitably follow suit.

[red-iron-pine]

which will never fly in the US in a million years.

take a look at the Fortune 500 list and notice how many health and pharma companies are in the top 50 (and/or top 10)

[bubblewand]

Add to it that all our retirement accounts are invested in these companies, and it kinda looks indistinguishable from a really roundabout way to have a very-regressive redistributive retirement scheme that also has crazy-high fees (whatever part of the overpayment to healthcare companies that doesn't make it to shareholders is basically part of the account management fees)

Yes, I'm suggesting that like 10% of our nominal GDP is actually a deeply fucked up regressive wealth redistribution scheme that doesn't buy tangible productivity, but is essentially a tax-like drag on the economy, but way less efficient than most government-run redistribution schemes. Because it is.

[mindslight]

I don't think squinting and framing things that way is particularly productive on its own, and you didn't go anywhere with the idea. One could also characterize it as big jobs program. But these framings belie that the structural "inefficiency" is the crux of the problem - both resource-consumption wise, and also in terms of (not) providing good healthcare. For example, how many full time skilled doctor equivalents are flat-out wasted by being spent jumping through "insurance" company bureaucracy? Or how many nurses is the "insurance" industry wasting directly?

[bubblewand]

I agree that the core problem is that we’re simply spending far more than necessary for the level of care we receive, but the side effects like being a white-collar makework jobs program (the upscale counterpart to the military, sort of) and redistributing (a little of the) money toward retirement accounts are what make the problem “sticky”. There’s a lot of temporary collateral damage if you fix it.

[diogenescynic]

>ACA has survived 12 years and enabled a lot of people to obtain health insurance that would not have been able to otherwise, with Republicans wanting to kill it that entire time but failing to do so.

My insurance is more expensive than ever and quality of care lower quality than ever.

>Do you think there was any other system Democrats could have passed instead that would have lasted that long?

Medicare for all. Or lower the age gradually (cover kids and elderly first). They should have voted on it during the pandemic but Pelosi blocked it and AOC wouldn't do anything. They're all fakes.

[tzs]

You'd probably have the rising cost issue no matter what had happened, because that problem affects pretty much all first world health care systems. The US is way more expensive than others, but the ratio of US costs to the costs of others has stayed roughly constant over at least the last 40-50 years.

[diogenescynic]

Exactly this. They went the entire pandemic without even bringing a vote on Medicare for All. The democrats are not left wing at all. They are complete corporate sell outs. They don't actually do what their voters want, they represent only their donors.

[mindslight]

Agreed, but at least the Democrats (or their specific donors) were smart enough to not kill the geese that lay golden eggs. Republican policy is now like "it's free meat! and killing is a natural process!"

It's hard to tell if it's more accurate to still label the Republican party as also "complete corporate sell outs", or if the real dynamic is its controlling corpos got bought by foreign interests aiming to take down the whole United States (rather than merely being content extracting wealth from the masses).

I swallowed my pride and started voting conservative (aka Democrat) in 2020, but that doesn't mean I'll stop criticizing them.

I do have to wonder if say pushing the Democratic party itself to adopt something like ranked pairs voting for primaries would be more effective than hoping for it in the finals. The idea being that as time goes on that becomes the "real" election where more people feel enfranchised from being able to express themselves, and generally happier with the results if they still have to end up supporting a compromise in the finals.

(This is assuming what's left of the Republican party doesn't dramatically reinvent itself after it's finished crashing and burning)