Now that thats out of the way.
I hate the ACA. Its overreach by what the government should be doing. No where in the constitution does it say the government is allowed to force law abiding citizens to do something. ACA does exactly that. It forces people to do things against their will. Or they will be forced to pay a fine. Alright, don't down vote me just yet.
Lets repeal the ACA. But I certainly see things that should be quickly made into law.
* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.
* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
* Lastly, I want hospital prices published. I want to shop around.
* I am business friendly, but these are common sense laws.
I think EVERY Republican can get behind these thoughts as every other Democrat, but forcing me to pay for it, when I just want to live off the land in some small town somewhere. Complete overreach and strictly unconstitutional.
A hospital cannot "publish prices" because prices vary wildly based on many factors. Even if they did, how am I supposed to know what I need for my healthcare? If I go to the doctor and they say "you need a surgery and it will cost 10,000" the posted prices do not tell me if I need that surgery at all, just what they cost. And, of course, the most expensive medical care is emergency, a time when price shopping is not possible.
> Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
I'm not opposed to this, but it does remove state control over insurance regulation, which is an anathama to Republicans. I also have no idea how it will drive down costs? Are some states that much healthier than others?
> Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
I don't even know where to start. If I can opt out of paying for some medically approved procedures, where does it end? Can I say that I want to opt out of ob/gyn care for unmarried women?
Does this exception generalize? From the start, I felt it was immoral to go into Iraq, topple the government, get 4000+ US soldiers killed and cause the deaths of hundreds of thousands of Iraqis. The pennies you pay for birth control a nothing compared to what I as compelled to pay for a war I didn't support from the get go. Can I get my money back for that one? I'm sure my objection to it is/was as sincere and deeply felt as your objection to birth control.
First, separation of church and state, your faith doesn't get to be part of government decisions.
Second, do Jehovah's Witnesses get to not pay for blood transfusions in other people? And before you cite that blood transfusions are far more necessary, I think you should hold fast to your fiscal conservative tenets and help prevent unwanted burdens on the state from being born.
If pre-existing conditions can't be denied, and insurance can't be mandated, how do you prevent people from only picking up insurance when they get sick/hurt?
I graduated just before 25, and my first job didn't have benefits because although I was working 40 hours they called it casual.
> Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
No, you shouldn't have the right to decide what your employees get to do with their health care. You don't have the right to decide who they sleep with and how. This is the theocratic, forcing my bullshit voodoo beliefs onto others crap that makes the republican party so repugnant.
1: If people choose not to get health insurance and then have to go to the ER, who pays for that? You and me. In most cases, it is cheaper for people to get preventative care and reduce their chances of a very expensive ER visit.
2: Preexisting conditions. Sure, but without a guaranteed customer base supported by subsidies then those people will be effectively denied insurance by having to pay insane premiums and deductibles. I have seen no evidence thus far that effectively counters this argument.
Lastly, you say you want to live off the land in some small town somewhere and you don't want the government to force you to pay for other people. Splendid! Say hello to Thomas Jefferson for me. But who builds the roads that lead to your house? What about utilities, water, internet? If you slip and fall down the stairs and break your leg who do you call, 911? If so, who pays for the 911 service, let alone the ambulance to take you to the hospital?
Again, I do agree with your premise, but since in my experience most libertarian arguments tend to crack under the pressure of public goods (like national security), where do you draw the line between independence and the needs of the populace as a whole?
I think the problem is that healthcare after years of this broken system is now seen as private consumption rather than a public interest (like infrastructure and basic education).
I think this is something that a lot of small-government conservatives don't want--it's moving responsibilities from the state governments to the federal government.
The problem with this POV is that young, healthy people end up having no insurance and thus leave the older, unhealthier population to pay all the bills, whereas a full-insured population would distribute the financial load.
Also, it would lead to young, healthy people foregoing insurance in order to save money, and then when catastrophes happen (you're talking about living on the land, so imagine something as harmless as scratching yourself on rusty farm equipment, being bitten by an animal... both can send you to the hospital for weeks!), these people would face financial ruin.
The purpose of mandatory healthcare thus is to protect elderly or otherwise pre-conditioned people from having to pay devastatingly high premiums, and to protect people literally from their own short-sightedness.
2) Sam Altman agrees with you that it's okay to repeal it as long as we maintain the best parts of it.
> "If Congress ends up repealing it, I hope they earnestly try to preserve the best parts, and put in place something better."
We have to start somewhere. The provision about preexisting conditions, and by extension the ACA, is literally life-saving.
Yep, and I hope it's to prevent "lowest common bidder" syndrome on plans. Why does Delaware get all the Corps? Why does a East Texas Court get all the patent cases ?
Frankly, my Texas health care plan sucks. Doesn't cover "anything".
> Lastly, I want hospital prices published. I want to shop around.
Can't shop around in an ambulance.
Well, let's put that to the test. I consider myself pretty liberal. Here's what I think about your bullet list.
* Re: individual mandate
I actually agree with you very strongly on this. When the government wants to force me to pay for something, there's already a long-established way to do that: taxes, with services rendered by the government and thus fully accountable to the people. Forcing us to pay for private services sounds awfully similar to forcing us to pay for British tea, which isn't supposed to be how our country works. If the government wants to force us to pay for health insurance, they should tax us and provide universal coverage.
* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.
Agreed on preexisting conditions, disagreed on higher costs for the affected. "Slightly" quickly becomes a loophole that enables "outrageous". And anyone who lives long enough will eventually acquire a condition anyway. Seems kinda redundant to optimize for that. Just distribute the cost evenly with the understanding that everyone will eventually receive the benefit.
* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
That's what the original post is about. When kids have health care, it's easier for them to make their own jobs instead of going out and begging someone else for them. Sounds like a win for this audience on HN, no?
* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
The goal of health-related regulation should be to improve health-related access and outcomes. There is no question, based on data, that birth control improves women's health, allows them to finish school or further their careers in greater numbers, and eventually increases their lifetime earnings potential, which of course contributes back. If you make exceptions for people's precious feelings, you're looking at an awfully slippery slope. I envision a bunch of assholes declaring that they will opt out of vaccines for religious reasons, then everyone else starts opting out of paying for vaccines and, well, hello again Mr. Measles. No, terrible idea. You don't have to like the latest military campaign to acknowledge the need to pay for a military, and likewise, you don't need to approve of the way others behave to acknowledge the social benefits of birth control.
* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
Sure.
* Lastly, I want hospital prices published. I want to shop around.
This just doesn't work unless you publish a single price list at the national level and force all health providers to honor that list (Japan). There are two problems. One, sometimes your health needs are too immediate to allow shopping, and you're beholden to whoever happens to pick you up and treat you. If you're bleeding out on the road, you're not gonna stop someone from calling the ambulance just so you can go on yelp and find the best service. Seems like a bad idea to build policy around the assumption that buying health care is like shopping for shampoo. Two, as a person who is likely not a medical professional, you probably wouldn't be able to make sense of any such price list with respect to your needs. Any such list would be detailed beyond the common person's understanding (see Japan), and anyway, you would need to seek diagnosis to know what to pay for in the first place.
> * Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
I don't think you can simply equate having a job to "do[ing] something with yourself". Neither can you equate not having a job to not "do[ing] something with yourself". As always, situations (especially in the macro) are complex and subtle and solutions can't be boiled down to a simple directive.
Adults < 26 are often not the ones responsible for not being able to obtain a job. Yes, they may have chosen a field of study that's not in demand (even though many were probably told to "do what you love"), but they've also likely had very little opportunity to impact things like domestic economic policy, employment trends, or even employers not recognizing shifts in demographically driven skill-sets.
> * Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
In a system where much (most?) health insurance is provided as an employer paid benefit, why should my employer get to decide whether I'm opted in or out of a particular thing based on religion?
Ideally (from my point of view), religion plays zero part in health care. What is wrong with a benefit being available to all and only used by those that want to use it? Is this so different from the "in the privacy of my own bedroom" argument?
Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact.
This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered.
Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand.
Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).
I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different?
If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.
This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
Insurance with pre-existing condition is just health care. You are not insuring against anything.
My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.
It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children.
There is no need to require everybody to buy an overprized service bundle.
So if you lose your job and your health coverage, insurers would be able to deny you coverage.
But if you never have a gap, then you can't be discriminated against.
Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.
There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time).
This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance.
Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them.
Then there are the people who prefer paying for things out of their pocket as they go.
The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.
As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.
I am a bit confused by this story. Was Zach not covered under his families' health coverage? He also went to: Westminster School - one of the most expensive private high schools in the US.
Now, one could argue he had a pre-existing condition and thus, was not covered under any health care providers plan, but he states: "I was virtually uninsurable." This tells me there were options, but none that covered the entire cost of the surgery. Honestly, this story alone makes me seriously question the purpose of this post.
Source: I know someone for whom this was the case pre-ACA.
A friend was virtually uninsurable for having once been diagnosed as clinically depressed. Flat out denied coverage.
It's unfortunate that we're not able to get these conversations going in a way that's ... what? "unbiased"? I don't know what I'm asking for, but I think it's some variant of honesty and openness. And I think that we're missing a lot of the truth, for ourselves and others, by having to couch our statements in ways that aren't entirely forthcoming.
That said... I'm still glad that medicaid covered my uninsured ass when I broke myself trying something I'm not good at (skiing). I remember thinking (as I was bundled up in the medic's sled) that I was not too different from some New Zealander with a busted body part... about to be carted off to free medical care, to get me back on my feet and working as quickly as possible.
Thanks, Obama.
Pre-existing condition. Anthem denied me coverage.
My ortho guy said, I don't understand. It was a good outcome.
This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.
A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this:
http://www.patheos.com/blogs/dispatches/2017/01/11/republica...
Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.
There is a big distinction between "pro free enterprise" and "pro business". The former supports capitalism, the latter crony capitalism.
> Under Republican policies, these businesses would not exist
I think the GOP has yet to figure out what their health care policy even is. They really need to figure out how to be for something again.
I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.
The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment.
Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit.
There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\
- It cost me money
- It's not perfect
Arguments in favor of ACA:
- It literally saved my life
Regarding increasing premiums, the complaints tend to be anecdotal. According to the National Conference of State Legislatures, in 2016, the average monthly net premium increased just $4 -- or 4% -- from 2015 to 2016 among the insured that take advantage of subsidies.[1]
Furthermore, premiums have gone up year-over-year every year almost every year since I've been paying for my own insurance -- and that's well before ACA.
There's an interesting chart on the Kaiser Foundation website, where it shows the average plan prices and percent increase year-over-year broken down by state. It also shows that, after tax credits and with very few exceptions, plan prices have remained stable (0% change) between 2015 and 2016.
I understand and sympathize with the high premium prices, but I have serious reservations about the assertion that the high premiums are due to the ACA and not external factors.
[1] http://www.ncsl.org/research/health/health-insurance-premium...
[2] http://kff.org/health-reform/issue-brief/2017-premium-change...
If you're self employed and make over $50,000 a year no matter where in California you live, you'll have to pay full retail premium prices without any discount. My company as a whole makes over 50k a year, but less than 100k a year (still getting off the ground). Thus a monthly premium of $460 a month for a standard decent PPO plan puts a large burden on me. Additionally, if I don't get health coverage I'll have to pay a heavy tax penalty at the end of the year. Essentially as a bootstrapped small business owner, health insurance is a large burden of cost and I was forgotten in the Affordable Care Act. Instead my cost to purchase a plan skyrocketed as I subsidy other people's care. That is not fair, everybody is not paying their fair share. Middle class self employed are the one's who got hurt the most.
Finally go compare CoveredCA.com and then go use https://www.blueshieldca.com. CoveredCA literally is one of the worst designed and functioning apps I've ever seen. It constantly errors and doesn't keep state that I am logged in. The UI/UX is terrible. I'm guessing CoveredCA was outsourced to a non-technically competent contractor overseas. Compare that to BlueOfCalifornia which is a great site, beautifully designed, and functions as it should. This is why government can't have nice things.
Rates for 2017 increased significantly, from -3% to 116% depending on the state: http://www.thefiscaltimes.com/2016/11/01/Here-s-How-Much-Oba...
I think the ACA was responsible for temporarily suppressing rates. Now that the costs are better understood, we're back to around where we would have been without it.
I, for one, am very much looking forward to purchasing insurance from the best provider in any of the 50 states, not just the few available to me in CA.
Before ACA, as a full-time worker at decent companies I paid maybe $50 a month for my insurance, my employer picked up the rest. When I went to the doctor, filled a prescription, or anything else routine, it was $10-$20 max. In the one year where I had a lot of care (broken wrist), I think I paid my out-of-pocket max of about $750 and that was it.
After ACA:
Catastrophic plan at pretty much every company I work for now (same for many of my friends in non government jobs). Minimum deductible of $1500-$2000 as a single guy. Probably 5x that for someone with a child and wife. When I go to the doctor, I pay for everything out of pocket at full price: $300 for a prescription (in the US they push up the drug prices to astronomical levels - we cannot buy from foreign sources), $200 for a simple doctor's visit. I have never hit my deductible which would then pay 80% of my costs.
Oh and I can't actually just go and get things like a hearing test or sleep study - I first need a referral from my primary physician at $200 / visit. In exchange, I get to put $100 away each month tax-free into a 'FSA' account. It is mostly use-it-or-lost-it by the end of the year, and will go back to my employer (i.e. a perk for them, not for me). At the end of this year, it basically turned into a $200 gift from me to my employer.
If Obamacare is repelled at the Federal level, could a state just implement its local ACA? what prevents California for instance of giving health coverage for its residents? California is a good example since it "the world's sixth-largest economy" (If California was a country) I'm sure healthcare companies wouldn't want to cut themselves out of this market?
This would give California and SV an even bigger advantage regarding what is described in Sam's post.
* Preserve some form of protection for people with pre-existing conditions (this covers the "save my life" part)
* Lower costs of health insurance for both individuals and the public (perhaps dramatically)
* Actually address the underlying healthcare issues directly, i.e. implement policies that will reduce the cost of healthcare itself, not just the cost of insurance
In particular, the risk of losing some important things (like coverage of preexisting conditions) seems extraordinarily low.
I've been paying my own premiums for 9 years. Before ACA, premiums went up ~5% per year - 8% one year, perhaps. Since ACA, I've seen increases of 25%, 20%, 20%, 25%, then 11% then 13%. OK, yes, it's anecdotal. But "it goes up every year regardless" is missing data there - pre-ACA there were inflationary increases - post-ACA there are increases to cover millions of people who weren't included before.
It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.
Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with.
I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?
We also have a large contingent of people who take immense pride in voting against their own self-interest. They'll look to Canada's system and say "yeah but they wait for days to get an x-ray for a broken arm" ignoring the fact that they themselves couldn't even afford to get an x-ray. But it's worth it because even though I can't get healthcare, the people I hate can't get it either.
As shown by the most recent election, it's political suicide to imply that America isn't the single greatest nation in the world. It's even worse to suggest that we should be asking some other country for help. Those other countries are communists, and the only communist we like is Russia.
Recent experience - my daughter sprained her ankle, so went to the hospital for x-rays. I live outside the city so the doctor we saw was coincidentally our local GP. The price $0, time waited - about half an hour, this was on a Sunday night.
One thing that may be a factor here is the medical practices are run by doctors - no professional manager people which, from what I understand, seem to be in the US health system. The doctors, in general, really are people who want to make people well and thats what they do. Sure they like to make a buck and they do but not at the expense of everyone else.
If you let non medical people into the system to manage it then, I'd look closely at their motives, I suspect you'll find sometimes their motives aren't pure.
The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers.
This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less.
Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.
Oh we definitely look abroad. In fact that's one of the major arguments for a single-payer system in the U.S. - such a system exists successfully in every other capitalist democracy. So why can't we make it work here?
And this looking abroad is not a tonic against bad thinking. Conservatives routinely look at health systems in other countries and decry them: long waiting lists for elective procedures, high marginal income tax rates, etc., etc. Any flaw in another system is magnified and considered a non-starter.
Obamacare was based on an older Republican plan which had been implemented by Mitt Romney in Massachusetts. But in the run-up to Obamacare conservatives hyperventilated about "death panels" and how the ACA was going to destroy the economy. None of which came to pass.
https://mises.org/blog/how-us-states-compare-foreign-countri...
Everyone understands the healthcare systems in Canada and most of Europe. There is no point mentioning it because for most of Republicans it's a non-starter. It's incredibly niece of you to think a bunch of liberals have never thought to look elsewhere, at best. At worst you wanted to just blanket insult the US.
So what's the answer? How can health insurance providers help people with pre-existing conditions, and also not gouge young healthy customers?
Is the healthcare industry just charging too much money?
I believe that single payer systems can bring prices lower with more efficiency, but there are plenty of things that can be done that are less controversial (combating waste, increasing administrative efficiencies, etc).
One personal example from my life that put health care costs into perspective was surrounding the issue of Midwives vs. OB/GYNs when we were having our first child. We were approved by our insurance to have an OB/GYN deliver our child, which would cost the insurance company about $5,000 if everything went well (more if there were complications). But they wouldn't cover us at all if we delivered the child with a midwife, which cost about $1,500 and has been shown in study after study to reduce the likelihood of more costly intervention.
In our case, we paid the midwife out of pocket, but there are so many people that don't have the economic freedom to make that choice and the result is that their insurance companies pay far more money for child births than they would have otherwise had to.
Again, just one example, but I'm sure there are thousands more.
Certainly there is some waste, fraud, and abuse in the healthcare system which could be cut. But ultimately the only way to significantly cut costs would be to ration care. It's a hard issue and no one likes to talk about it.
* Taxes go up, but they go up less than health insurance premiums would. Remove insurance companies as an industry. [1]
* Price controls on providers (inelastic demand of healthcare means "the market" sets the price to "you pay whatever it costs so you don't die") [2]
* Allow Medicare to negotiate with drug manufacturers, otherwise buy from other countries [3]
That's about it. If Sam and YC want to see this fixed, start advocating for politicians who support single payer.
Startups will not fix this problem. Blog posts will not fix this problem. Political activism will fix this problem.
[1] https://www.youtube.com/watch?v=LtplKTHa4TA
[2] https://www.cms.gov/Research-Statistics-Data-and-Systems/Res...
[3] https://www.nytimes.com/2016/02/02/upshot/the-real-reason-me...
Yes. Twice as much as the rest of the world in fact. Mostly due to lack of competition (25 year monopolies for simply adding a antacid to an existing drug) and zero negotiation on pricing.
The President Elect said as much yesterday.
https://www.washingtonpost.com/amphtml/news/wonk/wp/2017/01/...
PS health cost is US are not just stupid expensive, it is broad day light extortion. the victims for some reason prefer not to see it as robbery, but rather to argue about qualities of their robbers. charging $600 to empty the urine bag is possible only because the whole hospital system is rigged (i.e. excessively regulated and monopolized).
I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible.
I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off.
Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?
What I read, and I did read this online and haven't had the time to look for primary sources so please take with a grain of salt, but worth looking into is this:
pre-existing condition check was a major risk to the insurance industry since nobody knew how much it was going to cost them. So the ACA told insurance companies we'll subsidize some of your costs until things settle down (this is different than subsidizing people's payments). However when it came time for the gov to pay, Republicans blocked most of the subsidy payments to health insurance companies (I think they only received 12% of the expected amount).
And then because insurance companies didn't get that subsidy they obviously passed the cost onto consumers. And I'm sure whatever subsidy was further promised by the Gov they could no longer rely on so they priced that risk in as well.
"I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company."
Before the ACA, because you couldn't have gotten any health care coverage at all. Thus after the ACA, you had an opportunity that would not have been possible (safely) previously.
The plan for my family last year cost over $1200 per month, and this year rose to $1400/month.
Previously, with employer-provided plans I paid at most $400/month for my family.
Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.
A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month.
In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan.
The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what.
I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price.
I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment.
One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.
We already have a progressive tax, but let's add an individual mandate, tax credits that phase out at 400% FPL, and cost sharing subsidies which phase out after 250% of FPL.
The maximum value of the tax credits for your family would be nearly the full cost of the premiums at 133% FPL, let's say $12,000. Then on top of that the cost sharing reductions would reduce your out-of-pocket maximum -- which if you're truly unlucky could run your family another $14,300 -- to a maximum of $4,500, so that's worth potentially another $10k.
What this means is ACA is a $12,000 - $22,000 tax on your family depending on your health care utilization, as income rises from 133% - 400% FPL.
For a family of 4 the 133% FPL = $32,250 and 400% = $97,000. So as you make that extra $64,750, in addition to all the other taxes you are paying, you are also phasing in $12,000 - $22,000 of increased payments for the same exact health care. Now that is one hell of a tax.
So while you and your spouse are working your asses off to earn $150k, you can look back and appreciate how $10k went to the town, $10k to the state, $30k to the Fed and ~$15k to the SSA. So it's really just the cherry you're being charged an extra $15k for insurance, come on, you can afford it!
I won't mention all the other subsidies you lose out on for being a productive member of society. Because when you realize the real tax rate approaches 100% on the first $97,000 it's a bit of a buzz kill.
The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage.
If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.
Isn't this just because now insurance companies have to cover preexisting conditions and also not charge them exorbitant prices? Naturally, they would be taking a loss in order to do this so that burden is instead shifted onto the healthy people. To prevent healthy people from just not buying insurance, the mandate was made because it's economically unfeasible without them.
If you're the type of person who would normally use a high deductible plan, you're worse off, but that's the way it was supposed to be. Presumably if one day you get very sick though, you will still be able to get insurance.
Would that still be true if you had to pay retail for all your care?
The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?
Deaths due to homelessness (2010)[2]: 700
Deaths due to lack of medical care (2009)[3]: 45,000
What's different is the magnitude. Although the United State's patchwork of services for the homeless is ostensibly supposed to give everyone access to food and shelter, people do fall through the cracks. But it is not an endemic problem like lack of health care.
[1] Debatable, and I can't find a solid source. The only malnutrition related deaths I can find are in elderly populations and abused children.
[2] http://www.nationalhomeless.org/publications/winter_weather/...
[3] http://news.harvard.edu/gazette/story/2009/09/new-study-find... this is a higher end estimate from 2009, the lowest estimate I could find was 18,000 from a study done in 2002
(I'm the first story in the article)
Great question. Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item.
My opinion is because the system we have today is basically a wealth transfer from the taxpayers to large interest groups (nurses' unions, big pharma, etc).
The healthcare system is totally a disaster, and it really should be fixed, but giving college-aged kids a free pass for a few more years isn't really a solution.
If that's the case, addressing the cost is the foremost issue, instead of forcing everyone to join a universal plan. That does not help addressing the root problem above.
The Japanese system is not terribly different from ours - it still depends on private employer-provided health insurance. But per capita costs are less than half the US cost, with higher utilization and far better outcomes. The key difference is that Japan has strict national-level price controls. The price of identical products and procedures is identical in every facility. This eliminates both complexity and negotiation between insurance and providers. A government board carefully tracks costs for profiteering and makes adjustments.
Do that, and you get rid of the whole "in network/out of network" nonsense of the American system.
We spend several times more in hospitals and clinics than what we spend on prescription drugs:
http://www.beckershospitalreview.com/finance/17-fascinating-...
(nearly $1.6 trillion to large providers, $300 billion to drugs)
So the costs are not concentrated in drugs and insurance. There are certainly some drugs that are very lucrative, it's just that they aren't the dominant spending.
Good luck trying to get political support for anything that hurts the insurance companies.
If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else.
Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes.
* - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about.
edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P
Having insurance tied to employment is utterly terrifying. You'll stick it out in a sub-standard job to maintain coverage. You'll be fearful of taking risks on self-employment. It's the exact opposite thing you'd do if you wanted to encourage entrepreneurship.
http://www.denverpost.com/2016/11/08/coloradocare-amendment-...
So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses.
What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.
Just take hope! If you can just make it through this year you won't have to worry about the question of purchasing insurance as an individual, because as a family with several preexisting conditions (fertile female, children/disease and injury vectors) without the ACA you'll be effectively uninsurable unless you can grow your startup fast enough to make a group plan feasible.
[1] https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-cov...
But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA.
Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place.
So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement.
It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations.
This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.
Yeah, the significance of rescission and the ACA's prohibition is often overlooked. Prior to the ACA, if you got sick enough and expensive enough, insurance companies could -- while you had outstanding claims, and this happened while people were in the hospital -- retroactively cancel your insurance, refund your premiums, and walk away leaving you fully liable not only for any future healthcare, but for anything they hadn't paid for yet from the time when you had coverage. Now, this could generally only be done based on an omission or inaccuracy in initial disclosures, usually related to a preexisting condition, but there was no requirement (federally, some states had controls) that the be intentional or significant, and insurance companies would hunt out errors once care got expensive.
The ACA elimination of exclusion for preexisting conditions itself elominated most of the basis for rescission and the onerous disclosure requirements that it was based on errors in, but the ACA also explicitly prohibited it except for fraud or intentional misrepresentation of material facts.
My job ended in January '16. I got a large severance and left the US for 7 months. I sold some stock in July, but other than that, my income was $0 each month. Looking forward, my income was likely to be just as erratic, with most months being $0. After spending way too much time talking with the folks at CoveredCA trying to figure out just how to fill out the forms for such an uncertain income level, I finally got all the information on my application and got denied. I couldn't even buy an unsubsidized plan. The exchange failed hard for my scenario and I ended up having to buy insurance directly from the health insurance company I was with when I was employed. It was quick and easy and cheaper than it would have been on the exchanges. And now, to add insult to injury, I'm probably going to have to pay a penalty for not having US health insurance for all those months that I wasn't living in the US, since I'm pretty sure I didn't pass the threshold for being a non-resident.
As a programmer, I'm all to familiar with code that handles the 90% case and just assumes those other edge cases don't exist. It's lazy and error prone and a sign of an amateur programmer. The ACA feels like the legislative equivalent of that sort of code. In their hurry to create a system where the majority of those without health coverage could get it, they created a system that's truly terrible for edge cases like me.
If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years.
This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.
So, to pursue some things on my own time I had to negotiate a sabbatical with my company (which they generously allowed), so I could stay on employer health insurance.
If I wasn't able to do that, I'd be up shit creek, because there's no way in hell I'd risk my wife getting pregnant without health insurance.
I hope more and more people decide they feel no social obligation to things. Mass peaceful "law breaking" is really the best option, imo.
Seven years is a long time, especially if you want to get married or have kids or get credit or not pay a ton in interest. Note also that bad outcomes in this case will compound; you've had a catastrophic injury and now you have higher interest rates and everything else.
"Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay"
http://www.wsj.com/articles/health-cares-bipartisan-problem-...
Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.
If you don't have employer-provided health insurance, you're still basically screwed even under the ACA.
Have you been to a doctor before? Then you might have a pre-existing condition.
The ACA has flaws but it also has some great features that need to persist: minimum care requirements, pre-existing condition exclusions banned (having a pulse is a pre-existing condition BTW), no lifetime caps on treatment.
What's the alternative? Still haven't heard anything.
Prior to the ACA, nearly every employer-based coverage plan stopped dependent coverage at 19-years old or upon college graduation. Those that allowed older children would refuse dependent coverage if the children's employer offered health care, which meant that if you got a entry-level job out of high school at a company that offered insurance at any price, you couldn't use your parents' insurance.
After the ACA, every plan, employer-sponsored or exchange-based, must offer dependent care up until 26-years of age.
2.5 million <25-year olds gained health insurance in the first year after the expansion, which was before the mandate was in place.
The ACA gets credit for the expansion since it caused the expansion.
Mandatory enrollment is what makes it possible to have that preexisting condition part - the basic idea of this (or any) insurance is that it spreads the risks over a larger pool of people, with the insurance companies taking a cut of the money for administrative costs and profit.
If you want to require that the insurance companies cover high-risk preexisting conditions without providing an increased customer base to spread those costs over then you'd better be prepared to see insurance companies go under.
> increased costs of forcing insurers into the ACA
Insurers don't have to participate in the ACA exchanges, and in fact many don't do so. Some participated in the beginning but decided there wasn't enough profit to be made or were losing money, so they've pulled out of the exchanges since then or have significantly raised their rates for their exchange plans. As an example of this, I believe United Healthcare (or its exchange-specific subsidiaries) no longer participates in most exchanges as of 2017 (http://money.cnn.com/2016/04/19/investing/unitedhealthcare-o...).
Interstate insurance competition isn't going to make it any cheaper to insure someone with a preexisting condition, or do you think that your local hospital is going to suddenly say "Oh, ccrush has insurance provided by a company in Montana! We can't charge San Francisco rates, we have to charge Montana hospital rates!" If you do think that, go talk to some hospital billing folks and they'll be happy to correct you.
One thing that the ACA did put in is capping the amount that insurance companies could spend on non-medical expenses, including both administration and profit. All the stuff early on about non-compliant plans having to shut down? That was for crap insurance with high premiums, higher deductibles, crappy service, etc. but with EXCELLENT profit margins. After all, if I can sell insurance but drop you when the bills start to come in, then all of those premiums you paid me are profit.
Hmm. I've heard many small companies could not afford to provide health insurance for their employees after ACA passed ( I don't know the details of exactly the causal chain there ). So they stop providing it and pushed people to use ACA which had ridiculous price hikes and also in some states companies withdrawing from the exchanges.
In other cases I've heard companies have pushed people part time status in order to avoid having to provide health insurance and other benefits. I think that is mostly lower wage employment.
My own rates working for a small company a few years before the ACA and after went up much high even before ACA was about to pass in anticipation. There the insurance representative who we talk to every year stated clearly why there is an increase -- because of the volatility and unknown effects of ACA they decided to increase prices. After it passed and was being phased in our rates were going up much high.
Some things were nicer, like no pre-existing conditions, no lifetime maximum, some free preventative checks overall it has been worse.
Now, no doubt it has helped many people, but I am not sure if small businesses and their employees (especially in the tech sector) saw a benefit.
This is a really sincere recommendation: if I were you, I would research that and figure out if it's true or not. There is plenty of propaganda going around on this subject from all sides; it's dangerous to rely on things you've heard.
This may have impacted some companies, but none of the ACA small-business provisions were phased in until your company has more than 50 full-time employees. If your startup gets to a point where they have 50 employees, you should probably spend the money to get them health care.
I shopped online and bought a sensible plan just like anything else. There were tons of choices and plenty of competition.
This whole notion that we'll all be doomed without it is utter rubbish. The entire Healthcare system is broken, starting from our agricultural subsidies to our ridiculous prescription drug prices (which many pharma-lobbied Democrats just voted to keep high) to the artificially low supply of doctors (you don't need 12 years of school to prescribe penicillin).
ACA is just 2000 pages of nonsense on top of all of that. We can do better at all facets.
1. I shopped online and bought a sensible plan just like anything else.
There are literally more than 50 million Americans with pre-existing conditions that would disqualify them from buying insurance at any price. Many of them were fortunate to have employer-backed insurance, but that doesn't change the fact that they were desperately dependent on it.
2. (which many pharma-lobbied Democrats just voted to keep high)
41 Republicans voted against it, 13 Democrats did. Singling out the Democrats calls into question your intentions..
3. you don't need 12 years of school to prescribe penicillin
The ACA and other changes have greatly expanded the responsibilities of PAs and NPs. They can treat and prescribe in nearly every setting. CRNAs and DNPs are working more independently than ever. In addition; over 25 new medical schools have been established in the past 8 years, along with over 6,000 additional residency positions (which are paid for via CMS funds.)
It was impossible if you had any pre-existing conditions, no matter how trivial.
The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.
Still, we all know what it's like to have a major design flaw in the legacy codebase.
I think the anti-ACA lobby sees this as a feature not a bug.
Similarly, a lot of people that support the ACA don't support the ideas behind it, as much as they support something being done from the previous, untenable situation. Obama took mostly Republican ideas and ran with them, now the Republicans have disavowed any involvement with them, and Democrats have adopted them as good (or at least better than what was there before, even ACA supporters acknowledge that it's a deep compromise from what anybody wanted.)
I think that the attitude of "it's going to help my side or nobody" is a much stronger driving force than the desire to prevent people from taking entrepreneurial risks.
However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores:
Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA.
The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA.
For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.
Absolutely agree. The ACA (or repealing the ACA) are both "solutions" to the wrong problem. So much potential innovation in the health care space is illegal. If it wasn't illegal, someone might (gasp!) find a way to provide a valuable service for less money than in the current system.
It will not, and cannot, be fixed by regulation, because of what you said - any regulation MUST be approved by the big companies. They'll never approve something that goes against their interests.
This could not be further from reality. We have more government distortions in our healthcare market than countries with completely socialized healthcare. For example:
Medicare: socialized medicare for the elderly, which alone creates more distortion than a universal program would cause by inflating demand/prices for non-qualifying citizens.
Medicaid: socialized healthcare for specially qualifying poor people, which creates the same distortion as Medicare.
An oppressive FDA: which, coupled with overly-powered IP laws, grants de-facto monopolies in the medical product industry. We have an incredibly expensive and subjective medical equipment pre-approval process (as compared to a less-terrible FDA that would just be in charge of labeling, preventing fraud, and maintaining accountability in the event of incidents). Then there's the length and flexibility of patent protections in our current system (maybe we could cut those protection times in half, and patent trolling would not be a lucrative industry).
Oppressive occupational licensing: It's way too hard to become a doctor of any kind, even the kinds that don't manually put things into your heart. This will be a major battle as AI comes to the point where it can better diagnose conditions and largely replace generic/non-specialized pediatrics. Of course, the government will not make this easy.
Plus a slew of more minor things like malpractice regulation, and now the ACA (which is not so minor).
If we cleaned up/removed all of the problems in the above and replaced it with single payer, it would be OK and we would have something similar to Canada/other countries with long wait times, not much access to specialists, and a system where the government gets to decide who gets the last liver transplant and who dies.
Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL.
Is there any country that has implemented this successfully?
But you can't "improve" the ACA into single payer. You can only get single payer by starting over from scratch.
The pathetic thing is that a public option, the original plan, could quite easily be improved into single payer. And despite the largest Democratic majorities in both the house and senate for several decades, with a sparkly new progressive Democratic president that campaigned primarly on health care reform, they couldn't pass it. It seems the Democratic party has something to learn from the Republican party on how to get shit done.
The ACA (or similar basic rules: no pre-existing, must cover, supports small business and self proprietors as the market goes more that way) is needed for entrepreneurship and in cases where you can't get it through a job, it is a must for starting business today. Other places have a competitive advantage to starting a company in a country that has healthcare figured out and away from the job.
We should be able to get insurance as a pool of individuals. The current insurance companies are not setup for non employer based healthcare and need to either change or go. They group based on company or individual not pools of people across companies and individuals, which is a broken legacy system. We need consumer facing companies to be in healthcare if private healthcare is the main thing, companies in auto insurance and other insurance are more consumer focused (Geico, Progressive, Nationwide etc). I wish for more competition in this area that is consumer focused not employer focused.
Insurance needs to be remove from employment (probably through legislation or market benefits) to ultimately solve this consumer facing insurance problem for healthcare. We also probably need a separate health insurance plan for catastrophic events and a healthcare plan that handles day to day healthcare needs, bundling them is a bit wrong when compared with other insurance i.e. car maintenance is not covered under auto insurance, home maintenance is not covered under home insurance.
Ultimately, fixing healthcare is needed for business and quality of life reasons. Our system is becoming a competitive disadvantage to businesses in the US.
ding ding we have a winner. This is a no brainer that anyone, Republican or Democrat, should agree on.
Sure, it's nice that pre-existing conditions are covered better and 26 and under people can get insurance with their parents, but those kinds of benefits could have been covered by a one or two page bill. What's in the rest of it? Special deals for corporations such as AARP.
The law does nothing about making malpractice insurance more affordable, or making the malpractice lawsuit environment more rational. Why is that?
Why is my employer still involved in my health insurance? Why not move the tax benefits from my employer (it's a company, and cannot get sick) to me? My employer doesn't need the insurance. I do.
Why can't I buy insurance across state lines like other insurances?
Why are there separate 'risk pools'? The US is a single market - there should only be one risk pool. This would put maximal pressure on the insurance companies in terms of cost as they would have to compete for my business instead of negotiating cozy deals with companies (and companies don't get sick).
Why does the gov't get to tell me what's in my plan? If I'm a single male, why do I need to buy a plan that covers ObGyn? Why can't I buy a high deductable plan anymore?
Why does Obamacare think its wrong for doctors to own medical facilities?
If controlling cost is so important, why is it practically impossible to find out the cost of anything ahead of time? This makes making decisions based on cost impossible. Why is the price one person pays radically different than what another person pays? Why does cost have no relationship to quality? I can get an MRI with a brand new machine or with a 15 year old machine that produces crap images, and the crap will cost more. Why not require publication of prices?
Why is it that my dad, a wounded combat veteran, cannot get decent health care at the VA in a major metropolitan area? The VA is completely controlled by the gov't. It is the gov't. And yet, if he goes to a private hospital to get decent care, he gets penalized.
Because then pretty much EVERY insurance company will pick up and move to the one most desperate state that writes laws in their favor, doesn't tax them, allows them to sell substandard insurance, gives them liability protection and forced arbitration and in every way abuse the customer.
And the industry will become abusive, fraudulant, manipulative, and untouchable. Every state will lower its standards and revenue streams to keep insurers from leaving and taking jobs with them. And the customer will have very few if any good choices and no recourse when screwed over. Over time, the industry's power over the state will become even more entrenched. Exhibit one: The credit card industry, and south dakota. Go watch the Frontline episode I refer to in another thread.
I'd like to answer some of your other questions like "why do I have to buy a plan that covers obgyn" but I'm too pissed over having to pay for rear seatbelts I'll never wear, a space program I'll never use, fire hydrants I'll probably never need, and taxes for schools I'll never attend. Living in a society sucks. I mean, I have to pay for roads I'll never drive on. It's bullshit. I mean even my freaking insurance-- I have to pay for all these diseases that it'll cover! I'm NEVER gonna get ALL of them at once. And only one of them can even possibly kill me, maybe two max. Why should I pay for protection from a heart attack AND cancer treatment?!!! Bullshit, man. That's how they get you. I mean, I saw tonsilectimy on the list and I don't even have tonsils any more. Tyranny. I want an a la cart health insurance plan where I can figure out what I'm likely to get and only get insurance against that specific disease!!!
I'm not convinced that's providing productive selection criteria.
From someone too old to be on their parent's insurance, while I'm 100% behind the reform that disallows previous conditions from affecting ability to get coverage, the ACA was effectively a shake-down that made me delay taking the risk to go full time on my startup -- the options for coverage in my state were expensive and very low-quality, and the penalty for opting-out would have been $4000 for my domestic partner and I (on top of the additional taxes we paid to support ACA).
It's interesting to me that we as a society have long accepted that people have to work for food and shelter, leaving a permanent underclass in the dust, while we're uncomfortable to say the same about healthcare.
But of course, it doesn't matter. Those who oppose the ACA or the individual mandate or employer requirements or the notion of healthcare subsidies are dancing around their justifications and are reluctant to come out and say that people with health complications should just be out of luck. Instead, they'll dismantle, maybe introduce an alibi entitlement scheme to save some political face, and leave a status quo with the exact same result.
Mitt Romney had similarly reformed Massachusetts law in 2006 as Governor.
https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...
I see the article briefly touched upon the American notion of health insurance being tied to employment.
Nobody seems to want to really solve this problem, just band-aids and lip-service. Neither mainstream party would consider a single-payer system, nor direct government negotiation with drug companies.
It's as though the drug and insurance companies are better represented (and have more rights) than its citizens.
Heck, even Medicare is divided into at least four regions to "negotaiate" regional prices.
How do other countries perceive this?
The US falls further and further behind in healthcare and affordable and available high-speed internet. Let's see some real progress.
INSURANCE EXPLANATION OF BENEFIT
Adhesive bandage. . . . . . $300 | Covered: $.02 | You Owe: $299.98
All I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now.
What happens if you don't have insurance? To me any system where you make sick people pay more than rich people seems bonkers no? If most people's employers already pay it on their behalf, isn't it a business tax already?
None.
> I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now.
Because actual change is near impossible these days. (Ultimately this is largely a result of flaws in our electoral system. Most notably, gerrymandering gives Republicans a near permanent lock on the House.)
> What happens if you don't have insurance?
You die.
> To me any system where you make sick people pay more than rich people seems bonkers no?
Republican congressmen are bonkers and/or evil.
> If most people's employers already pay it on their behalf, isn't it a business tax already?
That's a large part of the problem. It got tied to employment in during WWII when the government mandated salary caps for some industries so firms competed on benefits. I think almost everyone agrees this is bad but it's impossible to change because of gridlock.
As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly.
Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts.
In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.
The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture.
What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk!
For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1.
I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it.
Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it.
Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.
The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster.
In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn.
There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome.
I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be.
Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece).
Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows.
Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.
But it's untrue to claim ACA provided benefits to any CA startup in terms of coverage, guaranteed issue or pre-existing conditions.
If you wanted to start a company in CA pre-ACA and you had prior credible coverage, you could get a great plan at a competitive price (the so-called "rating adjustment factor" was capped for the guarantee issue plans) with immediate coverage for pre-existing conditions.
But I am all for an alternative to what we have now or what we had.
The most important thing IMO is to make sure that people don't get hit by pre-existing conditions.
https://www.washingtonpost.com/opinions/why-is-the-number-of...
Example. Out of college. Got job. Had insurance and didn't think much of it. $2 all RX
Mid '80s had kid. 5 days in hospital (C section) and it cost $500. Insurance was 59 per month. (I making $36k)
Got thrown out of tech into federal job with federal insurance. Excellent coverage. Got $102k prostetic from New york hospital for< $5000 out of pocket.
My life with health insurance was been charmed. I am so glad I dont have to start like these young people.
- Before the ACA we had Blue Cross and I inquired about maternity coverage. My wife was looking at a shoulder surgery so we were locked in. Blue Cross offered us a $1000/month rider that had to be in place for 21 months before birth and then they would cover anything over our high deductible. It worked out to about $25,000 on top of our regular premiums before they would pick up the bill. We jokingly priced getting an apartment in another city instead.
- Then the ACA came out. Maternity was included free and the premiums are about the same. We had a baby and had to cover twice the deductible. The marketplace gave us some trouble due to stupid bureaucracy so we priced out getting a plan directly (non-ACA) but the price was so much higher and it covered less. So, even with the marketplace, the coverage and affordability made it an easy decision.
Anyway, I could live without the subsidies (we haven't qualified for them every year) and I wish the marketplace was a little easier to work with. Though I feel like our coverage is so much better now. Why take it all away?
I'm sure there's more as well, but this definitely helped several friends of mine. Seems like these kind of things would have been impossible without large swaths of the ACA.
The fact remains - covering pre-existing conditions, kids till 26, and low income households is expensive. You can pay it by increasing the insured pool - which is what ACA tries to do via the individual mandate, or by introducing a single payer system whose buying power would be so big that they will substantial leverage over healthcare provider. As a society we have decided that a single payer system is socialist, so it cannot be adopted here (and it has its own problems - wait times, lack of R&D incentive etc.). So now we have to choose between not providing healthcare to 40-50 million people or pay increased premiums to cover for those.
Some reforms that may somewhat bring down the premiums: - Offer subsidies to even middle income people, not just poor. May be set the income limit by geography - Make the individual mandate more expensive to incentivize healthier people join the pool - Offer a public option
I look at it this way: Right now, I'm with a large company - I have a wife who left corporate life to raise our daughter. It's all riding on me. And on that, I have some ideas, one has become a small side gig, but if they grow enough to become my focus, that essentially opens the basic question of how I'd provide health insurance to my family.
Thankfully, I have a backup plan to some degree, as I happen to be a citizen of a European country as well as the US, but it's an imperfect backup plan as my "other" nationality is a place with notoriously difficult small business bureaucracy, and while I could live in another EU country, I'd need to establish the ability to support myself before anyone's going to let me stay.
Ideally, we'd stay in the US, because let's face it, this is a pretty great country to found a company, warts and all. But we have to not be having to worry about something as basic as healthcare if we're to take the kinds of risks that lead to innovation.
If this is how the government wants to do it, don't call it insurance. Just call it socialized medicine, because I am definitely not getting what I paid for.
* Pricing: How about transparent pricing up front for all non-emergency services? That means the price you pay, and that your insurance pays. Not some mystery of "you are responsible for some unknowable amount if the insurance company doesn't pay" or "we might make you pay your entire deductible".
* More effective implementation of high deductible health plans that's simpler for people.
* Medical expenses and insurance tax-deductible, full stop. No messing with HSA, FSA.
* When you are diagnosed with a condition, your current insurance is responsible for the rest of your life for related expenses. No new insurance company would deny you because it wouldn't cost them anything for your preexisting condition.
* Subsidize normal health insurance for poor people.
Need your appendix removed? Better get a loan from the bank. Just because they can.
At the time, I had sleep apnea and had to pay almost $500 a month for health insurance. That was more then I spent on food, almost as much as I paid for rent. (It was more than my car payment, which I paid off two years prior.)
18 months is a very short time period when you're trying different things to see what sticks.
If the ACA was an option, I'd probably had another 4-6 months to go. Would I have found something that "stuck?" I'll never know.
> Precision CNC milled from aircraft grade aluminum to 1/1000ths of an inch tolerance
What you need aicraft-grade aluminum for? And a 1-mil tolerance? Are you building a really tiny aircraft?
"Premium design" stops when the design choices are the best you could ever need. Beyond that, it's no longer a matter of engineering, it's about far less respectable traits.
I mean, we pay taxes for streets, so people can get everywhere. We pay taxes for schools, so people learn everything. Why not pay taxes, so people are kept healthy?
The whole public healthcare stuff doesn't even work like a real insurance, so why not throw this stuff away, make a health tax everyone pays, call it exactly that, and be done with it?
Even if you have a rep that favors the ACA it gives them an idea how much effort in to saving it.
Why is there little or no start up innovation in the insurance space? Why aren't YC17 companies able to attack this?
Is the tradeoff worth it? That's the question.
1) Healthcare costs are out of control.
In the US, healthcare spending is 17% of GDP, the highest of any country in the world; the next highest is France, at 11% GDP. [0] The reasons for this are very complex and intertwined, but there are a few major issues:
(1a) Intellectual Property protections: When only one company can sell a drug for the first 10 years of its existence, they effectively have a monopoly and can set the price to whatever they want.
(1b) R&D costs: If it costs $10mm to develop a new drug to treat a deadly disease that affects less than 1% of the population, then naturally the company must set a high price for the drug to cover costs of R&D; this is related to (1a).
(1c) Primary care providers and pharmaceutical companies are accountable to nobody when setting their prices. Because the majority of people pay for healthcare via insurance, they are price insensitive. After all, if insurance is paying for your healthcare, what do you care if the cost is $100k or $1k? (As an example: A family friend of mine ran a "compounding pharmacy," where he compounded multiple drugs into a single pill, so people who are prescribed 15+ pills to only need to take one. The insurance companies considered the resulting compound to be a "new drug" and therefore he was able to set its price to literally whatever he wanted.)
2) Health insurance costs are out of control.
This is a complex issue but it comes down to a few major factors:
(2a) Risk pools cannot cross state lines. As far as I can see there is literally no reason for this.
(2b) The requirement to cover pre-existing conditions increases insurance costs for everyone. As many have mentioned in this thread, it makes no sense to call coverage for pre-existing conditions "insurance." If you already have a disease, you aren't insuring against it; you're just paying for it. I do think that people have a right to healthcare, and even as a republican I think that taxpayers have a duty to subsidize those with pre-existing conditions. But I don't think we should be including this obligation in the cost of insurance from private companies. It should be a separate budget item, like social security or medicare or medicaid (or better yet, take it out of the defense budget...). If private companies need to insure (read: pay for) pre-existing conditions, then they effectively become the gatekeepers for this tax, and they have every incentive to make it as high as possible.
[0] http://www.commonwealthfund.org/publications/issue-briefs/20...
That way analysis becomes easier and all perceived sample biases can be alieviated.
We are now on an ACA plan. $270 with subsidies. Think about that. The government doubled the price of the plan or more, and is paying with our tax dollars the difference between my $270 and $780.
The ACA helped many people. It helped people under 26. It helped people with pre-existing conditions. It helped give free or low-cost health care to people that couldn't afford it because now the government is picking up the lion's share of the tab.
As much as people like to rag on the Republicans, and they deserve it, I don't think they will throw out the good parts. I think they will look at the industrial recommendations such as expanding risk pools across states (Commerce Clause allows this regulation), and other rational plans. Will it be perfect? No. Will it be better than the current ACA? Maybe.
https://ycharts.com/indicators/us_health_care_inflation_rate
Health care is not becoming more affordable. The rate of inflation in health care is significantly higher than the US inflation rate.
https://fred.stlouisfed.org/series/T5YIFR
How is that affordable? How are $600 epi-pens affordable?[1] How is a 4000% price hike on a 62 year old generic affordable?[2] Google for "snake bite hospital bill." $153,000. That's not affordable. That sounds downright fraudulent.
It seems they should have named it something more appropriate, like the Universal Health Insurance Act. Insurance that is no more affordable than the overpriced health care available in the country. But point this out, and everyone starts their partisan bickering and nothing gets done at all.
[1]https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-...
[2] https://www.washingtonpost.com/news/to-your-health/wp/2015/0...
Without actual PRICE DISCOVERY nothing(in terms of reform) works.
I got a tetanus shot (booster as an adult, Tdap) and called around to different clinics. Prices ranged from $131 to $39. For what is required by law to be exactly the same thing.
That "well your insurance might mean you will pay a different amount" is EXACTLY the problem. No one can easily determine the price of anything.
Is there a base-model Chevy that is sold at one dealership for $35K and at another dealership in the same city, for $65K?
No, because people would very quickly do price discovery...
Also, the medical ratio of youth to elderly is 1:6 and before the ACA, youth would pay about 1/6 of elderly costs. Congress unfairly mandated that ratio to be 1:3 meaning youth pay 75% more than they should. They already have to pay for student loans, save for a house, and now they have additional burdens paying for smokers and those who drink daily sugar Cokes and thus obese.
Tax tobacco like other countries and NYC/NYS and use that money to make premiums for youth and middle class more fair.
Good riddance!
BUT
If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts.
It's inhumane for the wealthiest country in the world to take away basic healthcare for it's most vulnerable citizens.
If you are so 'smart' and so 'great' - then figure out a way to introduce efficiencies, pricing intelligence etc. to get people more and better coverage - instead of just smashing some law because it's not perfect and it was written by 'Obama'.
