[raw_anon_1111]

So I happen to be in Costa Rica for the month. Just like every other 1st world country, it has managed to have universal health care that is better and cheaper without private insurance.

Even if you do get private insurance for quicker access, it’s still much cheaper than the US.

I just spoke to someone who flew down here to save $30K on dental work.

The problem isn’t the ACA, it’s the ass backwards American health care system. I was at a meetup of American ex-pats here and half of them said they established residency here to join CAJA - the health care system

[nostrebored]

ACA enshrined the worst parts of the American healthcare system for years to come. It is a politicized victory that is the best solution for no American citizens. Places I’ve been with fully privatized healthcare or single payer are both significantly better for consumers.

Insurance companies have raised prices to restore profit, were briefly a mandatory expense, and will exist for years to come.

[ipsento606]

> ACA enshrined the worst parts of the American healthcare system for years to come

before the ACA, insurers could deny coverage for pre-existing conditions

people have forgotten how bad things used to be

[antisthenes]

> people have forgotten how bad things used to be

Not really, because whereas before things were bad for people with pre-existing conditions, now they are really bad for everyone.

People are paying exorbitant prices either for insurance, for routine health care stuff, or for both.

There was no free lunch, so we traded some health care for the chronically ill, for slightly less healthcare for everyone else. The insurance companies make sure it's an extractive zero-sum game in terms of actual healthcare provided.

[raw_anon_1111]

When I was looking for healthcare after my employer went tits up right before the ACA went into affect, I couldn’t buy insurance at any price because of a pre-existing condition. Mine you that I have had my ore-existing condition since birth in 1974, had one surgery my entire life - foot surgery in 1996 - and this was 2011 and now I’m 52 and still haven’t had any complications from it and don’t expect to.

I was also a part time fitness instructor, runner and could past any of the standardized fitness assessment standards for someone who was 5 years younger as far as push ups, sit ups, running etc.

I had a contract so I could have easily paid more based on risk.

Before anyone mentions COBRA, that’s only an option if your former group plan still exists and it didn’t when the company went out of business.

Just looking, even now the ACA Silver for my wife and I would be around $800 a month in my state. Even ignoring medical costs have gone up more than inflation, that would have been $550 a month in 2011 if the ACA had been available.

[CGMthrowaway]

We traded the cruelty of Exclusion for the cruelty of Extraction.

[tptacek]

What does that mean?

[CGMthrowaway]

Before ACA, insurance had a more traditional "insurancey" role by excluding pre-existing conditions (aka managing moral hazard) in order to make money via premiums. In the "guaranteed issue" world post-ACA, insurance companies have pivoted instead to extracting as much money as they can from an increasingly vertically integrated ecosystem (PBMs etc)

[raw_anon_1111]

You have the two mixed up. Insurance companies - even for group insurance like through your company where they always had to accept everyone - required you to have “continuing coverage” and not have gaps or you had waiting periods.

The ACA also was written to enforce that through mandates and subsidies - a carrot and stick approach. The moral hazard was caused once there weren’t any mandates because of lawsuits by Republicans and the insurance companies still had to accept everyone.

[dragonwriter]

Before ACA, insurance had a more traditional "dump you when you were in need" role that leveraged pre-existing conditions rules by, if you fell ill in a way which was likely to be sufficiently expensive to make this profitable, looking for any minimally tenable evidence of an undisclosed pre-existing condition (just to have something to cite as a pretext, it didn't need to be convincing), using it to justify cancelling your insurance, and avoiding any legal remedy by refunding your entire lifetime of premium payments.

Of course, whether or not you actually had a pre-existing condition when you had signed up for the original insurance, you now have one that prevents you from getting new insurance,

[LorenPechtel]

The problem here is that pre-ACA you didn't have insurance, either.

Yes, they would (maybe--some plans saw huge sticker shock because the original didn't actually pay much of anything) sell you "insurance". They would offer a plan for a few years, then close it, offer something new. The old plan would see patients getting sick, costs would rise. Premiums were based on costs *for that plan*. Soon the healthy jump ship for something else, now the old plan is only the sick and the premiums go into a death spiral.

Thus the reality was that any ongoing problem soon you were uninsured.

[twoodfin]

Why is that inherently bad? Should I be able to buy fire insurance on pre-existing embers?

[throw0101c]

> Why is that inherently bad? Should I be able to buy fire insurance on pre-existing embers?

What if someone gets Type 1 diabetes as a child so they can no longer get insurance because of that "pre-existing" condition: if they get cancer for unrelated reasons they should just be saddled with medical debt? Or because of your Type 1 you can't get coverage, and you get t-boned in your car by a drunk driver.

Certainly it sounds 'unfair' that someone who smokes (a personal choice) gets similar cancer coverage for someone who does not smoke. But it also means that if your ((great-)grand-)mother had cancer, and you get it through no fault/choice of your own (i.e. genetics), you can also get coverage. (This latter effects a cousin of mine: her aunt (mom's sister) died of cancer at 37, her mom at 63; so now she's wonder when here number will come up. We're in Canada, so have universal care, but it's still something in her DNA.)

There are many circumstances in which you suffer through no fault of your own, and universal health coverage is present in many societies because it was decided to protect those people—even if it allows some 'free-riding' by others making poor choices.

People make all sorts of crazy decisions to prevent the "wrong" people from getting what they "don't deserve":

* https://en.wikipedia.org/wiki/Dying_of_Whiteness

[ikr678]

Pre-existing conditions also continue to frame healthcare as 'insurance' against a bad thing happening to you, when it should just be a regular service like any other.

You don't need 'insurance' in order to get your vehicle serviced, but that is what the US does with healthcare.

[raw_anon_1111]

The most it will ever cost me to go from “not having a working car” to “having a working car” is the cost of used car that will reliably get me from point A to point B.

I can’t say the same about health care

[tptacek]

When one of my kids was 4, they had an unexplained seizure. Hospital workup, whole nine yards, never recurred; it was probably a medication reaction. Years later we were denied coverage from all the private insurers over it (more accurately: we were denied any coverage for that child).

Similarly, insurers would as a matter of course exclude from coverage any woman with one of several extremely common conditions, including endometriosis, PCOS, fibroids, and adenomyosis.

Prior to Obamacare, insurers were free to deny coverage wholesale for these conditions. It would have been fucked up to extend coverage but exclude any neurological conditions from my kid, but the actual outcome was worse: they were under the law entitled to withhold any coverage.

[raw_anon_1111]

If you live long enough, you will have a pre existing condition.

The way it was suppose to work with the original mandate is that everyone had to be insured either through their employee or the exchange. So you couldn’t just buy insurance when you were sick. The Supreme Court struck that down.

If you lost your job, before the ACA, you could not get health insurance outside of working for someone and having group insurance at any cost.

But you do realize that the entire idea of not being able to get insurance because of pre-existing conditions is completely unique to the US?

Costa Rica for instance (where I am right now for a month and half) allows anyone to become a resident as long as you have guaranteed income of around $2000 a month or you deposit $60K into a local bank account and they arrange monthly disbursements and you pay 15% of your stated income to CAJA. Healthcare is both better and more affordable here.

The same is true for Panama. Why can’t the US figure this out?

[LorenPechtel]

And if you had an expensive dependent better work for a big company. Saw it happen--wife lost her coverage through work because they had an employee with an expensive kid. Next year insurance wasn't offered.

[GenerWork]

>If you lost your job, before the ACA, you could not get health insurance outside of working for someone and having group insurance at any cost.

This is a flat out lie. You absolutely could buy health insurance without being at a company.

[raw_anon_1111]

Not if you had a pre-existing condition - the entire point of this thread.

[ChadNauseam]

It interacts badly with insurance being offered as workplace benefit. If you quit or lose your job, you'd lose your health insurance. And any plan you signed up for after that would then treat you as "pre-existing embers" and expect you to pay accordingly. The bundling of health insurance with workplace seems like the healthcare original sin to me.

Obama couldn't change that, so the ACA redesigned the system to work with it. Despite being called insurance, health insurance is no longer really viewed or designed to be any kind of insurance. Instead, it's supposed to be Netflix for healthcare. You pay a flat rate, and then get unlimited healthcare. Obviously, the issue with this is that if you don't need healthcare you can just not sign up for the subscription. So the ACA tried to solve this by requiring everyone to sign up. Once everyone is required to sign up, it's not right to discriminate against preexisting conditions. It may not be an especially good system, but it is coherent.

[mjevans]

The US is allergic to taxes. Maybe it's a marketing thing. Benefits paid for by society.

Maybe a department of Return on Investment. See what those taxes pay for. Contrast to buying private versions of the services at the same SLA or better.

[twodave]

It’s more that the US is more like a collection of 50 little countries, and it’s supposed to be hard to accomplish much at a federal level. That separation has eroded a bit in the last 50 years but it’s still very much a part of our political ideology.

[ajkjk]

it's bad for the person, obviously. The point of society-wide policies is not to maximize economic efficiency; they're supposed to making society a good place to live. Of course if you only look at them under an economic lens they're going to seem bad. Economically the best policy would be to kill all the sick people.

[LorenPechtel]

Because my pre-existing condition happened either at conception or sometime before adulthood. I wasn't in a position to buy insurance before then.

[bspammer]

Because people aren’t objects.

[sixo]

We as a society accept the insurance system as an implementation of "funding healthcare" because market capitalism is supposed to lead to lower prices, fair allocation of scarce resources, and innovation, among other things. That is, the insurance industry is a market solution to a moral problem.

If insurance companies then can wiggle out of covering pre-existing conditions, they're no longer solving the moral problem they were brought into the world to solve, and now we need some other solution to solve the rest of it. Then, whatever that other solution is, it's solving the hard part, so why not extend it to solve the whole thing and cut the insurance middlemen out of the economy entirely? What are they even doing at that point besides extracting a rent?

(This is one answer among many good ones to what is really a bad-faith question—health-insurance is not a lot like fire-insurance at all)

[lotsofpulp]

> Insurance companies have raised prices to restore profit, were briefly a mandatory expense, and will exist for years to come.

Why do their stocks underperform so badly?

https://imgur.com/S8bNSM2

[rybosworld]

Why would a 3-year stock chart be indicative of underperformance?

[lotsofpulp]

It is a 5 year chart, and the 10 year is not free on that website.

You can find out similar results for longer periods here:

https://dqydj.com/stock-return-calculator/

https://dqydj.com/sp-500-return-calculator/

[hibikir]

It's a difficult fix, because the real issue here isn't who pays, but how much it's paid, total. If the cost of care in the US was the same as the cost in, say, Spain, the vast majority of people would have little problem paying out of pocket, and having just high deductible insurance for really big ticket items. At the same time, it'd be easy to have the government pay for it all. The US system is just very expensive in general, so it's a problem regardless of who pays for it.

Most of the costs are ultimately salaries to Americans, and money handed to American companies, so most savings would come from someone's livelihood. That's why we cannot reform: The party that actually cuts costs will build resentment for decades, and create a blip of unemployment. Nobody wants to do that, and therefore you aren't going to be a serious, relentless attempt at cutting costs. We've seen how the attempts that the ACA made were counteracted by consolidation at all levels.

Serious cuts have to have no mother. Say, if we ever did have an AI that worked well enough at this, and outcompeted primary care physicians. Foreign pharmacies bypassing all controls and being able to hand you much discounted drugs the day after. Telemedicine and cheap travel put together to make surgery that didn't involve an ER visit just as easy and much cheaper than using the US system. Straight out disruption, because the incentives are such we sure aren't getting improvements in regulation.

[raw_anon_1111]

Would doctors need to make as much money if the cost of education wasn’t so high? Would they need to charge as much if they didn’t have go have a staff to chase down payments from patients and deal with insurance companies?

Not to mention that because of Bush, the government is not allowed to negotiate drug prices.

[SV_BubbleTime]

Costa Rica is a beautiful country. But it is in no way “first world”.

It has no military, and is effectively dependent of the US and in best cases neighboring countries. It has excellent weather and soil which account for its fruits exports… and outside of some niche industry, is mostly reliant on tourism which means importing money.

I love that country and have been many times. But if it were god forbid wiped off the face of the earth, it would be sad and annoying at best.

Costa Rica has “free healthcare” / healcare from taxes because it has 5 million people, about 1/2 of New Jersey.

This isn’t some mechanism that the US just refuses to use. It’s a matter of scale. You either don’t know and should remain silent on the topic, or do know it and lack the honor to not state it.

[raw_anon_1111]

Costa Rica purposefully got rid of its military so it could provide services. It didn’t feel a need to fund three unnecessary wars in two years.

Guess which other country has universal healthcare - China. They are just slightly more populous than the US.

> This isn’t some mechanism that the US just refuses to use. It’s a matter of scale. You either don’t know and should remain silent on the topic, or do know it and lack the honor to not state it.

China does have a military…

Maybe you should take your own advice. Every other country in the world seems to have figured this out.

[nradov]

Please stop spreading lies and propaganda. China does not have "universal healthcare" in any meaningful sense. They may claim to have it, but it's not something that poor people can actually access for expensive treatments. Patients have to pay out of pocket for most services.

[raw_anon_1111]

So let’s talk about Canada, Great Britain, every country in the EU…

[SV_BubbleTime]

Is that Canada and Britain that the have an ever persisting complaint that the delays are absurd? Among the specific points that…

With Canada now ending the life of 100k citizens a year making their MAID program now the leading cause of death in the country out ranking cancer and heart disease? How strange that in Canada you can deduct health expenses on your taxes… what a strange thing for a place with free healthcare?

And in Britain you mean the scandal-free and extremely popular NHS? I guess you have a great point there because it’s not their elite would immediately come to the US for care.

The grass is not greener. This is a bad system made worse and worse by heavy handed government “helping”. Healthcare in the US only got worse after ACA.

[raw_anon_1111]

You know that before the ACA, there were lifetime maximums and if you couldn’t get treatment you would probably die?

And all of those people with pre existing conditions didn’t have just “delays” getting healthcare they didn’t get it all.

So sure insurance is great in America for you if as your handle suggests you work in tech in SV.

I don’t have a dog in this fight. I’ve got an exit plan if I have to get insurance before I’m 65 amd may just retire here even after 65

[rjrjrjrj]

> With Canada now ending the life of 100k citizens a year making their MAID program now the leading cause of death in the country out ranking cancer and heart disease

Nope. Total MAID deaths (since 2016) is expected to reach about 100k in mid-2026. Most of them elderly people with a terminal cancer diagnosis.