Many See I.R.S. Penalties as More Affordable Than Health Insurance | Hacker News Reader

Many See I.R.S. Penalties as More Affordable Than Health Insurance

nytimes.com

162 pointse15ctr0n369 comments

Personal experience with ACA: As of 2016, we're onto our 3rd insurer. Each prior one has dropped our local doctors, physicians groups and hospital. With each insurance change, our deductible has gone up, our premium has increased and our co-pay, co-insurance has increased.

In effect, our ACA plan has become an extremely expensive catastrophic insurance plan.

You're not alone. In Texas, they cancelled almost all (or maybe all) individual PPO plans (affecting about 367k people), leaving us to choose HMO or EPO plans (the lesser of two evils). And about a 20% increase (per year) in insurance cost for the last 3 years. I at least hope some folks are benefiting from the ACA, I'm certainly not.

> In Texas, they cancelled almost all (or maybe all) individual PPO plans (affecting about 367k people), leaving us to choose HMO or EPO plans (the lesser of two evils).

I know Scott and White[1] is still offering PPOs, but apparently they only service 77 counties in Texas. A quick check of healthcare.gov tells me that none of the big insurers are offering PPOs, though. I don't know if there are other small-ism nonprofits like SWHP serving other parts of the state and providing PPOs.

[1] https://swhp.org/en-us/

What'd you have before the ACA?

I had an individual PPO plan. Also, my current plan isn't an ACA "marketplace" plan, it's a non-marketplace HMO plan.

In CA, that's not the case. Our insurance went up maybe $50/person, but we got mental health care, acupuncture, and various other benefits we didn't have before. Oh and we have pre-existing conditions that would prevent us from being insured if we didn't have employer-based. And this is all PPO.

You have coverage, but having care is a little different. For each of those features, do you have local providers who are willing to take on new patients and provide that care at the offered reimbursement rates? In much of CA, the answer is no.

For me in SF, it hasn't been an issue. We are PPO blue shield which everyone takes.

SF proper has Healthy SF public coverage as well.

Here's an example of the concept just today:

Fecteau’s story illustrates a common complaint by health-care advocates here: Dental insurance doesn’t mean access to care. Part of the problem: Washington has one of the nation’s lowest reimbursement rates for dental care provided through Medicaid..."

http://www.seattletimes.com/seattle-news/times-watchdog/wash...

Same here. Had a plan I liked cancelled out from under me. Result is higher premiums, higher deductibles and much higher max out of pocket fees. Lots of little things not covered that were before.

And I wasn't able to keep my doctor either.

Are you getting subsidized or do you make $85k+? Why only catastrophic?

likely because the incredibly high base deductibles (6k per person for example) on most exchange plans mean that most people will never actually utilize any insurance.

Well, that's not traditionally how health insurance works in the US, but it's how all types of "insurance" should work - it should not be for routine costs. Insurance, generally, should be for unlikely unexpected costs. Otherwise, it's just involving an extra middle-man in payment, and that middle-man is going to make a profit.

It's unfortunate that in the US, even for completely routine medical costs, you can't skip the middle-man, because prices are hidden and fake, and the real prices are negotiated between the middle-men and the medical provider (as well as which tests or procedures are allowed, under what conditions). I think the fixation on "everyone should have good health insurance" is making this dysfunctional situation permanently unfixable.

Yes, it's funny to me how so many educated adults are in this conversation, when the problem is mostly political.

On one hand, you have a population that believes that no one should be left to die if they show up at a hospital (probably due to their religion and whatnot).

A significant portion of the same population also believes that everyone should stand on their own two legs and that offering healthcare to all via increased taxes is socialism.

Conclusion: We end up with a system where all costs are distorted and people are given this illusion that they buy access to subsidized health care (aka health insurance), but they get to satisfy their egos by pretending to deserve the health insurance they have and they get the satisfaction of knowing that their neighbors aren't getting free handouts from their taxpayer money.

Side benefit for employers: You get a trump card over an employees' mobility because the best value for health plans is via health insurance plans tailored for employers, ideally white collar due to the type of work.

> On one hand, you have a population that believes that no one should be left to die if they show up at a hospital (probably due to their religion and whatnot).

Or out of simple self-interest. Having health insurance doesn't guarantee you'll always show up at an ER capable of demonstrating to the hospital's satisfaction that you are insured, with the necessary documentation (e.g. after a car accident or a mugging).

by law, emergency care has to be provided without regard to the patient's proof of ability to pay.

This is part of why so many emergency rooms close.

> On one hand, you have a population that believes that no one should be left to die if they show up at a hospital (probably due to their religion and whatnot).

No. It's a sign of national pride to have a country where people aren't left to die in the streets. In fact, countries with higher levels of social services such as national healthcare are also more irreligious than the countries where people do in fact die in the streets.

howlin: People never or almost never "die in the streets". That's just scary FUD, not reality.

They certainly do in many parts of the world. I personally saw the dead body pickups in India. Seems like the parent aspires an American health care system more similar to the developing world.

Oddly enough, the American health care system is so broken that for many people that would be an improvement.

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

> I think the fixation on "everyone should have good health insurance" is making this dysfunctional situation permanently unfixable.

Nah. Every citizen should have good health insurance that requires no out-of-pocket expenditures.

There should be one plan, available to every citizen. There should be one payer, the Federal Government.

Anything else is a recipe for price-gouging and ballooning costs.

but see, that's not "insurance"

right, it's "care", and otherwise the sentiment is correct

With the exception of catastrophic coverage plans, neither is what we call "health insurance" in the US. :)

And what will happen is you will not get much health care. Certainly much less than you got in 2005, for much more than you paid in 2005.

Insurers routinely pay out over %100 of premiums in claims. Meanwhile government programs with benefits- like welfare- blow %75 of their budget on overhead and only pay out %25.

Economics is like physics. You can wish it wasn't so. You can look at optical illusions, but the reality is always there.

> government programs with benefits- like welfare- blow %75 of their budget on overhead and only pay out %25

That's hard to believe. Source?

It is hard to believe because it isn't true. In the U.S., the government-run health care systems are the most efficient systems, far better than the private insurers.

> And what will happen is you will not get much health care. Certainly much less than you got in 2005, for much more than you paid in 2005.

Other countries that have single-payer universal coverage have much better care, and absurdly better quality-of-outcome-per-dollar-spent than the US.

Also, I'm nth-ing dmitriy_ko's request for a citation... along with a request for a quote on the actual overhead-vs-payout ratio of private-sector "health insurance" companies. (Make sure to parse those reports very finely... as we've certainly learned from the creative ways that the Intelligence Community has lied to Congress, the DoJ, and the American public, there are many ways to make a statement that is strictly true, but so misleading that it might as well be a bald-faced lie.)

"Insurers routinely pay out over %100 of premiums in claims."

Because there's zero controls around costs.

How much healthcare do you get in the US for $2928/year? That's how much the UK National Health Service cost the UK government per person in the 2013/2014 reporting period, for a comprehensive universal healthcare system with no deductibles, no co-pays other than a minor prescription charge (7 pounds, unless you're exempt due to low income), and which is consistently ranked higher than US healthcare by the WHO.

If we can cut that by 75% since government programs are apparently so wasteful, I'm assuming US insurers should be able to offer some insanely great programs in the ~$3000/year bracke, since the UK apparently ought to be able to get away with providing this level of service for $750/year.

The problem is that the USA is funding a disproportionate share of the medical advances. So while it may seem absurd that we spend double for worse outcomes, I'm not sure it's so simple.

While that is true, it is quite clear that it is not what drives healthcare costs.

Firstly, industry only accounts for less than 60% of research in the medical field in the US to begin with. The rest is made up by donations, grants from various organizations, and about 28% from the NIH that are not part of the healthcare spending.

When you look at the R&D expenses borne by industry you get things like Pfizer, which in recent years have spent about 17% of revenues on R&D. Typically less than their profit.

Given that Pfizer gets a substantial proportion of their revenues internationally (in 2009 this was ~56%), despite massive restrictions on advertizing, while their US sales costs are substantially higher than elsewhere (e.g. in many European countries, ads for prescription medicines is outright illegal), most of their available cashflow after cost of sales/marketing is accounted for does not come from the US, and is unaffected by US healthcare costs.

If this split holds across the industry, then US healthcare sources accounts for 30% of US healthcare medical research funding.

Your 100% vs 25% is for completely different metrics.

Insurers will pay out over 100% of premiums for some small percentage of people, but will pay out less than 100% of what they take in premiums overall, or else they go out of business.

Insurers seem to make enough money to pay a huge staff and process a lot of paperwork, but you also have to consider the higher costs of health care due to the health providers also needing more staff to do "coding" (looking up codes which precisely classify medical services administered, there are many thousands) and other paperwork (and IT systems etc) needed to get paid by insurance companies.

I would be quite interested to see your data. A quick google search indicated to me that the vast majority of insurers pay out less than the ACA-required 80-85% of premiums and therefore were required to pay a rebate to their customers under the new law. Certainly 80% < "over 100%". They call this the Medical Loss Ratio (MLR), which I find to be an amusing term. It is interesting to note that it is considered bad for the MLR to be too high, because this indicates poor control over expenses.

It would also be interesting to see your data on government payout ratios as well. Government employment is at the same time notoriously stingy but also forgiving. It's well known that civil servants are difficult to fire even when they aren't performing their duties. I could believe that the remora effect of underperforming laggards could push overhead costs up somewhat but the statistics you suggest seem quite excessive.

I can't vouch for this website's data or slant [1], which suggests that Medicare's administrative costs are around 3% of premiums, while private insurance administrative costs approach 17%. Medicare is reported to be a good example of a system with excessive MLR which apparently leads to high rates of fraud. Sort of like not giving the IRS enough money to audit people, reducing the impetus to pay legally-owed taxes. In these cases it is better to marginally increase overhead.

[1] http://www.ahipcoverage.com/2014/01/03/myth-vs-fact-administ...

Yeah, that's bullshit. The oft-quoted figure of 3% for Medicare may not take into account the premium collection that the IRS handles, but with outside agencies it's still 6-8%.[0]

[0] http://www.cahi.org/cahi_contents/resources/pdf/cahimedicare...

"The bottom line: Government spends about 70% of tax dollars to get 30% of tax dollars to the poor. The private sector does the opposite, spending about 30% or less to get 70% of aid to the poor."

https://www.theadvocates.org/effective-government-welfare-co...

Two of those three works cited to arrive at the "~70%" figure are ~thirty years old. It's not looking good for the author. Let's look at the paper by Edwards that's only ~9 years old...

Edwards's first citation for his "~70%" figure is one of those two thirty-year old studies. His second is one is a paper by Tanner from 1996. So, let's look at that one...

Sadly, the Tanner work is a dead-tree book, page 136 isn't available in the Google Books preview, and Mr. Edwards doesn't bother to mention the source of Tanner's numbers.

So. Two out of three sources for that "Government welfare programs spend 70% of every dollar on overhead" claim are ~thirty years old. One of those sources can't be easily verified. It's not looking good for the basis of that claim.

But, let's be charitable. Let's presume that the claims of the twenty-year-old paper were based on then-recent information that was correctly interpreted and is still valid, twenty years later... [0]

Remember that Tanner is talking about all US government welfare programs. We're talking -specifically- about Medicare. As mentioned here [2] the worst case overhead for Medicare is 8%. That's a far cry from the 75% figure cited by MCRed, and far better than the 25%->35% overhead figure cited by Mr. Edwards for private-sector charities.

Medicare is really well run and gives really good outcomes per dollar spent. It's a shining example of a long-standing, effective, well-run government program. Sure, if you look, you can find horror stories of bureaucratic failures and mismanagement... but the same is very true (and happens far more frequently) when dealing with private sector "health insurance" companies.

[0] Some reasonable contemporary scholars found much to complain about in the work. A choice quote from one criticism in 1997: "Tanner uses the familiar tactic of dividing this spending by the number of poor people ... [t]he intended inference is either that a lot of the money goes inappropriately to people who are not poor or that the bureaucracy siphons off most of the funds. Neither is correct. Most of the resources do go to the intended beneficiaries, but are not counted; about 80 percent of welfare spending takes the form of in-kind transfers, and poverty is defined in terms of cash incomes only. Administrative costs of most government welfare programs are under 12 percent." [1]

[1] http://www.independent.org/publications/tir/article.asp?a=42...

[2] https://news.ycombinator.com/item?id=10840804

There should be one plan, available to every citizen. There should be one payer, the Federal Government.

Should this also be the case for food, housing, and cell phones? If not, why?

Because those are things that are an actual market. Health care often times isn't. You can choose what grocery store you go to, what apartment you rent, what cell phone you buy. Usually, unless your planning sucked, you have days/weeks/months to figure out what is good value, and compare prices, that kinda thing.

Health care, on the other hand, can be, and at least in my case, usually is, a monopoly. I've got 1 large company that runs most of the doctors offices and all of the hospitals in the area, so they don't have many competitors. Also, for emergency stuff, you don't have a chance to even think about shopping around. Broke a bone? Yeah, sounds like a great time to pull out the phone and shop around for doctors that would be able to set it for cheaper.

> Should this also be the case for food, housing, and cell phones? If not, why?

Because the heart transplant for your child, or elderly care of your mom, or your cancer treatment is not like a cell phone. Or is it? It is for me at least. Is that something that needs to be explained?

Single payer systems are not hypothetical utopia / sci-fi scenarios. This is already happening in many countries where people are happier and live longer.

Do you have any examples where healthcare regulated like cell phones with a good outcome?

Surely if it is such a great system, someone would have stumbled on it.

I have examples of where it is regulated like the cell phone and it doesn't work -- pretty much any third world country where regulatory agencies are practically not functional. There you go to to the doctor to get a shot of antibiotic, instead you get a shot of saline. Because antiobiotic shots cost money. Etc.

The very obvious difference is negotiation.

If you had a gunshot wound that needed treating, and you arrive at the hospital to find today only they are charging 1 million dollars for bullet removal (what a coincidence), but the hospital one state over was doing bullet removals for only 100,000$ - are you in a position to negotiate? Is there any reason at all that this hospital would lower its price to match its competition? (as would happen in a competitive market)

Now flip it and say instead of a gunshot you broke your cellphone. You arrive at best buy and they say today only the iphone costs 1 million dollars, but a store one state over has it for 600 - are you in a position to negotiate? Is there any reason at all best buy would lower its price to match the competition? In fact, this happens every day at most every major retailer.

In the US we ascribe much higher value to freedom of choice & markets, etc. We have elected to take the good (driving a disproportionate share of medical progress) with the bad (twice the cost for worse outcomes).

As a counterpoint, I'm from the US and I completely disagree with this. I never ascribed any such value to the "free market", especially when it comes to health care.

See direct primary care (not available everywhere) for a partial solution.

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

Correct. These days, in the US, at least, it's more of a payment plan with an insurance component than true insurance. I think we've even sort of stopped referring to it as insurance and usually call it "health care" or something.

"Not for routine costs" and "high deductible" are hardly the same thing. You can conceivably have a $0 deductible for treatment and no coverage for routine prevention. Thus, you pay nothing when you break your arm- it was unlikely and unexpected- and you pay full cost for checkups.

(Of course, that creates a bit of a perverse incentive, nudging you to skip preventative care and lean on treatment)

In my case, that was not true. While I had the high deductible bronze plan, I benefited from the insurance-company negotiated rates to still get a savings compared to the providers' billed rates.

Personal experience with nearly all health care insurance plans since the 90's: Each year the premiums go up, the out of pocket costs increase, and benefits decrease (beyond more than general inflation).

I understand premiums going up annually. I don't understand 30-50% increases year on year.

When I read this stuff, I'm a little astounded about how bad the situation must be in other states. Here in the Pacific Northwest, my premiums have actually been going down and the plan offerings are getting better. The provider I was on did go out of business so I had to switch, and I'm now paying less for more services.

And, to be totally frank, having had a pre-existing condition that kept me from buying any insurance (literally no one would sell to me pre-ACA), the law's been a net positive for me.

I feel bad for people in other states, in Oregon it was been a pretty sweet deal for me.

Yeah, it's pretty crappy in NC. First year of ACA we only had one company even offering any insurance in my county. And yeah, it's county-based for some reason - if I lived 2 miles in another direction I'd have had multiple options about 10-15% cheaper than what I had available.

Second year we had another option in our county which was about 15% higher than BCBS (which had gone up about 25% from the year before).

Apparently some/much of this has to do with our state choosing to opt out of dealing with increased medicaid funding, so... yay... I guess they get to show obama how bad ACA is by... digging in their heels while we all just pay insanely increasing pricing?

We are > 100% from where we were wrt premiums from 2012. I expect some increase every year. I don't expect > 100%.

Colleague of mine is now facing > $1800/month health insurance pricing. He's... early 50s, married, 3 kids. This is with a $10k deductible. Another colleague with just one spouse and a child was facing going from $1300->$1650 this year, again with a fairly hefty deductible.

Given that this is effectively only something you'll get any benefit from if you're in a horrific accident of have a massive illness, this is now just really expensive catastrophic insurance.

I might feel slightly better about some of this if I actually knew anyone personally (beyond Frondo now!) who's benefitted. In my social circles, this has not even been close to a win for anyone. Either insurance has gone way up for people who can afford it, or it's still too expensive for some of my friends who are still unable to afford it (because they don't make enough money to qualify for the 'subsidized' pricing).

Bring on single payer...

We started on a $1500 indv / $3000 fam deductible PPO in 2014 for about $800/mo for two people. In 2015 the premiums went down maybe 0.5%. In 2016 the premiums have gone up 6% and the out of pocket max went up $500 per person to $4k.

ACA has absolutely been a net positive in my life. I had cancer in 2012 and so it would have been literally impossible for me to get health insurance outside of a group plan. With ACA I've been able to go independent, start my own business, choose my own clients, and fully control my destiny.

The ability to get insurance for an affordable price (the parameters of which I realize people differ on) with pre-existing conditions outside of group plans has been one of the big wins of ACA. It's at least reasonable to argue that particular problem could have been addressed outside of the massive and controversial implementation that was ACA as a whole.

I agree. The Federal subsidies should actually be limited to subsidizing pre existing condition coverage. I am willing to allow tax dollars to cover the difference of pre-existing condition coverage since it would be a net gain for everyone. The problem is that the subsidies are available for everyone, regardless of prior insurability, thus, just like student loans have accelerated college cost inflation, subsidies for almost everyone in the middle classes have resulted in price increases.

Essentially, pre-existing condition insurability is where the government could have make a huge impact with minimal disruption to the overall system. Much like there are government mortgage guarantees available for higher risk borrowers, the same kind of system could have helped the pre-existing conditions people get coverage while not throwing the baby out with the bath water.

The alleged goals of the ACA were to get everyone insured. However it shouldn't have taken thousands of pages to accomplish that. A good portion of ACA has nothing to do with insurance at all.

I wish there was some scope restriction on bills. For example the latest highway bill contained passport revocation provisions for those with delinquent taxes. This forces politicians to reluctantly vote for something they don't like because the overall bill is important. Poison pill amendments are often not poisonous enough so we get stuck with a bunch of really bad laws.

> The alleged goals of the ACA were to get everyone insured. However it shouldn't have taken thousands of pages to accomplish that. A good portion of ACA has nothing to do with insurance at all.

My own view is "getting insured" shouldn't really have been the goal, at least not with the current 'insurance' system in place. The goal should be making sure people have access to care/service, not access to purchase insurance. I have insurance, I'd be hard pressed to use it outside of a catastrophic event, because I have such a high deductible. Headaches with blurred vision... I may eventually go, but... I don't really want to be on the hook for $10k+ in bills just to find out "oh, it's nothing, get some rest".

Expanding medicaid would have ensured that more people would have had more direct access to care with minimal disruption to everything else.

> Yeah, it's pretty crappy in NC.

That's because your state is run by people who want desperately for the ACA to fail, and so they are intentionally making it as crappy as they can.

For comparison, my state's ACA plan is the same as Medicaid (several choices of insurance providers and I believe no cost for prescriptions).

The more surprising part was our Republican Governor was the one that advocated for it and pushed it through the party line (with a lot of grumbling). His argument was it would save the state quite a bit of money and so far I believe it has.

> Apparently some/much of this has to do with our state choosing to opt out of dealing with increased medicaid funding, so... yay... I guess they get to show obama how bad ACA is by... digging in their heels while we all just pay insanely increasing pricing?

Well, the increased Medicaid funding is temporary, but comes with permanently higher Medicaid spending. So a state might reasonably not want to accept that offer.

Doesn't the federal government continue to cover 90% of the costs beyond 2020? That's still a pretty huge increase in funding.

To clarify, yes. After 2020, the federal government continues to cover 90% of the cost (compared with 60% normally) of the expansion indefinitely. So, for a state government, it is likely the cheapest way to ensure a large number of low income people are insured.

60% is not the normal federal share; the normal federal share varies by State, depends on state economic performance relative to other states, and is a minimum of 50% for certain populations, 65% for other populations.

What you said doesn't contradict the 60%. 60% is the normal federal share. I had a job that specifically involved forecasting state budgets (which obviously involved looking at historical trends) and forecasting the ACA's impact.

To clarify, these variations have historically averaged around 60%, and likely will continue to (sans ACA expansion): http://kff.org/medicaid/state-indicator/federalstate-share-o...

There's a difference between 60% being the normal federal share, and a variable amount that, averaged across all states, averages to about 60%, being the normal federal share, particularly when addressing particular states policies, since the share for any particular state tends to be pretty consistent over time (e.g., the California regular FMAP has been the minimum, 50%, because of the states better-than-average economic health for long enough that I frequently have to remind who work on systems where it matters that that's not a fixed amount) and maybe be significantly different than the average.

The increased Medicaid funding is permanent, though the 100% federal funding share for the expansion population drops in stages down to its permanent level, which is "only" 90%.

My premiums have gotten lower (in one case they were completely covered by my employer). My father is going through some very expensive medical care right now for cheap and my mother has insurance for the first time in more than a decade. What has gone up is my providers increasing their charges with the final negotiated price being something like 50% higher than before.

Let's be fair here. The ACA said that the feds would match the expanded medicaid enrollment for a few years, but after that the states would need to continue to sustain the larger enrollment on their own. Medicaid is a significant chunk of state budgets, and doing that meant raising taxes, or lowering expenses in other areas, or taking on debt.

It's not as simple as "screw obama, and screw poor people we ain't doing it." In the post-crash years, while money was scarce, there was some real concern over where the money would come from, how much it would need to cost, and how states would cope.

If your state can't sustain something with the federal government funding 90% of your expanded costs, then maybe you need to rethink the state you're in. It's no doubt, most likely in the "south" in some form, so I'm not surprised the government can't operate correctly.

I'm paying less out of pocket now than my share at my last job, with netter coverage... though this year I'm paying as much for a plan with $1k more for deductible... it's pretty sad... I keep it because I'm on a few medications that would be far more out of pocket.

Something needs to happen with USPTO, especially medicine at this point.

Something needs to happen with tort reform and the cost of FDA approvals. The FDA process is hugely expensive and inefficient. Contrast the FDA with Switzerland.

The patent system is essential for medicines. I know many people don't like that reality but who will invest in pharma companies if their investment could quickly be nullified due to the loss of intellectual property? Would you invest in a company when the competitive advantage that company is immediately rendered moot?

However, there are definitely places for reform, so I am not fully defending the USPTO system, I am simply suggesting that a strong patent system is a fundamental motivator of pharmaceutical innovation.

Pharmaceutical companies still make generic medications that are no longer covered by patents as well as over the counter medications. As for approval costs, the biggest cost for these companies is marketing, plain and simple. The actual people doing the research, I'm guessing are not solely guided by their pay or patents for that matter. I would presume that many people just want to make society better.

I am not suggesting that patents go away entirely, but their scope should definitely be reduced... extension patents in particular should not receive the same 20 years that original patents receive. The patent system has resulted in generations of gaming the system to the point where it no longer works.

I'm unconvinced that patents serve the public good in this day and age. I am convinced, however, that the vast majority of patents granted should not have been.

"Bring on single payer" - like the veteran's administration? Because that works so well?

Those #s are insane

The reason nobody could sell you insurance with your pre-existing condition before is that regulations prevented making plans for conditions. EG: You couldn't make a national diabetes insurance plan for people with diabetes (and the economies of scale that go along with a pool of all people with diabetes) because it was effectively illegal.

If the ACA had merely fixed that, then your premiums would be going down more and you'd be getting better insurance.

You know what? My pre-existing condition was that I'd had my gallbladder removed in the early 2000s. That's it. Uninsurable for 10 years because of an operation which I recovered from fully in less than a week.

Telling me it's "regulations" that had every insurer reject me? Pull the other one, it's got bells on.

Citizen Frondo, you don't understand. If the market says you must not be insured it is right because the market is always right. Why, on this board you had people tell with a straight face that one should not bother to eradicate schistosomiasis and malaria in the African continent because if the continent was meant to be productive people would be spending money in the project right now.

If the OP is correct, then it is not the market that is enforcing the insurance scheme to reject cover for him based on pre-existing conditions, but rather the state that is making it illegal for schemes to be tailor-made for specific (pre-existing) conditions.

My preexisting condition was "history of headache". I was denied by every insurer that did business in our state in 2010 and 2011. I wish I was kidding. Had I failed to mention the headache thing and sought treatment, I would have been vulnerable to rescission.

My "pre-existing" condition was that I'd been to the doctor for heartburn in 2008 and been prescribed a 2 week course of medication.

Sorry - it wasn't quite the same as not being able to get insurance at all. Didn't mean I couldn't get insurance at all, but was 'rated' fairly higher than what was originally quoted.

>"The reason nobody could sell you insurance with your pre-existing condition before is that regulations prevented making plans for conditions"

I didn't know about this, but it changes quite a bit regarding pre-existing conditions. Could you please point me to a citation or something about this?

" Here in the Pacific Northwest, my premiums have actually been going down and the plan offerings are getting better."

You are in the minority.

Every insurance company that provides Obamacare in Oregon is increasing rates for the average customer this year.

http://www.oregonlive.com/health/index.ssf/2015/07/more_than...

In fact, the State of Oregon has actually ordered some of the companies to increase their rates more than they'd originally planned.

http://www.cnbc.com/2015/06/22/oregon-dumps-cold-water-on-lo...

That seems really crazy, but then... Frondo just said the company he was with before went out of business. Why? Were they, in fact, not charging enough to cover their costs (supposedly the motivation behind Oregon raising prices)?

I feel bad for people in other states, in Oregon it was been a pretty sweet deal for me.

I moved back to Oregon from California several years ago. I was astonished at how much more expensive insurance was in OR than in CA.

I've been told that Oregon has had a lot of protectionism for local health insurers, so they didn't have to compete much. So perhaps you're just seeing Oregon coming into line with other states...

(By the way, I had a pinched nerve in my neck when I moved. No insurer would take me, and one told me that they wouldn't insure me until nine years had passed without any symptoms)

Unfortunately, your situation must be specific to Oregon. I'm in Washington, and the closest plan we could get to what we had pre-Obamacare went from a $2500 deductible to $6300 with a premium increase of around 40-50%.

In my opinion, the problem was never the unavailability of insurance. The problem was (and still is) the out-of-control pricing of medical care -- $5000+ for non-sterile gloves [1] is a bit extreme.

[1]: http://www.rd.com/health/wellness/wildly-overinflated-hospit...

I agree with you. I wish more people would realize their quibbling over a treatment for a symptom when they're hashing out a regulated private insurance marketplace v. single-payer. Our existing insurance system allows a lot of perversions of the marketplace and contributes to the root cause, but having the government sign a blank check isn't the answer either. We need to return ordinary market dynamics to health care if we want something that's sustainable over the long term.

The expensive gloves problem is due to cross subsidization and cost recovery. A good portion of the problem is due to under-market Medicare reimbursement rates; another part of the problem is that certain demographics that aren't eligible for Medicaid due to their lack of legal status incur expensive care (via the emergency rooms) that goes unreimbursed. This problem is especially accute in places like Texas.

I would suspect that more free primary care clinics could take some of the burden off of emergency rooms in terms of cost and those free clinics could even be funded by insurance companies from the money their saving from not having to pay for $5000 gloves anymore.

A cash-payment medical system would also solve some of these problems. With opaque pricing, hospitals get away with solving budget issues by overcharging. If you actually saw the menu of what things would cost and you were paying out of your pocket, nobody would ever tolerate $5000 gloves. Market forces would fix the cost overages very quickly. As it is now, very few people actually directly pay for their own care and thus are less motivated to care about price. "Insurance covers it," is all many people care about.

I think we need to talk way more about cost/pricing/fraud/transparency than the "insurance" red herring, which just became a problem because of cost in the healthcare sector.

It isn't ACA that has caused me problems, or at least the law itself.

The description given matched my experience with insurers before ACA. My problem with ACA is Healthcare.gov (still). It is possible to go through the entire application process, make one mistake or fail to provide the right detail, and end up disqualified from buying insurance through Healthcare.gov (in my case, I used a mail forwarding service address, because I travel full-time). There is no do-over, no online process for correcting the problem with the application. You have to go through a protest process that involves mailing physical letters somewhere. Fuck that. I'd go back to the nightmare that is pre-ACA private insurance, before I beg some bureaucrat, by mail, for the privilege of paying too much for insurance.

Healthcare.gov got a lot of flack in the beginning for costing too much, delivering too little, and being too flakey. All of those things are still true. It's also dehumanizing.

The traveling full time "problem" affects me as wel. When some company or another asks, "Where do you live?" My response is preceeded by an audible shrug.. I seems that many companies actually plan to come visit me and are put out when I explain that my physical location is really of no concern to them. For example, banking. If I give a Texas address and agree to Texas terms and conditions, why would it matter that I spend 11 months a year in Europe. My mail arrives, I do my transactions online.. So what's the problem? Twentieth century thinking, that's what.

Those are most likely regulations enforced on to the banks. By the time it gets to the low-level employee that checks/asks/confirms your address, it's probably morphed a bit, and each employee has their own interpretation of what is "okay" when it comes to addresses.

The federal exchanges (for which healthcare.gov is the portal) were never intended to be a good choice (or even to have to exist at all), they were in the law as a minimal fallback to be applied for states that failed to implement their own exchangees.

Yes, my "home" state is Texas, which has been extraordinarily regressive on ACA. It might be time for me to consider making another state "home".

Who's your carrier currently? I'm in Oregon as well, and I'm not impressed with the offerings here, at all.

I believe 18-20% was the norm for the past decade or two. Nationwide, I think the growth has supposedly slowed very slightly.

That doesn't make it any easier if you're one of the people who are getting screwed, though.

I've been buying insurance for a more than a decade, in multiple states. (direct, not via employers). I can't say I've seen annual rate increases of 20% year in year out for 2 decades. That's simply not sustainable.

By way of example, my $100/month policy would be $3800/month after 2 decades of 20% year on year growth.

I believe 8% annual inflation has been the normal rate for many years -- slightly decreased following ACA enactment, but rates then increased by a few points due to less-healthy enrollees, so it's a bit of a wash (not counting all the people who now have health insurance, to be sure). Premiums also only cover part of the cost increase; higher deductibles and reduced coverage are also used to defray costs, and aren't as obvious to the end consumers. Finally, plans that don't conform to ACA minimum coverage requirements have been killed off, so some individuals are seeing their rates increase commensurate with their improvement in coverage.

It's was pretty easy to predict: allowing enrollment after a diagnosis was politically popular but a terrible economic disincentive to not buy insurance (because at that point, it isn't insurance -- it's a subscription plan for your treatments).

The young and healthy needed to enroll for the economics to work, but the individual mandate was delayed for years -- because coercion isn't popular politically, and there was a reelection to win in 2012. Without the coercion, why would a 20-something buy insurance?

So begins the death spiral. The only thing that can save it is very high penalties for failing to get insurance on the individual marketplace. This would be politically disastrous -- "we know the plans are expensive, but it will be even more expensive to not get one!" isn't a great selling point.

It's not only that you have to pay up so that others may wait until they're sick -- you have to buy a plan that covers things you don't need. I have to pay for all sorts of treatments I'll never use -- addiction counseling, prenatal care (I'm a man), etc. -- because it was considered unfair that I should pay less for consuming less (why this argument doesn't transfer to auto insurance, where men pay higher rates, I don't know).

I know liberals are going to argue "that's why you need to take the market out of it and have single payer." It's a consistent argument only if you believe that you'd be better off with single payer. Some people would be; I know I wouldn't be. I'd end up paying even more for everyone else who isn't paying.

But, politically, that's dead on arrival. Democrats just voted to abolish the cadillac tax. Everyone knows the ACA is an albatross on the Democrats' neck. The sorts of anecdotes in this thread are all over the place. "We just didn't go far enough, try single payer" is not going to win the day anytime soon.

If a Republican wins the presidency, we'll see a full repeal of the entire thing (Dems will not filibuster if they know what's good for them). If a Democrat wins, we'll see gradual repeal, marketed as tweaks and improvements.

Personally, I'm fine with a strong subsidized public option for the truly indigent (oh wait, I just invented Medicare). After that, let the market bring costs down by removing regulations. It's no coincidence that laser eye surgery, teeth whitening, cosmetic surgery is all generally affordable -- markets and competition have formed.

A good market would be one where you paid your doctor out of pocket for recurring, predictable costs and then bought insurance from a private company in order to guard against unforeseen catastrophes -- kind of like how your auto insurance policy doesn't pay for oil changes and car washes.

And what if someone is irresponsible and didn't qualify for Medicare but also didn't buy insurance? What happens if they get cancer? I hope they have family and friends to bail them out. It would be great for charities to lend a hand. I don't think the role of government is to take care of you, because it isn't the government taking care of you. It's the government coercing others to take care of you, against their will. It is not charitable to hold a doctor at gunpoint and force him to perform a surgery. So for everyone who believes that healthcare is a "right," I expect that you're freely giving away your excess time and money away? Or do you just expect others to?

I'm already paying someone else's medical bills -- I can calculate how much I give to Medicare each year, it's more than enough for someone else in this country to see a doctor for the entire year. I'm also paying way more than I should for my family's insurance plan because I'm indirectly subsidizing others. I wonder how many people are getting free healthcare on my dime, and what excuses they have for not being able to afford it on their own. I'm a little tired of being told how great it would be if I just paid a little more and others paid a little less.

> After that, let the market bring costs down by removing regulations.

This is hilarious, given that the US has the most expensive healthcare system in the world, outpacing far more regulated countries by vast amounts....

You might be right that you're hampered by bad regulation, but heavy regulation of the healthcare system have beaten the US consistently on cost for most of the developed world.

The United States' healthcare system undoubtedly is heavily regulated. It just so happens that it's simultaneously stupidly regulated: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730786/

> This would be politically disastrous -- "we know the plans are expensive, but it will be even more expensive to not get one!" isn't a great selling point.

IANAL but it's my understanding that the individual mandate only passed Constitutional muster because it was not punitive. If it were a penalty or crime instead of a tax, the legal interpretation might change. Then again, the Supreme Court had been all over the place lately.

It passed constitutional muster because the Supreme Court (specifically the Chief Justice) is unwilling to wade into this particular political morass. This was not the first decision which has been made by post-hoc rationalization because of magnitude, political significance, side effects, and judges' policy preferences, but it is one of the most notable.

"I don't think the role of government is to take care of you, because it isn't the government taking care of you. It's the government coercing others to take care of you, against their will."

The government does a lot of coercing people to do things against their will. That's why we have police, court systems, jails, and so on. Heck, we've had drafts! That's literally coercing young men to march headfirst into combat to protect the country!

And many people believe the draft is morally equivalent to slavery (which they do not support either).[1]

[1] http://gregmankiw.blogspot.ca/2006/11/rangel-and-friedman-on...

That's fine, I personally don't support the draft, but still. What about the legal system? Don't you see there is a problem with forcibly locking a portion of our population away behind bars? After all, that's what the government does, "for your own safety". Do you really feel safe in a country where the government can decide that murder is a "crime" for which you should be inhumanely LOCKED AWAY FOR LIFE?

P.S. Extreme sarcasm above...

The only justifiable coercion is against coercion. Someone injures you physically or financialy. Forcing someone to do something they don't want to including dieing or giving you their things is coercion. Coercion is always unjust and only fit as a reciprocation for coercion.

Cite?

*The Golden Rule. "Treat others as you would like to be treated"

So you're prepared to invalidate close to 100% of all employment contracts in the US?

Quite the contrary. Those are entered into willfully and not coercively.

But they are paid, largely, via taxes that I would believe many people would like to not pay. Taxation's gotta be a coercive thing... what's your take on that?

Does financial coercion exist? If wage slavery doesn't count, what does count as financial coercion?

I have recently revised my views in light of Michael Huemer's latest book, which I found convincing (, despite my initial reluctance to accept many of his findings).[1] It takes at least a book to explain his reasoning (which rightfully separates political legitimacy and political obligation from each other and independent moral obligations), and I won't bore you with poor paraphrasing here.
[1] http://www.palgrave.com/page/detail/the-problem-of-political...

You admit to sarcasm, but say the murder victim was an 3rd trimester fetus... now you have yourself a modern day political issue.

Was going to post something like this - you beat me to it.
"I don't think the role of government is to protect our country, because it isn't the government protecting our country. It's the government coercing others to protect our country, against their will."
Obviously, we have a volunteer force, but haven't always had that - conscription, as you brought up. It's fine to have a volunteer force, until we need more. Then force is brought in.

If you can't convince others to defend your country through rhetoric and compensation, perhaps the country isn't worth defending; your comment implicitly assumes every state is worth sacrificing young lives for.

> your comment implicitly assumes every state is worth sacrificing young lives for.
no, it assumes those in control of the state believe it is worth sacrificing young lives for.

Apologies if I misread your comment, but I read the following quote to imply that coercion was acceptable once the volunteer army was not enough:
>It's fine to have a volunteer force, until we need more. Then force is brought in.

I don't believe it is acceptable, but the people in power probably (often?) do believe that it's acceptable, generally because it's not their own lives at risk.

"... to secure these rights, Governments are instituted ..."

it's almost like our government is supposed to "establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare", right?

"It's no coincidence that laser eye surgery, teeth whitening, cosmetic surgery is all generally affordable -- markets and competition have formed."
This isn't the best example to have chosen. All of these procedures are discretionary and nonessential. If I find the cost of an elective nose job too pricey, I can take my time and shop around. Or I can just go without a nose job altogether and be totally fine. The only thing that will suffer will be my vanity, and, well, it's suffered before. :)
On the other hand, let's imagine my kidney is catastrophically failing, and I need it removed or replaced. I'm probably not going to shop around at that point; I'm going to accept my doctor's recommendation that I be hustled into the nearest ER as soon as humanly possible, and I'll be stuck with the bill after the fact. I have neither the time, nor the expertise, nor the inclination to wait and comparison shop. For another thing, nobody is generally in a "market" for emergency kidney surgery. It's not something you anticipate. It's not something you expect to have done, much less seek out and shop around for. And there are no economic substitutes for the surgery. It doesn't lend itself to a market-based system in the same way that elective goods and services do.

Most medicine doesn’t happen on an emergency basis. E.g. if you’re diagnosed with cancer, or find out you should get a heart bypass, you have time to shop around for doctors.

And even in the case of emergency care, there's at least the potential that you could prepare in advance by familiarizing yourself with the market. But hospitals won't tell you what anything costs ahead of time, which is practically an invitation to gouge ("just leave your wallet and bank account passwords with the front desk...").
Even auto mechanics are required by law to give you a written estimate.

No you don't, because hospitals intentionally obfuscate their pricing, and in many cases it's impossible for them to even tell you what your final bill would be for a procedure.
This is the source of the problem. There is no 'market' to speak of. There needs to be laws requiring hospitals to provide prices up front and honor them after the fact.

> you have to buy a plan that covers things you don't need.
Well... isn't that sort of the point of insurance all together? There's always going to be someone in an insurance plan getting some treatment that I'll never need, no?

Can never need under any circumstances (prenatal care, for example).

No, it's not that the insurance money is going into a pool to pay for someone else getting that. It's that they are forcing you to buy coverage for something that you can't possibly use (e.g. child dental care for someone with no children).

>A good market would be one where you paid your doctor out of pocket for recurring, predictable costs and then bought insurance from a private company in order to guard against unforeseen catastrophes -- kind of like how your auto insurance policy doesn't pay for oil changes and car washes.
That works great if everyone is basically healthy. And it falls apart completely for people with ongoing medical conditions who either don't make a lot or are too sick to hold down a job.

If the government has billions of dollars in funds to blow up people, they have a few billion to heal people.

> It's a consistent argument only if you believe that you'd be better off with single payer. Some people would be; I know I wouldn't be.
There is no need to believe or not believe. We are not talking about alternate realities, other modern, successful countries with better healthcare, longevity and quality of life have a single payer option.
> After that, let the market bring costs down by removing regulations.
Right. Point to any country where removing of regulations for healthcare has resulted in higher quality care.

There's no guarantee that a single-payer would cost any more to you out-of-pocket than your insurance premiums. In fact, being able to draw against bonds and general taxes suggests to me that it'd do better.
In fact, giving the sheer amount of bloat the entire billing apparatus of hospitals, the machinations of health insurers, the weird regulatory captures, and whatnot of the current system, I don't think it's unreasonable at all to at least give it it's day in court.
Your writeup to me basically reads as a "Fuck you got mine" libtertarian approach to healthcare, and one that frankly falls flat on its face if you acknowledge even the slightest personal responsibility to one's civilization or even to one's older, more enfeebled self.

I'd end up paying even more for everyone else who isn't paying.
You're neglecting the fact that unless you get hit by the proverbial bus, you will eventually have one or more very expensive medical conditions, just like those freeloaders you're being forced to pay for now.
The whole idea of selling "insurance" in a market where you know that everyone is eventually going to file expensive claims is just stupid. No other insurance market works that way, nor could it.

> "that's why you need to take the market out of it and have single payer." It's a consistent argument only if you believe that you'd be better off with single payer.
No, it's a consistent argument for those who think beyond themselves; it's good for society as a whole. One doesn't have to believe one personally benefits, that's now how liberals work.
> A good market would be one where you paid your doctor
A good market for healthcare is one where it isn't a market, but a social good provided to everyone, like other civilized countries do. The market is not the correct answer to every question of how to distribute goods and services.

No, but it is the only answer to how much those services cost, which is a necessary question to answer if you intend to apply accounting to resource allocation and consumption.

> but it is the only answer to how much those services cost
No it isn't; and that which can be asserted without evidence, can be refuted without it as well.

You assertion assumes ignorance as a starting point.
Be enlightened: http://wiki.mises.org/wiki/Price

The Austrian school, no thanks, that school of thought hasn't been mainstream since the 30's, for good reason; it's wrong. Here, you be enlightened and catch up to the modern world: https://en.wikipedia.org/wiki/Mainstream_economics

other "socialist" civilized countries, you know, like the ones that regularly innovate and push the boundaries of science and attract millions of people each year because of a higher standard of living and less taxes. oh, wait... The "market" is just a synonym for individuals co-operating together for their mutual benefit. The "public" option is one where a faceless bureaucracy with a monopoly on power steps in and dictates terms. Disclaimer: I have lived decades with a single payer system and left in part because of it.

>I have lived decades with a single payer system and left in part because of it.
No you didn't.

> like the ones that regularly innovate and push the boundaries of science and attract millions of people each year because of a higher standard of living and less taxes. oh, wait...
Propaganda Americans seem always believe, as if the rest of the world were a third world country. The Nordic countries top the world standard of living, America, not so much. Quality of life, the U.S. doesn't even break the top 10. The U.S. isn't a shining city on a hill, it's a waning rotten empire slowly sinking back into 3rd world status for its average citizen.
> The "market" is just a synonym for individuals co-operating together for their mutual benefit.
That's a nice theory, it's just not true in the real world.
> I have lived decades with a single payer system and left in part because of it.
And which country would that be?

>I have to pay for all sorts of treatments I'll never use -- addiction counseling, prenatal care (I'm a man), etc. --
Yeah, I know! Outrageous! Next thing you know they'll be asking me to pay to educate other peoples children!! Oh wait....
Having a society full of healthy babies (remember those babies are going to grow up to be adults someday) and people without substance dependency is beneficial to you.
Are you also upset that the people who live across town from you have roads that you never use?
The whole idea of "insurance" is to pool risk anyways. Do you also go on a rant like this every year you don't get into a car accident?
>because it was considered unfair that I should pay less for consuming less (why this argument doesn't transfer to auto insurance, where men pay higher rates, I don't know).
There are some countries (and Montana) where gender discrimination in auto insurance is illegal.

You're unfamiliar with how the American political system works. Presidents can't repeal laws, only Congress can do that.

> I know liberals are going to argue "that's why you need to take the market out of it and have single payer." It's a consistent argument only if you believe that you'd be better off with single payer. Some people would be; I know I wouldn't be. I'd end up paying even more for everyone else who isn't paying.
US government currently pays more per capita than eg UK NHS, and you still get stuck with insurance, co-pay, and bills for your very expensive health care.

Because the ACA is the largest transfer of wealth from the youth to the aged that has ever been attempted. It also is because the fines for not buying into the system are too low that participation by healthy people isn't sufficient to pay for the sick.
The process is designed to make people so irritated with insurance companies that they demand the government take over as payer when it is the government that created the mess in the first place, approved the rates, and then set up the impossible system of not forcing everyone paying.
I am all for a system that pays for checkups and catastrophic but lets be honest, if the system is wholly free so much money will be lost to worry warts it won't be funny. there needs to be a deductible but not so high that people who need something done don't

Not like this.
Right before Affordable Care Act went into effect I checked my insurance quotes so I could later compare how much money I would save getting affordable health insurance (which is how Obamacare was sold - that it would put the insurance companies in check and make everything affordable).
It was a 300% increase.

If you don't have preexisting conditions, you can still buy PPOs from the big insurers as non-ACA plans.

Don't you then face a penalty anyway for not having an ACA compatible plan?

I think he's saying, you can buy a plan from outside the official marketplace. You still want to get a plan that qualifies as a real health insurance plan for the purposes of the penalty. It's probably pretty hard to NOT do that when buying a plan, however.

Based on my search this year, that isn't necessarily true. Here in Denver, all of the insurers that were offering PPO plans in years past have left the individual market (not just the ACA exchange), save one: Anthem BCBS.
Availability appears to vary widely, both from state to state and within states. If I lived in western Colorado instead of on the Front Range, I'd have a couple of PPO insurer options. If I still lived in Minnesota (where my previous health insurance policy was written), I'd have dozens of options from at least four different insurance companies.
I really miss my insurance policy from BCBS of MN.

Don't miss it too much, my BCBS of MN policy just went up 45% year-over-year. It's pretty good coverage, but it's still nearly $10k/year just for the premium for my wife and I.
Still, I was also one of those pre-existing conditions that simply could not buy any insurance before the ACA.

I spent many hours looking for this and couldn't find any individual PPO plans that cover Austin, Texas. If you know of one, please send it my way.

I am in Cedar Park and was offered the Scott & White PPO when I was on healthcare.gov. I didn't go with it due to the state limitation.

I researched Scott & White, and it looked like you had to go to their doctors, which for me defeated the purpose of getting an PPO over an HMO (i.e., I can choose where I go, I don't need a primary care physician). Scott & White's offices weren't close to me, and their clinics got bad reviews.

I have been to S&W and you are right to be concerned - I have had care and billing issues. That's why BCBS with HMO to me was preferable to S&W PPO even though I hadn't read through their "PPO" plan to the level of detail that you did.

And so it goes, National Healthcare like Britain or Canada is what America needs and what the medical establishment does not want. But somehow I think America would screw that up as well.

For what it's worth, I have talked to doctors who want single payer just as much as some of us.

It is vastly less hassle for doctors to have to deal with a single entity for all reimbursements. No hiring collection agencies to hassle patients, no mysterious nonpayments, no switching networks, one set of rules to learn and that is it.
They'll also probably end up paid a bit less under such a system.
The tradeoff is worth it.

Paid less maybe but save a massive amount on costs. Overall they'll come out with more margin and more time.

I work in health tech and all 12 of the physicians I work with think single payer is the way to go.

Having done my time in health care startups with an emphasis on billing and reimbursement flow, let me say that I would have been overjoyed to have been put out of business by single payer (or by a U.S. version that, like Medicare, would be "single, multiple private administrators"). Medical billing is just an utterly perverse environment to deal with, and the Feds were the only player who would consistently tell you exactly what to bill, how to bill, and why to bill it that way.

Have any of them worked in a single payer system?

I think it would bankrupt the government if they did single payer without price caps on drugs. We already spend about double, as a percent of GDP, on health care compared to other countries. Getting the costs under control is the only way to approach reforming health care that's going to work.

So get those costs under control, it's not like you need profiteers like your boy Shkreli profiteering off this stuff. Also ban drug marketing while you are at it. They spend half that money on marketing the drugs to consumers.

But then we'd miss the entertaining statements, like:
“Do not take Stelara if you are allergic to Stelara or any of its ingredients.” (Duh?) - https://www.youtube.com/watch?v=5ZzRAGeXtgU
And many others - http://www.sluniverse.com/php/vb/off-topic/34611-crazy-drug-...

With single payer, the government suddenly holds a lot of cards even without explicitly making laws. Most drugs have alternatives. Facing the threat of having all drugs that have sufficiently good alternatives disappear off the approved prescription lists makes most pharmaceutical companies quite reasonable to negotiate with even for players like the UK government that "only" represents 60 million people.

When a little bit of socialism fails, why is the answer always more socialism?

Because socialism works? Just today: change of health insurance. Need primary care physician. Takes six weeks to be seen. Six weeks, to be scheduled for minor surgery. You might choose to waste an hour on the phone to find a less booked-out physician. In Socialist Britain you are guaranteed to be seen within 48 hours! Here in the US the only thing guaranteed is the waste of time.
Seems that is a feature of the plan. If you aren't seen on time you won't consume healthcare and the insurance gets to keep all the pretty money paid to them.

From my understanding among people I know it does not work even close to that way in Canada. It's one of those things that's definitely up to the actual implementation.

What doesn't work that way in Canada? For that matter, doesn't work what way?
If you mean that in Canada you're never ineligible for your physician because you changed insurance providers, that's basically right (except when you move between provinces, in which case you need to change physician anyway). So the whole problem cannot happen in Canada (nor in the U.K.).
I'm not saying everything's roses and perfection in commie-land... I'm saying that the U.S. system is just obviously horribly worse than all the socialist implementations.
(Well, okay, let's be fair... the U.S. system is probably better for the rich. When I was living in California, and had a medical incident, I got VERY good treatment... for which my employer's insurance company paid a HILARIOUS amount of money, and presumably charged my employer commensurate premiums. I mean, no-expenses-spared levels of treatment. I think Canadian doctors would have been slightly less cavalier about running up the bill.)

I have lived in a number of countries during my career and I have personally experienced two overseas socialist healthcare systems in my life, one third world and first world.
In the third world country, I had to have a very niche test that could only be done at the largest hospital in the city, a government owned hospital. It was a terrible experience. The corridors were packed with sick people sitting and waiting on the floor, it was hot and the ventilation was poor. I had to wait for hours to be seen while hoping I would not catch some disease while feeling incredibly sad for those around me that who must endure that hell regularly while for me it was just a once off.
In contrast, in the first world, the hospital care was just as good as the USA but without dealing with a billing department(can't remember why I was there, might have just been to see a physician for a cough). But from what I was told by a doctor and nurse I befriended while I was in the country, everything was done on a government budget. You want an MRI? If you don't have insurance, the expense comes out of the physicians allocated budget. What happens if the doc has expended the budget? You wait until the next budgetary cycle. Want a procedure done (that is deemed non-urgent)? Its free, but you need to wait months until there is space for you. Non-urgent includes cancer that won't kill you ... a friend's mother waited 6 months to get her stomach cancer removed. She was uninsured and it was free. Good deal (the surgery was something like 12 hours long with multiple surgeons working in shifts!) but they knew that if probabilities did not work in her favor, the cancer might have spread before they could remove it. They decided it was not worth selling the house and other assets to pay for private surgery. It was a good call in retrospect, but if it were my mother, I would have sold my house.
Another friend had a benign brain tumor. The doc was very reluctant to send him for an MRI. Three months later he got one. They instantly sent him for brain surgery. Removed it (for free!). But had it been malignant and spread, the time it took for the doctor to decide to use the MRI might have killed him.
The doctor friend I mentioned above, would tell me government bureaucrats would fight him on his spending, analyzing each of his patients and second-guessing his expenses. He hated them with a passion.
I remember only reading complaints about the UK system until ACA began to be debated, then suddenly it was the benchmark of great healthcare.
tldr; socialized medicine is great, and I would definitely support it, but don't fool yourself into thinking it's all that great. The upper-half of the middle class would still take private insurance and would still prefer being seen at private hospitals where they get the best care no expense (or bureaucrat) spared.

> I remember only reading complaints about the UK system until ACA began to be debated, then suddenly it was the benchmark of great healthcare.
Things changed significantly for the better after Labour came to power in 1997 and began to significantly increase the budget for healthcare. I remember long waiting times for non-urgent care as a constant item in the news growing up in the 80's and 90's. With the increased funding it largely ceased to be a problem.
Currently the UK spends about the same as the US on public healthcare (a little under 8%) but gets full universal coverage free at the point of use. Selling your house to pay for healthcare in the UK isn't unheard of (desperate parents taking their kid abroad for experimental cancer treatments) but it's nothing like as common as it is here in the US where medical debts are the commonest cause of personal bankruptcy.

The 48-hour target has a stupid side effect: in order to meet it, lots of GP surgeries won't let you book more than 48 hours in advance. You have to ring up within minutes of opening time in the morning to book a slot.
Similar things happen with the 4 hour target in A&E: if you're in hospital but conscious and not bleeding, expect to wait at least 3 hours. Having said that, I've twice been in for "this is either nothing or an early warning of something very deadly", been checked over, and of course not had to pay anything. That risk assessment looks very different if it might cost thousands of dollars.
The NHS is completely fantastic at bread-and-butter medical care: diabetes, asthma, minor injuries, obstetrics (it is insane that anyone ever has to pay for this), handing out antibiotics and contraceptives, and so on. The complaints people have tend to be about long waits for non-urgent surgery (anything up to 18 months), and the refusal to pay for marginally effective very expensive cancer drugs.
The only charge is $10 to get your prescription filled, and even that is waivable in poverty. On that subject I have noticed that US pharmacies stock a lot more OTC stuff, presumably due to the difficulty and expense of getting prescriptions. They'll even let you buy dangerous things like 500 paracetamol at a time.

If you're not literally about to die in Canada you're looking at multi-month delays to see any kind of specialist.
Meanwhile my friends in SV just whip out their credit cards, pay a small deductible, and get seen immediately.
Single payer isn't all sunshine and roses.

I feel though, there are more successful examples of it working than there are examples a deregulated health care market working (which is what is advocated by many -- "why can't it be just like the cell phone market?" -- search for sibling posts around here to find it).

It isn't but in most countries that have single payer - you also have the option to go private if you can afford it. Single payer is there if you need it so no-one goes bankrupt, but those with the means can get quicker treatment if they want to pay for it.

Implying that public health care is necessarily a "socialist" thing.

Because they've proven to work, for a lot less money than the US spends on healthcare per capita.

Same here. Texas resident on to our 3rd insurer after BCBS dropped PPO. Twice as much for less coverage with twice the deductible. F*cking Obamacare.

Comparing to my "free market" insurance before the ACA was passed, I had much more coverage (it was real insurance: eg: pay in advance against a risk, rather than covering pre-existing conditions which violates the definition of insurance, since you're not pooling money against risk, but paying for current liabilities.) ..... and not only did I have more coverage, but my deductibles were 1/5th what they are now and the costs were 1/5th as well.
Effectively obamacare is 25X more expensive for me (and this is comparing plans in two different states since I recently moved.)
AND! On top of that-- rather than just getting insurance when I needed it (Eg: you just sign up and buy it) you have to have enrollment periods and all kinds of arbitrary limitations and a 60 minute application process on a "marketplace" that really gives you minimal information about the plans, and demands to know far more about you than you really ever had to give up before to get insurance.
One thing about insurance-- and Warren Buffett has made a lot of money on this-- is that they invested the proceeds between when they were paid premiums and had to pay out claims-- and so insurers paid out more than %100 of their premiums, because some of the investment returns would be spent on claims. This allowed them to keep premiums low, and they still made a profit.
Obamacare basically made this illegal because now instead of selling insurance (or good insurance which was demonized as "cadillac plans" during the "Debate") you're selling "programs" -- so the incentive is to not buy until you get injured then sign up for insurance (and just claim you have a life change to get around the limited enrollment periods.) Which means the economics are on its ear and its completely unsustainable. And when it totally collapses-- I predict that people will be claiming its because "insurance companies are too greedy"
After all, they complained about "greed" when insurance companies were paying out MORE in claims than they were getting in premiums (can you name any government program that has provided more benefits than it costs-- effectively negative overhead? Hell, as I understand it welfare spends %75 of its budget on overhead and only distributes %25 as benefits.) No matter how much government screws up this situation, they will blame industry and use the utter failure as "proof" that they need even more power (and even more intrusions into our lives) and even more money to "fix" it.
None of this is a surprise- it was all predicted by those opposing the ACA.
Fortunately, the asian countries are developing first rate hospitals and medical tourism industry.
The only question is, will I be able to accumulate enough to retire to Thailand or somewhere before I get hit with a serious medical condition? Looking at how things have turned out in other countries (eg: New Zealand where if you're "old" you're just not covered and you have to leave the country for basic things like dialysis, even though there are dialysis machines in the country)... I've got a ticking clock.

What was the lifetime cap on your pre-ACA insurance? Could you get it if you had been sick before applying?
Here's a sadly common scenario: you have a baby born prematurely and they end up in NICU for a month because of a heart condition. They exceed their lifetime cap after two weeks because NICU has always been atrociously expensive. Because they have a heart condition, they are never able to get insurance on their own.
Basically, your pre-ACA insurance was an implied one-shot deal. You have one chance to get sick and get better, because after that you'll never have insurance again.

$2M IIRC, and yes.
The reason that NICU is so expensive is government has driven up the costs astronomically by intervening in the market place over the past 100 years. The ACA is not reversing that, but accelerating that. If the lifetime cap for infant care was $1M, the effect of this intervention is $961,583. Or put another way, that baby would cost %96 less or about $40k for the stay in the NICU.
This is according to the study done by Milton Friedman in the 1970s showing government interventions drove up costs 26fold, and drove down availability. (So, there's probably 30 years more of impact not accounted for in that 26x figure, its probably 50x now.)
Not true about never having insurance again, and anyway the reason pre-existing conditions were excluded is that plans that specifically targeted people with those pre-existing conditions (all diabetics need insulin, right? why not buy it in bulk?) were illegal.
So, government is the cause of the problem in the first place.

NICUs were not very common until the mid-1970s so this component of care probably wasn't covered in Mr Friedman's study. Prior to that time premature babies with congenital issues typically just died.
And medical underwriting was a thing because people that have been sick before are bad bets. There's no need to imagine some kind of conspiracy here, it was just business.
But hey lets just make up some more numbers to fit the narrative.

> just claim you have a life change to get around the limited enrollment periods.
How stringent are they on proving this? Do they just take your word?

I don't agree with your statement about the New Zealand healthcare system. For instance, in regards to dialysis:
For patients using a haemodialysis machine at home, the health service provides the dialysis machine and all the medical supplies patients need, so the treatment itself is free. The same applies to patients on peritoneal dialysis.
Patients do have to pay for things like some medications and home haemodialysis patients usually also pay for the extra power and water needed to run the machine and to keep them warm during dialysis. Some District Health Boards contribute some money to the cost of power and water.
(from http://www.kidneysociety.co.nz/about-us/frequently-asked-que...).

"The only question is, will I be able to accumulate enough to retire to Thailand or somewhere before I get hit with a serious medical condition?"
I was fortunate enough to do just that. Never had to be hospitalized in the US. Retired (very early) to Thailand. Ended up needing surgery. It was actually rather pleasant. And inexpensive. [1] I'm glad it didn't happen in the US.
[1] http://medicaltravelsite.com/blog/foot-surgery-at-siriraj-ho...

'New Zealand where if you're "old" you're just not covered and you have to leave the country for basic things like dialysis, even though there are dialysis machines in the country'
Source for this? I know more than a few old people here on dialysis. The system will even pay to have a dialysis machine in your house if it's long term so you don't have to keep travelling to the hospital.
Care is universal, the only reason someone could be rejected is if they're not a New Zealand resident.

>None of this is a surprise- it was all predicted by those opposing the ACA. Fortunately, the asian countries are developing first rate hospitals and medical tourism industry.
What a joke of opinion. Reality won't stop you from making up non-sense, will it?

From mid-2014 to early 2015, my premiums went up from ~$450 to over $1400, and the deductible increased from $5000 to $10k. This was with a single provider (BlueCross) in Pennsylvania. After the final increase I switched to an ACA-tax-exempt insurance alternative, and I no longer carry regular insurance.

> But plenty of healthy holdouts remain, and their resistance helps explain why insurers are worried about the financial viability of the exchanges over time. They say they sorely need more healthy customers to balance out the costs of covering the sicker, older people who have flocked to exchange plans.
Ah, the tragedy of the commons at work.
Healthy people don't buy insurance because it's too expensive. Insurance is more expensive because there are too many expensive sick people and not enough healthy people paying into it.
It's a terrible feedback loop, one which the IRS penalties were designed to solve.

As a Canadian, I am astonished at how expensive even the cheapest of these plans are. My monthly healthcare cost amounts to $178, once you factor in the taxes I pay that go to healthcare. That's cheaper than any of the plans in this article. How do people find these prices bearable?

They're cheaper than getting sick and not having insurance. I'll pay almost anything to ensure that a sudden medical event doesn't bankrupt me.

> "I'll pay almost anything to ensure that a sudden medical event doesn't bankrupt me."
Exactly, and reflects the mafia-esque choice imposed on the consumer when rates are increased: pay the absurd rate or face absolute ruin if (when) a sudden medical event occurs.

It's mildly terrifying. If you're unlucky enough to break a major bone or get cancer or something like that, you could literally be on the hook for millions of dollars. I lived overseas for a couple of years, and when I got back to the US one of the first things I did was obtain health insurance because of this.

Might be a better option to just declare bankruptcy.

In many cases that's true. Medical debt is the cause of most personal bankruptcies in the US. But it's not a good option either, so better to avoid both if you can. If you have substantial savings then you'd stand to lose those to your creditors in bankruptcy. If you have no savings and don't plan on taking out any loans for a long time then it might be a decent option.

This is one of several reasons I have written off moving back to the US. A unexpected bonus of being an expat is I have no Obamacare requirement. I don't have to buy US insurance (since I couldn't use it anyway) and I don't face an IRS penalty.

Where's your greener pasture?

Thailand. It's not for everybody. But you can get world class medical care at a fraction of the price here.

The end result of the "Affordable" "Care" Act for myself and many others is that we pay more for lesser insurance. So we do pay "almost anything," then sudden medical events can, if not bankrupt us, still cost a pretty penny thanks to the high deductibles.

How high is your deductible? I think the highest I've seen is $5k, which is nothing to sneeze at, but also not really in the realm of bankrupting most families.

The plan I have currently has a $6k deductible for my family, for in-network care - $10k outside of network. This would not bankrupt us currently, no, but it would have as recently as a few months ago, and almost all other times in my life.

I thought that the vast majority of healthcare providers are amenable to payment plans and other forms of assistance.

Definitely, they'd much rather collect late or partially than have you try to evade collection or declare bankruptcy.
However, your room for negotiation is much smaller when you're paying a huge insurance deductible than if you're completely uninsured. Hospitals charge outrageous prices for the uninsured, partly so they have room to make a profit when insurance companies negotiate down, partly to make up for the fact that a lot of uninsured people will never pay, and partly because some people will pay it so they might as well try.
If you're insured with a high deductible, the insurance company has already negotiated prices down by an order of magnitude. Any further negotiation with your deductible starts to really hurt their bottom line, and might run into problems with their arrangement with the insurance company too.
I have to imagine that a payment plan could be arranged without too much difficulty, but actually reducing the total amount could be challenging.

I had an emergency appendectomy done in a little rinky-dink Quebec hospital. I was driven in an ambulance 150 miles, had general anesthesia, scope surgery, and an overnight stay in the hospital. Had to pay out-of-pocket for the procedure in cash. It was, all told, less expensive than the half-hour echocardiogram I had a couple years ago. Similar surgeries in the States have cost my insurance north of twenty grand.
It's insane.

> Similar surgeries in the States have cost my insurance north of twenty grand.
I'm assuming you're referring to the amount your insurance company had to pay, not the amount that you had to pay. If so, keep in mind that the prices insurance companies pay for procedures are not designed to make sense on an individual level[0].
I've explained this in more detail on previous comments, but basically, hospitals lose money on publicly-insured patients (Medicare/Medicaid), and so they have to make up the difference by overcharging private insurers. This is why the sticker price for procedures is so heavily inflated - they're intended to be the starting point for negotiation, and the insurers then negotiate standard rates (still inflated, but less so) for in-network providers.
In other words, the amount that your insurer had to pay for your ECG includes an amortization of the amount of excess cost that your insurer bears in order to (effectively) subsidize the patients on public insurance.
In theory, this should not affect your out-of-pocket costs (though of course, in the end, it all does come out of patients fixed monthly premiums, so you still are paying for it in some way).
Yes, this is unnecessarily complicated, but that's the way billing works.
[0] That is not to say that the amount that the insured patients pay for procedures shouldn't make sense on an individual level - just the amount that the insurer pays on top.

I still had to pay my $2500 deductible on the $2600 ECG, so the insurance company didn't worry about haggling them too much.
If you're young, relatively healthy, non-clumsy, male, and childless, chances are you might not go to the doctor once in a year, so it'd be a gamble, but you might very well statistically be better off pocketing the insurance premiums.
Better yet, put on a furry suit, bark convincingly, and go to a vet if you need some common medications or procedures that are mind-bogglingly expensive when prescribed for humans.

$2600 for an ECG is a ridiculous sum.
Out of curiosity, I checked how much my insurance pays a doctor for an ECG (I live in Austria). My insurance (SVAGW) pays 36€ for an ECG. Of course, the total bill would be a bit more since the doctor would likely also charge for consultation (33€), draw blood, order lab diagnostics (6€) etc. The total would probably be well under 200€.

You are lucky that you are in Austria and can check prices somewhere. In US It is really hard to get prices for any medical services (including serious and expensive surgeries) before they are scheduled or you already received them.
My friend had a C-section during the delivery, hospital billed insurance 40K. She paid her deductible. C-section just like many other procedures are not planned and doctors are making decision on-fly during the delivery and obviously you do not have enough time to discuss pricing or negotiate them. So normally in this kind of cases you see the price 1st time in the bill, when you get it in your mail in couple weeks after the fact.

They don't, which is why they won't pay for them...

That's because, at least in part, the costs in Canada and much of Western Europe are paid for indirectly through other taxes.

No, I factored taxes into my calculation. I am aware that "free" healthcare is not "free" unless you do not pay tax.

According to this [1] which is fairly consistent with other things I've read, US costs are maybe 25% higher than in Canada. What that means is debatable in the context of waiting times, etc.
[1] https://en.wikipedia.org/wiki/Comparison_of_the_healthcare_s...

Looks like it's almost double in the US:
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
Anecdotally, waiting to see a regular old doctor was faster in Italy than in the US. Some specialist visits involved longer waiting times in Italy. Going private in Italy was generally both fast and cheap: something like 100 euro for a chest X-ray done the next day.
Canada's health care system is good, I guess, but it's generally not ranked quite as highly as places like France and Italy, IIRC. More comparisons tend to be made with Canada and the UK because of the common language.

My understanding is that the Canadian system is a step above the US system but not otherwise that great on a global scale. This is pretty much Canada's national motto.

The US government was spending 25% more on healthcare, pre-ACA, and with less comprehensive healthcare than Canada. Actual healthcare cost overall (on average) is roughly double for all of the year's listed in the chart.

We don't.

In the macroeconomic figures Canada is reported to spend 10% of GDP[1] or about 4300 USD per capita on healthcare vs your 1524 USD/year[2]. There's two thirds missing right there, and if you are one of the higher payers (average includes kids, pensioners, students, unemployed/disabled etc), there's an even bigger gap. What explains it?
[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea... [2] 178 CAD -> 127 USD, times 12 - ok this is missing the PPP correction because [1] GDP is PPP corrected, so might be a little off

we don't. It is akin to a mafiosi stopping by every month asking for his "protection" money in case a terrorist group will take you hostage and ransack your place. In all other "normal" cases where you need security that said mafiosi says you have to pay for it yourself. The ACA proponent gladly accepts this outrageous proposition.

AIUI, your mafiosi are also obliged to protect you if you are a veteran, when you get old and when you have an emergency, and this makes regular protection much more expensive for you unless he gets protection money from everyone.

Health insurance is expensive because health insurance companies love money.

Also a dark calculation in these people who won't carry (even catastrophic) coverage.
If I get a major disease and a half million or million dollar medical bill, I'm not going to pay it anyway.

> It's a terrible feedback loop, one which the IRS penalties were designed to solve.
But it shouldn't be surprising that the IRS penalties (in current form) could not solve this. This eventuality was predicted before the law was passed in the Senate (e.g., [0]). It seems fairly obvious that this would happen unless fines are somehow pegged to the cheapest insurance rates (as dpweb notes in this same HN story[1]).
[0] https://reason.com/blog/2009/11/06/higher-premiums-less-cove...
[1] https://news.ycombinator.com/user?id=dpweb

Wouldn't the problem with that be, insurance companies would have an incentive to raise prices as high as they can, knowing that the public would basically be required by law to pay them (or an equivalent penalty)?
That incentive sounds pretty terrible for the public. Great for insurance companies though.

> Wouldn't the problem with that be, insurance companies would have an incentive to raise prices as high as they can, knowing that the public would basically be required by law to pay them (or an equivalent penalty)?
The public is already required by law to pay the insurance companies. But with a fixed, lower fine, I suppose there's a "laffner curve", where insurance companies can't raise their prices too much or enough people will opt for the IRS penalty that the insurance market would stop having enough buy-in.

https://www.healthcare.gov/health-care-law-protections/rate-...
Insurers are now limited to making 20% profit maximum under ACA to prevent pathological scenarios like that. Will there be a reduction in "innovation"? Maybe, but how much innovation do you need from a payment scheme? In any case, the game now is to increase their subscriber base by stealing from competitors or the uninsured, both likely to result in benefits to consumers.
I found this site helpful too:
http://obamacarefacts.com/obamacare-control-costs/

"If only the plan worked as intended! We were close!" -- the same refrain after every single failed socialist endeavor.
But in this case we had the smartest people study the problem! Economists from the top universities designed the incentives! How could it fail?

Has it failed? It definitely sounds imperfect, unsurprisingly, but to me it sounds better than the prior situation.

I'd have no problem with an actually centralized single-payer plan.
However, the ACA is shoehorning private, for-profit insurance companies into the middle of this, all the while constraining them and driving everybody's costs up by approximately 3x to most observations I've seen of myself and others.
To properly implement a government health care system would be to effectively destroy most if not all the for-profit insurance companies* and set up a system with a mandate for national health. Nobody's going to want to do that, politically.
* = Having a central system covering a lot of the basics, and insurance companies to provide "upsell" coverage could still exist, but those insurance companies would likely not be in the same ballpark of financial movement as they are today.

The plans have been a disaster. They got rid of the only plan that makes sense for young people: Catastrophic insurance (deductible of over $10,000).
The plans that remain have high enough deductibles to be worthless, but low enough to be expensive. The plans helps almost nobody. The only people who gain value from the exchanges are those who get a subsidy.
To make things worse insurance companies are pulling out in droves, and prices are expected to go up 40% year to year.
Things are not looking good.

> The plans have been a disaster. They got rid of the only plan that makes sense for young people: Catastrophic insurance (deductible of over $10,000).
Don't forget, that was by design. The law needs young, healthy people to put money into the system to support the expenses insurance companies would encounter due to the increased coverage for less healthy people.

I am okay with paying more to cover others who can't afford it. What I'm not okay with is losing my plan, my doctor, and my benefits, all while paying more.

When you think about it, the two are really the same thing. A lot of people (some 15 million) got coverage, and they're not paying for it, you are.

They didn't get rid of catastrophic plans, they just made them completely unusable. You need a hardship exemption and be < 30 to qualify for one, but they aren't eligible for subsidies.

To me as someone living in the UK, this is bizarre. Why would you need an deductables at all for it not to be expensive? This in itself indicates that your entire healthcare sector is entirely dysfunctional.
In 2013/2014, the UK National Health Service spent $2928/year per person.
This is the average, and includes everything from the costs of births to the costs of expensive heart transplants or cancer treatments. General practitioners. Specialists. Hospitals. Ambulance services. Subsidized prescriptions (in England there are prescription charges of 7 pounds per prescription; in Scotland and Wales prescriptions are covered by the devolved governments).
Since I moved here 15 years ago, I've been to A&E (accompanying my ex) and hospitals (same) several times; I've had a son; I've been to the doctors many times. The care has been excellent, and fast. We've never had to fill in a single form that is not purely medically motivated. Never had to take out my wallet other than the occasional few coins for a prescriptions (I'm Norwegian, and while Norway also has an excellent socialized healthcare system, being able to just walk straight out without going to reception to pay after seeing the doctor was a novelty to me too - things like general doctors visits carry a low co-pay in Norway). Best spent $2928 I could make.
Where is all this money going in the US? Surely someone, somewhere is making ridiculous profits that must have investors drooling and looking for contenders.
The US welfare system, or lack of one, is one of the reasons I'd never consider moving to the US. It seems so totally barbaric and arbitrary.

People have written about this before, but basically the US subsidizes medical expenses for the entire world.
That was able to happen because, unlike virtually anywhere else in the world, medical insurance in the US is private.
If the US changes that (which will never happen) I would expect medical costs to go up everywhere else to compensate, either that or research slows down.
One thing that might, might, help is forbidding medical companies from advertising at all, that might save some money. But the law of unintended consequences tells me it would have other effects that might not be so great.

Do you have any sources for this based on actual data?

It's true that the US has historically been a leader in medical research, but that largely comes from the federal government through the NIH ($32 billion in 2016.)

> US pharma companies like Pfizer gets more than 50% of their revenue from foreign markets.
To be fair, this statement doesn't really tell us anything. Pfizer's foreign market profit might be 2% of sale price, and their US profit 98% of sale price. So despite that figure, the majority of their R&D investment might still come from sales in the US.

That's massively exaggerated.
US industry accounts for ~60% of US medical research. The rest is NIH, donations etc.
US pharma companies like Pfizer gets more than 50% of their revenue from foreign markets. Thus if we split research contributions by region, only about 30% of US medical research is likely to come from US healthcare expenses.
Even if you took away all of that funding you still wouldn't account for the cost differences.
But that's not the whole story: US sales costs are substantially higher, as in many non-US markets you can't legally advertise, so the net contribution of US healthcare funds to US medical research is likely less,
It may still be true that the US pays more per capita for to medical research than most, but it simply doesn't make up all that large a proportion of overall medical research.

You've had a good experience, many others haven't. I personally had two family members die from NHS incompetence, and no compensation. There are horror stories like mine every day. I'd much rather have the US system, with all its flaws.

Can you elaborate? two deaths in the same family for negligence with no recourse to get compensation sounds sounds wrong.

My mother's second husband's stomach trouble was misdiagnosed. Because of the long waiting times to see a specialist, the cancer was too far gone by the time they found out what it was, and he died when he was 50. My wife's sister was taken to hospital with a gallbladder infection. Despite being extremely weak, the staff let her walk and she fell. She broke her pelvis, but they missed it. Despite being in severe pain and being very weak that they let her walk again, and she fell again and her condition deteriorated. She died a few days later, aged 36. Their incompetence killed her. The case was referred to the Ombudsman and the family got an apology, but no compensation for their mistakes. I do understand that horror stories also occur in the U.S. but the faster time to treatment, and better testing, would have saved my mother's husband, and the fear of lawsuits would have saved my wife's sister. As I said above, there are horror stories like these in the newspapers every day. Many, many more cases like ours are simply not reported.

> but no compensation for their mistakes.
You sue to get compensation.

You can sue them but it is a long process and you won't get U.S.-style amounts for payouts. That's if you can get that far. The staff cover for each other and use processes like the Ombudsman to delay and obfuscate. Also, the UK is not a litigious culture and my mother and other family members simply didn't want to go through more trouble.

You can't complain about not getting compensation if you didn't go through the process that would get you compensation.

Jut out of interest, do you know anyone who has claimed, and won, any decent amount of damages from the NHS?

I'm against Obamacare, but if I was for it, I would peg the penalties at 2x the avg basic exchange coverage price.
Also, people with high deductibles should make sure you take advantage of tax benefits, HSA for instance. The $6000 deductible may really only be a $4800 deductible once you figure in the tax deduction. If you're talking Obamacare coverage being 20% higher than the penality (I'm assuming the penalty is not tax deductible) that may end up being a wash and you're better off with the coverage.
Now consider the guy paying the $1800 penalty instead of the $2900 coverage. The coverage being effectively $2175 (considering a 25% tax break). He pays $1800 for nothing instead of $2175. Passing up $375 coverage. Again, Obamacare - pretty much a debacle as far as costs - but that guy maybe not be the wisest choice.

My current plan has an has an HSA component but the company that administrates the account, BenefitWallet, has some fine print in the account agreement that they charge an account fee for balances less than several thousand dollars. Realistically I only spend several hundred dollars per year on healthcare stuff so I don't think it is to my advantage to lock up that much money in a non-interest bearing account or pay the bank 120 bucks per year.

You are not required to use the HSA provider that your insurer/employer is tied to. You can pick and contribute to your own HSA account elsewhere, with one caveat. Your contributions are deductible from federal and most state taxes, but are only deductible from payroll taxes (social security/medicare) if the HSA contribution is deducted from your paycheck by your employer (and thus deposited in their preferred HSA provider).

Yeah, in my case it isn't though my employer either so there is another reason to avoid it.

I called the bank and they stopped charging me their HSA monthly fee, and credited back the past months fees - FYI.
I won't say which bank it was, but it rhymes with Smells Smargo!

I opened an HSA with my credit union (First Tech Federal). It has no monthly fees and even pays 1% interest, which is tax free as well.

One advantage to consider is that there is no time limit on when you spend the money. As you age, your health care costs will rise. How much interest are you really making on $5000 in today's environment? $50? $100?
Meanwhile, you save your marginal tax rate on any dollars contributed towards future medical expenses. That's a pretty good return on your money. $5000 at 28% marginal rate knocks $1400 off your tax bill.

~7% ($350)

I'm pretty sure that with HSAs you're not tied to a particular administrator. I think that you can get one from any administrator you want. If it's through an employer then they might only do direct paycheck deposits to a particular administrator, but you're able to opt-out of that and do the deposit yourself.
Don't listen to me though, I could be wrong, but it's worth looking into if you're considering an HSA.

As others have said, I think you can use another company. Also, some companies will allow you to invest any money above a certain balance. In my HSA, I can invest anything about $2000 (or maybe $2500?) into a number of different mutual funds. That plus tax benefits plus tax free growth is a pretty good deal.

Just contact your bank and open an HSA account with them - they'll fall all over themselves to help you do it.
It will be interest bearing and you can tie it to bill-pay and issue mailed checks directly out of it. It's great.
Also, you can leave unused HSA funds in the account and let them grow, tax free, for future medical needs.[1]
[1] https://www.irahelp.com/slottreport/how-you-can-utilize-hsa-...

Look for a HSA that is backed by a money market account. If you are young and healthy then a HSA based plan makes sense as you can put money away until you needed it. Better than paying premiums you never use. If you start paying it at 20 then you are looking at decent amount later in life assuming the stock market delivers.
If you have ongoing healthcare costs then the math becomes a wash and usually sticking with a PPO type plan is the way to go.
Looking longer term I can see the HSA becoming the norm and employers will pay into that rather than offering insurance plans. At this point the exchanges should become competitive enough to drive costs down if everything happens through the exchange.

It seems like you're saying you can write off any medical expenses which doesn't seem to be true according to the internet
> The IRS allows you to deduct qualified medical expenses that exceed 10% of your adjusted gross income for the year.

> It seems like you're saying you can write off any medical expenses which doesn't seem to be true according to the internet
He's referring to an HSA, which comes with triple tax advantages (contribute pre-tax, pay no tax on gains, and pay no tax on usage).

In Australia the penalty is 1% of your income (or more) https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-le...
This makes it a no-brainer for anyone earning over ~$90k to get health insurance (as it's cheaper than not having it).
Yet it doesn't force low income earners into having private health insurance: they fall through to the safety net of the public healthcare system.
It's not a perfect solution; but it's perhaps slightly better than what the USA has at the moment?

> perhaps slightly better than what the USA has at the moment?
Pretty much anything would be. Health care in Italy was better than in the US, and that's saying something - Italy is a nice place, but not always run that well.
A more market-based system might be better too as at least for some things there might be some downward pressure on prices.
The current system (including pre-Obamacare in that as well) just sucks.

When the WHO ranked the world's health care systems in 2000, Italy was actually the second best in the world: https://en.wikipedia.org/wiki/World_Health_Organization_rank...
That was 16 years ago, yes, but the country wasn't run any better than it is now.

Random personal anecdote. When I was a teenager, my family took a trip to Europe. This was summer of 1999, IIRC. Anyways, near the end of the trip, when we were in Italy, my dad came down with a cough and sore throat. Rather than try to gut it out for another week and then have to fly back to the US sick, we decided to try to find a doctor.
After consulting with the front desk at our hotel, we were directed to a small clinic a few blocks away. Being that it was evening, we were surprised they were open and even more surprised to be seen reasonably quickly (it was less than an hour, less than I usually wait at a clinic here in the US).
We were seen by a doctor who conducted the very typical medical exam. We mimed our way through it, and a prescription for an antibiotic was doled out. When we went to pay, we were waved away. "No money" they said, in broken English. They also gave us simple directions to a nearby pharmacy where we could get the prescription filled.
We walked over to the pharmacy, presented the pharmacist with the prescription. After waiting a few minutes, he came back with the pills. There was a cost for this, but I remember it being very cheap. Like a couple euro.
The whole thing, from start to finish, was less than 3 hours and only cost us whatever the antibiotics cost. Frankly, our biggest problem with the whole experience was the language barrier. Dad knew some French and I knew extremely basic Spanish and could puzzle out most things given enough time, but nowhere near close enough for a complex interaction such as seeing a doctor in Italian.
Fast forward 17 years (this happened to me last week). I'm visiting family in Tennessee and come down with the same sore throat and cough.
First, I have to find a clinic that accepts my out-of-state insurance. Then, I have to get there when they open because experience with these things has taught me that if I'm not there when they open I'm waiting a few hours. Fill out the 5 pages of forms. Pay a $30 co-pay before I even go back to see a doctor. And then STILL wait 2 hours to be seen. After the same cursory exam, the same prescription for antibiotics is doled out.
Walk down the road to the pharmacy and get it filled, waiting 45 minutes. Another $10. The whole thing from start to finish was probably 4 hours and cost me $40 out of pocket. No idea how much they billed my insurance yet.
The experience we had in Italy made a big impression on me. Even as a 17 year old, I walked away from that experience wondering why our system in the US is so broken. Surely we can do better.

When I first started reading about American health care being a foreigner I saw a persistent argument that in single-payer system "people will die in lines". Yet here in the United States the lines in medical institutions are greater than anything I've seen abroad, open slot for appointment with a doctor in one month is a usual deal.
And why can't I buy antibiotics without a prescription. Don't I have a right to heal myself?

> When I first started reading about American health care being a foreigner I saw a persistent argument that in single-payer system "people will die in lines".
This is one of the reasons I really wish international travel was within the reach of more Americans. So more people could observe and experience these other systems - not having to be told about them secondhand by commentators with their own agendas. Not just healthcare, either. Just knowing a bit about how other people live their lives and how things work in other countries is enormously enlightening.
That trip to Europe was one of the most pivotal experiences of my life so far. I learned so much about the rest of the world that coming back to the US after spending a few weeks overseas, everything looked completely different to me. It ignited a lifelong love of travel - one that I hope to share with my daughter as soon as she's old enough to accompany us.
> Yet here in the United States the lines in medical institutions are greater than anything I've seen abroad, open slot for appointment with a doctor in one month is a usual deal.
I live in a mid-sized city. If I need to see a routine general practice doctor for a typical problem (coughs, etc.) I can usually be seen the same day, but I'll probably have to wait a 2-4 hours depending on when I go.
But if I need to see a specialist (allergist, dermatologist, sleep doctor, etc) and it's not a life-or-death emergency, it's usually a 6-week wait for an opening. My only other option is to drive 2 hours away to the next (bigger) city that has a medical school and a large concentration of doctors. Sometimes you can get an appointment in a few days if you're willing to drive.
> And why can't I buy antibiotics without a prescription. Don't I have a right to heal myself?
As someone who suffers from recurrent throat infections at least once a year, YES. Some people in the survivalist and "prepper" communities say you can take "fish antibiotics" but I've never been willing to risk my health over stuff I read on the Internet from questionable sources.

> Some people in the survivalist and "prepper" communities say you can take "fish antibiotics"
This and food supplements, little-known or mostly unregulated chemicals, you can buy them online on your own. But as long as chemical is scientifically proven to help you, then nope, you need someone else's approval.
Fish antibiotics' makers surely provide some info (bare minimum "not for human consumption"), so they are covered if people poison themselves. Human antibiotics provide comprehensive usage directions yet it is insufficient.

And why can't I buy antibiotics without a prescription. Don't I have a right to heal myself?
Misuse and overuse of antibiotics is a huge global problem. Common bacteria are developing resistance, and the reason is the overexposure to antibiotics due to agricultural and medical overuse. If things continue like this, soon we'll have people dying of tuberculosis again in developed countries.
If people can buy antibiotics without a prescription, they tend to take short treatments for random flu-related symptoms. This is doubly bad: the antibiotic doesn't do anything against the viral infection, and unrelated bacteria will be exposed to a weak antibiotic and be able to develop resistance.

This is a good point, but isn't it the agriculture which mainly drives the overexposure? Even if it isn't I doubt that this is a reason why antibiotics are prescription-only. Almost every other group of pharmaceuticals in the US is also restricted.

from TFA:
> For 2016 and beyond, the penalty will be $695 per adult or 2.5 percent of household income, up from $325 per adult or 2 percent of household income last year.
The difference is that health care costs in the US are nonsensical. So high that it's really hard for the penalty to be less than the cost of insurance, until you have a six-figure income. If you make low-six-figures, you very likely get good health insurance through your employer (which ends up being priced much more reasonably because the group includes mostly healthy people).

Ah, I missed that bit.
I guess the difference is in the cost of healthcare then. Also we don't have health insurance via employers.

Inevitable result of thinking that adding even more government intervention would result in better, cheaper plans.
If they were really interested in making better, cheaper plans, they would roll back most of the ACA, eliminate the restrictions on buying across state lines (actually allow competition), and transfer the tax incentives for getting insurance from employers to employees.
Basically, all they had to do to make healthcare more affordable was to open up the Federal employees plan to everyone and transfer the tax incentives to employees. This was actually proposed by both major parties prior. It would have been about a 10 page bill.

>Inevitable result of thinking that adding even more government intervention would result in better, cheaper plans.
and
>open up the Federal employees plan to everyone and transfer the tax incentives to employees.
Seem somewhat in contradiction. I'd go with the first being the incorrect part.

The Federal plan operates like a big market. Each year, you can change between plans from a menu of hundreds of plans. You can also see other people's reviews of those plans. Over time, plans that can't compete drop out. Other plans get better and service gets better in order to compete.
Prior to the ACA, health insurance was heavily regulated. You could not buy across state lines. You could only buy (affordably) within the plans offered by your employer. Individuals oftentimes couldn't even buy plans (for any amount) that were offered to groups. With the ACA, this is even worse, but that's beside the point.
Creating a single market with the Federal plan would have removed tons of anticompetitive regulation and enabled anyone, regardless of who they worked for or self employed or whatever, to buy a plan from that single market.
Moving the tax incentive to people instead of corporations would have allowed people to pay for those plans with pre tax dollars.

It's a little offtopic, but this reminds me of Lessig's "the corrupting influence of money is the first problem facing this nation. That unless we solve this problem, we won’t solve anything else."
In my opinion the public option wouldn't have cost us much as a nation on the whole, and could have possibly worked out to great advantage, but was not going to happen because health insurance companies are too powerful for that sort of thing to get through.

> In my opinion the public option wouldn't have cost us much as a nation on the whole, and could have possibly worked out to great advantage, but was not going to happen because health insurance companies are too powerful for that sort of thing to get through.
The only public option that would have gone through would have been one that the insurance companies blessed, whereby there were the mediators of all the payments. Which is basically what we got.
If you solve the money problem you can solve a lot of problems, but until you solve the money problem few or none of the rest of these problems will get solved.

> In my opinion the public option wouldn't have cost us much ...
If you look at the margins the insurers are using (the maximum a public option might be cheaper), they're not much. 10% is rare. Given government inefficiency, I'd expect a public option to have been at least as expensive, and probably more expensive.
So why would a public option be cheaper ?

It varies significantly by state, but existing public options are similarly priced or cheaper in terms of cost per person than private healthcare.
https://www.cms.gov/research-statistics-data-and-systems/sta...

Where in the link does it say that?

Not the clearest source, I'll admit.
These are better, and show Medicaid spending roughly $5000/enrollee vs. roughly $8000 per capita overall healthcare spending in the USA in 2011 :
http://kff.org/global-indicator/health-expenditure-per-capit... http://kff.org/medicaid/state-indicator/medicaid-spending-pe... http://data.worldbank.org/indicator/SH.XPD.PCAP

The experience with credit card deregulation should put the lie to the idea that selling across state lines results in meaningful competition and better products.
After the Supreme Court ruled that credit cards could be issued across state lines, the issuers migrated to states with the weakest consumer protections. As expected, this was followed by a series of abuses: credit card issuers would raise rates without warning, hiked late and overlimit fees, and buried key information in fine print to obscure the true cost.
It fell to the federal government to impose stronger consumer protections, via the CARD Act.
Much of the ACA was concerned with strengthening consumer protections by ending policies like rescission, lifetime limits, or denial for pre-existing conditions. If we were to repeal the ACA and allow selling across state lines, we should expect the re-introduction of these policies and worse.

The Federal plan banned those things long ago and yet still created a functional market that helped contain costs and boost quality. It still does today. Only, just for Federal employees and Congresscritters.
The real issue is the ACA is a solution from 60 years ago that doesn't meet the problems we have today and has actually made a bad situation worse.

> eliminate the restrictions on buying across state lines
What's the law that prevents that? (honestly wondering)
> It would have been about a 10 page bill. It would never pass in the current gov't.

There's nothing that prevents companies from selling insurance along state lines - as long as they comply with the insurance regulations of every state they want to sell in.
See: http://theincidentaleconomist.com/wordpress/meme-busting-sel...
"Selling insurance across state lines" is a misleading way of saying that companies should be allowed to sell in a state without complying with that state's regulations, just the regulations of their home state. Given the example of how this played out in other markets (e.g. credit cards), a more accurate summary would be "remove state-level insurance regulation".

I'm glad someone changed the original title to "health insurance" rather than "health care". Using the two terms interchangeably has to be one of the biggest reasons why we get the shitty system we get for the amount we pay per year.

Every time I see one of these articles (or anything related to US healthcare) and read the comments, I can't help but ask myself how rotten a country can be. In this case, as a German, I dare say "rotten to the core".
It apparently is impossible to move the US healthcare system to a system where every person in the US is eligible to even the most expensive emergency healthcare without having to fear bankruptcy afterwards, and that's shocking.

Yeah, the vast majority of us have healthcare, aren't really sick, and occasionally when we do get really sick, our insurance pays the bills.
I had an emergency root canal earlier last year in the US, cost me zero dollars, and I've got one of those high-deductible plans (it's the HSA that covered that).
I'm actually a little surprised you (or anyone on HN) are so eager to jump at the "worst case" stories and presume they're normal. This is a data problem, not a "let's tell our horror stories" kind of problem. Every system has people who fall through the cracks, these half-baked "I'd just do X" without any research is exactly the kind of thinking that causes problems.

> I'm actually a little surprised you (or anyone on HN) is so eager to jump at the "worst case" stories and presume they're normal.
These "worst case" stories should not happen at all in any civilized country! One of them is one too much.

I suspect "worst case" may be a euphemism for "poor people".

Every country has people who fall through the cracks. It's noble and true to say this shouldn't happen, but it does, and in every country.
Germany, too.

> Germany, too.
Yes, it's mostly either illegal immigrants or self-employed one man companies, and I don't like that either... but even if you're not insured, you'll be taken care of in a hospital in emergency cases and not be stuck with a 500k+ bill...

I have health care through the exchange and it drives me crazy that I pay $300+ monthly and if I have to see a doctor I still have to cover the expense myself because I have to spend several thousand dollars out of pocket before my insurance begins to cover anything. It seems to me that ~$4,000 annually is a lot to pay for what is effectively disaster insurance. But if I don't pay it not only do I pay a fee but I run the risk that if anything truly horrible happened I would be bankrupt.
Health care in the US remains a disaster if you are not covered by your employer (I'm a contractor and thus not covered by any employer).

My employer is a big group of people and has the power to bargain with the health insurance companies. I think there are groups you can join that provide the same advantage.
But what you might not understand (and I'm about to sound like a big jerk) is the idea that maybe the system that works best for the country might not work the best for you specifically. That doesn't make the entire system a disaster.
There's perspective here that might not make you healthy, but it would at least provide a modicum of understanding.

HN devolves into non-scientific anecdote city whenever politics are discussed on this site and everyone goes from analytical to happily biased at the drop of a hat.
I wouldn't take any one off experiences here as anything other than that; isolated incidents which most likely don't represent the overall picture.

Don't you contribute your own money to the HSA? I know there are some tax advantages, but it seems a little disingenuous to call that $0.

Some employers (such as mine) offer only high deductible plans, but one of the options is for them to deposit an amount directly into your HSA. This has the benefit of returning purchasing power for most low costs to the competitive capitalist system while maintaining coverage for disasters.

My employer does that "for me", though I suppose you could in a way consider that to be my money (they'd pay it to me if they didn't have to put it in my HSA). It is tax-free, though.

> Yeah, the vast majority of us have healthcare, aren't really sick, and occasionally when we do get really sick, our insurance pays the bills.
That's the case in most modern countries. As far as data is concerned, the U.S. performs poorly in many metrics. The risk to individuals in the system compared to other nations is atrocious. The per-capita cost is atrocious. And the actual health outcomes are not spectacular.
I'm biased. As a Canadian I enjoy single-payer universal coverage and the freedom of not having to worry about private insurers and deductibles and copays and premiums and whether or not my doctor or hospital is covered or whether or not my insurer is going to fight me on something when my kid breaks his arm or what the health coverage implications will be if I switch jobs or start a business is totally worth the problems you tend to find in universal systems, in my opinion!

If the difference between Canada and the US were merely their healthcare systems, I'd be utterly indignant and demand change from my government.

This is unfortunate. Health problems are unpredictable and very expensive, in my experience.
I was grateful for ACA (unsubsidized) in 2015 in spite of being on a bronze plan with a high deductible. Why? Because even though I was generally paying for care out of pocket due to my high deductible, the insurance company had negotiated much lower rates for this care than what the providers wanted to charge me. I guess I could have dealt with the 10+ providers and negotiated lower cash prices myself but I have a day job. In my estimation, the negotiated rates saved me $3k compared to the billed rates.
People I know minimized the dent to their financial health as a result of it of ACA as well. Life and health is unpredictable and one can be hale and hearty one day and hospitalized in the ER the next. The thought of being without health insurance and allowing one's meager savings to be wiped out as a result is an outcome that sends chills down my spine.
I hope I don't come across as shilling but I am grateful for the ACA. It is not perfect but just like democracy, it is the best that this country has been able to scrape up after 200+ years of SOL-care.

I work with someone who has health insurance from the California exchange. His assigned doctor is about a 2 hour drive away. Maybe he has picked the cheapest plan but such a situation shouldn't really happen if this was well run.

_Assigned_ doctor?
Did he get put in an HMO? If he got a PPO plan, there shouldn't be a doctor assignment, right?
It could be that the only doctor he was able to find that could take his PPO plan is 2 hours away.

He had to choose a doctor, so I believe it is an HMO. He picked the closest one in Newport Beach but he lives in San Diego.

There's problems. We need health care for people though. Obama original plan was fine.
The republicans started in with the death squads, and the scare tatics. We ended up with a system that Insurance companies exploited.
I am waiting for someone to fix it, or offer a better solution. I have heard of nothing. Nothing feasible.
See--if I get sick I go to a doctor's office, or hospital. It might be the only industry that isn't required to offer a bill in advance? Doctors, and insurance companies can charge whatever they like, or at least that's been my experience.
I gave given this a lot of thought. I don't have an answer. My only plan would be to make medical bills bankruptable--for any amount, and at any time. There would be no ten year waiting. It's not feasible because it would clog up federal courts, unless we stream line the process. Made a medical related bankruptcy so easy you could send it in on a post card. I don't want to lose my shack because I get sick. Even now, people are losing their homes in municipal court because they got sick, and didn't have the ability to pay the outrageous bill. Hospital lawyers try to keep it quiet, but they sue.
A friend's wife is recovering from stage three cancer. I don't know the type, or wanted to ask. They were in Switzerland, and she got very sick. When they got hone they were expecting a huge bill--the insurance company would balk at. It was completely covered by the Swiss government. What a country?
We need a reform. We don't need a Blowhard in office who will make things worse?

FWIW as of 2015 California requires there be "primary care network providers with sufficient capacity to accept covered persons within 30 minutes or 15 miles of each covered person's residence or workplace", specialists within 60 minutes or 30 miles, and that there be sufficient capacity for doctors within those limits to accept new patients[1].
Getting that enforced isn't easy, but that situation not only shouldn't happen but should also be grounds for regulatory action against the insurer.
[1] http://www.insurance.ca.gov/0400-news/0100-press-releases/20...

Getting that enforced isn't easy
How is that even possible? How does the state mandate that some random provider step in and subsidize higher payments to providers in order to encourage them to take on more new patients?

By preventing them from selling their insurance on the state-run exchange if they don't meet the standards.

OK, name one case where that has actually happened -- where the state has successfully coerced a doctor to accept new patients at a loss or a provider to overpay to make such a doctor/group choose to accept new patients.
There is a good article on this problem (many doctors not accepting new patients, leaving regions without care except for ERs) on the front page of the 5/18/15 San Jose Mercury News.

> OK, name one case where that has actually happened -- where the state has successfully coerced a doctor to accept new patients at a loss or a provider to overpay to make such a doctor/group choose to accept new patients
It has nothing to do with coercing doctors. Why would it? If a insurance network can't meet its obligations it will be fined or shut down. If an insurer has to pay more money to a doctor in some area to meet its obligations it will then have to (though undoubtedly that will be eventually passed on to its customers).
Meanwhile it's an agonizingly slow process to get justice for the people that need it, but insurance companies forced to refund money for not meeting their network coverage requirements is in the news right now, specifically because "more than 25% of physicians listed by Anthem and Blue Shield weren't taking patients in the Covered California health exchange or were no longer at the location listed by the companies, according to the state's investigation."
http://www.latimes.com/business/healthcare/la-fi-obamacare-n...

That article talks about fines for overstating their networks -- stating in marketing materials that they had more participating doctor availability in given region(s) than they actually had availability for all policies offered. False advertising, in a sense.
That is very different from the problem statement: how do you make a network offer inducements at a loss to recruit additional providers?
I'd guess that most people buying off CoveredCA.org don't even bother to look at participating providers accepting new patients before buying a policy. There is no element of law that says to an underwriter, "Hey, you gotta add more providers in this area and that area now, or we will punish you." The law doesn't give government that power.

> That article talks about fines for overstating their networks -- stating in marketing materials that they had more participating doctor availability in given region(s) than they actually had availability for all policies offered. False advertising, in a sense.
They weren't falsely bragging about numbers in marketing materials, they were listing specific doctors at specific addresses in their tools for finding in-network doctors that were not in their network or were not at that address. Different from geographic density but related.
> That is very different from the problem statement: how do you make a network offer inducements at a loss to recruit additional providers?
It's really not complicated: by saying they can't operate in a certain area without a sufficient network. They either recruit more doctors or they pack up.
Perhaps you're missing that insurance companies in California don't usually operate statewide? I assume this is common across the country. The key is that care has to be available near your house or workplace. When applying for insurance you are specifically offered companies that have coverage in those areas (often at the county or city level of granularity).
You can't sign up for an insurance policy at the other end of the state from a company's network of doctors and expect them to sign up doctors around you, because, again, if they don't have sufficient density of doctors where you are, they don't cover people there in the first place.
> There is no element of law that says to an underwriter, "Hey, you gotta add more providers in this area and that area now, or we will punish you." The law doesn't give government that power.
Yes, it really really does.

If a insurance network can't meet its obligations it will be fined or shut down
What are you claiming its obligations are? Its obligations are to pay valid claims made by covered parties. It does not have a legal obligation to add provider capacity to a given region.

> Its obligations are to pay valid claims made by covered parties
No, its obligations are to operate legally within the state.
> What are you claiming its obligations are?
https://govt.westlaw.com/calregs/Browse/Home/California/Cali...
> It does not have a legal obligation to add provider capacity to a given region.
Correct. The other option is it could not operate in that given region at all.

The other option is it could (choose to) not operate in that given region at all
This was the choice taken by UnitedHealth, Aetna, Cigna, ...

Are you really asking how the state can regulate an insurance company? If a company can't meet network requirements it can't operate.

If you read the document in your link, you will see that that regulation expired last July.

That was just the emergency amendment. It's codified: https://govt.westlaw.com/calregs/Document/IE282722688B248DFA...

That's just another emergency amendment that expires in less than 3 weeks. Scroll to the bottom of your link.

At least in retrospect, this doesn't surprise me. If Kafka had been a 21st-century American, he probably would have written a novel about medical billing instead of The Trial. An incomprehensible cost structure represents, in some sense, infinite risk. Why wouldn't people be hesitant to engage?

I'm a Canadian. I'm curious to know what it would cost to match my level of coverage in the US.
1. Public medical care. Good care, normally easy to see a doctor. Excellent quality. Can use this as much as you need. 2. Occasional use of the parallel private billing system. Costs less than $300 Canadian to see a specialist. 3. Private coverage for paramedical claims (Physio, massage, drug plan, dental, vision, etc.). Pretty comprehensive. Costs about $100 Canadian a month.
I work for myself. Is it even possible to replicate such a plan without employer coverage? What would it cost?

I live in Arizona. My employer only offers high deductible health plans with a pre-tax health savings account. So, I pay ~350 USD per month for the plan to cover my wife and I. Then I also contribute to this health savings account, my employer kicks nothing in. For this, we get basic vision and dental completely covered. That is, routine checkups, cleanings, basic prescription eyewear. Everything is else is subject to a high deductible, ~10,000 USD. The insurance covers something like 20% of certain kinds of expenses until we hit the deductible, then it covers 80-100%, per year.
A few weeks ago I had an asthma attack and went to see a doctor. The office refused to tell me in advance what I would be charged, or even what my insurance would be charged. I ended up being charged $200 after insurance, and then an additional $100 for prescriptions.
Because I had not previously selected a primary care physician, it was difficult to see a doctor in a reasonable amount of time. The doctor I did find gave wrong instructions for one of the prescriptions, and forgot to call or even write down the other.

Should I take that to mean that there is no option to get equivalent insurance to what we have in Canada?

I think it depends on the state. We don't have a national healthcare system (disregarding a couple programs for the old or very poor). Obamacare laid down only the barest of national standards.

In California and a few other states Kaiser Permanente offers an integrated system. I signed up for it as it seemed the least complicated option.

I'm genuinely curious about this, particularly the "easy to see a doctor" part, because I know that quite a few Canadians travel to Thailand for non-emergency medical care mostly due to long wait times. That's according to a few statistics published by some of the private hospitals in Thailand. I've seen few outbound studies published by Canadian researchers, although here's one from last year [1]. From what I understand, out-of-pocket costs aren't that much difference between Thailand and Canada.
[1] http://www.ctvnews.ca/health/more-than-52-000-canadians-trav...

I think it varies a lot by jurisdiction, proximity to foreign centers, and type of procedure.
For instance, I live in Quebec. On the chart in the article, Quebec only had 6284 travelers, despite having a large population. Quebec's private medical system is more extensive than average, and I think you can buy more here than you can in some other provinces.
BC also has easier travel options to Asia. It would be quite a trip from Quebec, and possibly easier to buy locally.
Across the board, wait times tend to be long only for elective issues. I've generally had no trouble with them for and neither has my family.
Though some specialties seem worse off. For instance, if I needed a gastroenterologist in Montreal, I believe I'd have great difficulty finding one.
Also, in Montreal, much depends on your local hospital. Some have longer wait times than others, even within the same city. If someone doesn't know how to navigate that system, going abroad may seem simpler.

That makes sense, the variation by jurisdiction. It's kind of strange that a local person would find it simpler to go abroad than navigate the complicated workings of the local care system. Although it is pretty simple when you go to a medical tourism destination - you just get off the plane, taxi to the hospital, walk in and ask for sevice, and you get it.

What I want to know is, how much does it cost to provide that service to you? Not how much do you pay, but how much does it cost? If it's greater than $100 a month (how could it be less?), then someone is paying. What portion of Canada's budget is spent on the health system? Are you paying for your healthcare indirectly via taxes (in which case you're just unaware of the true cost) or is someone else paying (in which case you just won the redistribution game, congrats).
It still costs something to provide medical care. It's not like Canada doesn't need to pay their doctors. The cost in the U.S., contrary to public opinion, is not driven by insurance company greed. So, assuming the cost is about the same in Canada, how did you succeed in shifting the cost elsewhere in a manner that you're satisfied with?
And, if we were to replicate such a plan in the U.S., do you think we'd see similar results?

For cost, it varies by province, because health care is a provincial responsability.
Overall though, Canada's entire public medical system costs less per capita than America's public system (medicare + medicaid + whatever else they're including).
http://www.slate.com/blogs/moneybox/2013/01/23/chart_us_gove...
I checked the stats for my province, Quebec. In 2013, costs were a bit under $4000 per capita for the public sector. So that's about $333 per month.
Per province breakdown stats: https://secure.cihi.ca/free_products/4.0_TotalHealthExpendit...
As for replicating it....I'd wager that it couldn't be done nationally. It could possibly be done in a small state. It probably could have been done back in the 1950s, but there's been so much drift in the two systems since then that it would be difficult to imagine implementing it.
Because there'd be pretty wholesale change: no private health insurers. Also the fact that medicare + medicaid cost more than Canada spends already doesn't bode well.
But that could just be status quo pessimism.

Our employer-sponsored plan is roughly equivalent to this, and it costs the employer about $1,950 per month.

Interesting. Total private + public health care spending in my province is around $5000 per capita, per year. That covers everything I listed above.

My wife is from Hong Kong, and we're both seriously considering moving back there because of the cost of health care in the US. It's been a constant strain on our finances--any little thing can set us back by hundreds or thousands, even while insured! We never had problems like this back in Hong Kong. I really wanted to make our lives work in the US, but I don't see how we'll ever get ahead when raises and bonuses get eaten away by health care.

Can you summarize the healthcare system in Hong Kong? I'm particularly interested in options for non-citizens. Can you just walk into a private hospital and get treatment for cash? Or is it like so many places in the US where they don't want to talk to you unless you have proof of insurance?

The real problem is that no one knows how much anything costs - including doctors.
Ever ask them "how much is this going to cost?" They'll either tell you they have no idea, or give you a useless range like, "between $1k-$10k."

This drives me crazy. I walk in and want to pay cash, but they won't treat me because I have to show proof of insurance because they have no idea what they will charge when the bill is generated.

>"If something catastrophic happens," she said, “I feel like it’s better just to die.”
This is the richest country in the world in 2016, no other country has this problem, and this is the best our politics can do.
Sit with that thought for a little while.

Kind of a contentless article - of course there will always be people who choose the penalty instead of coverage. Some will be rational choices, some will be short-sighted. It looks like the overall forces, though, are good for the ACA - the penalty is going up, more healthy people are signing up for coverage, the risk profiles are stabilizing, etc. All of this should theoretically help create more choice in the exchange over time.

I don't know. I think the stories from people who are actually trying to use the ACA should bear a lot of weight.

No, they shouldn't. "The plural of anecdote is not data": of course you can go around cherry-picking people who are unhappy with the ACA; health care is extremely complicated, no solution was ever going to be perfect, and this law in particular attracts people with an axe to grind. But I can find just as many anecdotes of people who are a lot better off under the ACA. Stories are pointless; the only effective measurement is the bird's-eye view of the numbers as a whole: how many uninsured are there now, what is happening to the mean/median premiums, etc.

It seems to me this depends on how those people are selected, and the purpose to which one is trying to put the article.
An article about just a handful of people who choose to pay the penalty (rationally or not) is not a very enlightening way of evaluating the program overall, standing alone. I don't think this was the purpose of the piece, but it is naturally the way the piece will be used by opponents of the program. This is generally the role played by anecdotes in any policy discussion. (See the top of this thread for more examples.) For this information to be truly valuable for this purpose, it would be joined with a representative collection of stories about other people's experiences so one can form an accurate impression of how the program is actually working. (It could, of course, be debated whether the New York Times has provided this broader context in a meaningful way through its other ACA coverage.)
The article does provide some interesting human detail, and illustrate the depth of some people's convictions about (i.e., opposition to) the ACA, however, which seems valuable and enlightening in its own right. But this angle doesn't well serve anyone's political agenda.

As an European living in the US, the US health system is so utterly broken and asinine, it's not even funny.
You take a non-free market (I get sick, I need help - no choice involved) and apply seemingly free market logic to it. The result is a disaster, tada.
Single payer, all the way, everyday. Add private, optional insurance on top to allow well-off people to get private rooms, etc. But no one should worry about going bankrupt over medical bills, ever.
And yes, Austria is living proof that such a system can exist, with awesome results. Including electronic health records, the e-card etc. - all sci-fi ideas that US super genius companies like Google, MS, a myriad of startups cannot create.

It's not a free market system. I wish it was. It's amazing how people vote for government protected cartels. It took the press (Time magazine article two years back) an incredibly long time to start digging into fraudulent healthcare pricing - since then some things have started moving (legislation in some states to force hospitals to show prices, at least to bring in some semblance of a market and allow market forces to start operating). In a true free market environment such abuse by an incumbent/system would lead to innovation and new ideas that would quickly obliterate the monopoly, in this case the monopoly has the guns (i.e. regulation/government protected insurance and health care industry). Disclaimer: I lived in Austria/Germany for decades and their system is worse because it's totally closed to any potential market innovation while taxing the living daylights out of the middle class.

This is turning out to be a failure for some. It was for me personally. Was at a smaller company. Insurance premiums had been increased by a huge amount (probably 40% or so) in the 2 years _before_ Obamacare went into effect.
Representatives would come and would tell us a sad story about how all this legal environment is punishing them, and there is a lot of risk and uncertainty so they have not choice but to raise premiums.
So 3 years later premiums are way up, coverage is ... different. No lifetime maximums, that's nice, some free preventice checks and labs (unless the find something, then it becomes a paying lab or doctors' visit). Otherwise it is a about the same or worse coverage as before.
So far as far as the pocket is concerned, as far as the story I am told by employer, and by insurance representatives is that Obamacare is not a good thing. I want to believe, but I can't.
I knew it was going to be a so or so or failure when they striped the single payer option away early on. It wasn't agressive enough that's the problem. Without cost controls it is like plugging holes in hunk of swiss cheese. "Oh law wants to expand coverage for more people? Ok, everyone's premiums are higher now by 20%...."
I'll grant it that it might not be just the insurance companies to blame. Doctors, hospitals, pharma companies -- anyone in the money pipeline is guilty of abusing and taking advantage as much as they can.

Why would it not be more affordable? You're not getting anything.

You can pay and get something or pay and get nothing.

If you don't go to the doctor and don't need medicine, the "something" isn't valuable especially if it's more expensive than the "nothing". (I say that as someone with a preexisting condition who is happy to pay my premiums and get the medicine I need; I also grew up in a family where we didn't have insurance but somehow always had cigarettes and cable TV, so I know multiple perspectives)

I'm 30 years old and haven't been to a doctor in about 10 years outside of simple things that I paid out of my own pocket. Nothing that a year of healthcare would cover, and considerably lower than it'd cost.
I'd have paid in tens of thousands of dollars over the course of that time, and for what? What ifs?

When you're 60 years old you're going to want doctors and nurses who know what they're doing. That means someone needs to pay now to train them and their replacements.

So what you're saying is if I don't go to the doctor for 10 years, but pay $350/mo over the course of that 10 years for an insurance plan, the insurance company uses the money to fund college education for nurses and doctors?
Doubt it.

Do you know how insurance works?

Are you familiar with the concept of "insurance"? Most people would ascribe value to it.

Paying more for something that you don't need is a sunk cost.

Right. And if you get nothing, you pay less.

Evey once in a while I have to go to the emergency room for a serious migraine. All I need is a few drop of morphine. But I also get a bill for over $3,000. Of course, it goes in the trashcan.
The real problem with the medical system is its total contrivance to prevent people from treating themselves and having access to treatments at their actual cost -- the inflated pricing for the non-insured is the racket of the health insurance "mafia".

Morphine? Why not get a prescription for Imitrex?

Sumatriptan isn't a cure-all for migraines. I suffer from near-constant migraine-like headaches (sometimes diagnosed as migraines, some not - depends on the consultant), and they are actually worsened by sumatripan.
Morphine seems a little strong, but having tried every offered non-opiate medication (amitriptalyne, sodium valproate, gabapentin, propranolol, topiramate etc.) and only had any success with opiates (tramadol and codeine), it doesn't seem that unlikely.

Thanks, fair enough. I shouldn't have assumed the first-line approaches for migraine would work for everyone.

FWIW, reading the comments reminds me of Hilary Clinton's answer to "Is Obamacare helping or hurting the average U.S. citizen?" on Quora (https://www.quora.com/Is-Obamacare-helping-or-hurting-the-av...) The comments on Hilary's response seem resonate the comments here...

Insurance I had as self-employed for 12 years gave up in 2015 and would not renew. Crap bronze plan with highest possible deductible is almost 4x what I was paying.
The part I particularly don't like is that this is compulsory. I'd rather see private insurance destroyed than expanded under penalty threats. Or better, go back to barter.

Some people don't get insurance because the high deductibles mean they probably won't get any benefit. I think an even scarier effect is that I personally don't go to the doctor unless I really, really need to because of those same high deductibles (and the high cost of time off of work). Preventative care is expensive!

I've heard that, based on how the ACA was written, the penalty is only weakly enforceable; if you refuse to pay it, the IRS cannot garnish your wages or seize assets for it, etc. They can subtract it from a tax refund if you are owed one, but that's about it. So I imagine more and more people will find ways to not have insurance and also not pay the penalty, as both continue to become more expensive over time.

Interesting to see the anecdotal evidence in the comments that the ACA has been very good to some, and very bad to others.
It's been particularly bad for us. The covered employees are largely older (40+), with families, and it's a fairly high-end policy with a low deductible and a high percentage of covered inpatient costs.
We pay 100% of the premiums for employees. The cost, for one employee with a family, is now over $1800/month.
It is a high end policy, but...WOW.

This is actually further than I expected this to go. I'd figured companies would charge up to the penalty, not more than it, as charging more would drive customers away, and charging just a little less would net them the most money.

My individual/family plan has gone up by about $1000/year for the past two years. AND our deductible has increased as well! Not too thrilled with the ACA - it's becoming less and less affordable as time goes on.

I've always been a fan of HSAs + HDHP w/ extremely good coverage (no lifetime limits, etc.) beyond the self-insured amount. (Keep preventive care, birth control, etc. in the exempt amount, too, and especially public health stuff like vaccinations, since it reduces overall cost.)
I currently have an HRA (essentially a non-accruable form of HSA) through employer; it gets the incentives wrong so there's every incentive to use as much care as possible (slightly more convenient providers who charge 5x as much to the plan; as much care as possible).
I still have some hope ACA 2.0 could include:
0) Transparent pricing and mandate that anyone prepaying cash gets the medicare price. Maybe medicare prices have to rise.
1) Catastrophic/HDHP being encouraged for everyone. Potentially, subsidized for some income levels (i.e. money goes directly into your HSA, and HDHP premiums can be reduced.) I'd prefer if those premiums be market-based and then explicitly subsidized.
2) End employer deductibility for health insurance (over, say, 5-10y window); make it deductible, if at all, for individuals only. Employers for many many reasons should have nothing to do with health care -- privacy, portability, etc.
3) Pressure to reduce actual costs of health care delivery. End the AMA cartel's reign on care -- there is a LOT of care where 5% of the cost could produce a 90% as good solution, and people should be free to choose that if there are no negative externalities. Really, only antibiotics and contagious disease should have enforced minimum standards which can't be deviated from even w/ informed consent. This is especially meaningful for terminal or end of life care.
4) Any subsidies come from general tax and not from adjusting the underwriting (which is essentially a tax on people buying certain classes of health plan only, to cover others)
5) All government plans, except deployed active-duty military ONLY (i.e. care in war zones), go via this plan; end the VA and tricare. Provide superior care to gov/mil people by making this overall plan better, and for everyone. The President can have a personal doctor for COG reasons, but all other senior government people go through the plan, too.
6) Potentially fold medicare/medicaid into this as well.
7) Explore single-payer
8) Relatively unlimited access to medication (certainly imports from overseas), outside of antibiotics. If there is patent protection, shorten term. Reduce trials costs (safety must be shown, but not efficacy) -- efficacy and superiority can be decided by informed consumers, who may not be individuals, but could be insurers or other groups.

Before ACA we could barely afford health insurance for our family. After ACA it became evident that we can't afford to participate in this mafia racket if we truly want some money left over to pay for necessary medical expenditure. We were ready to face the tax penalty, but then my accountant found a loop hole. It's time for a repeal and replace -with some introduction of market competition. This unholy alliance of hospital-insurance-government mafia cartel needs to be broken.

Another Peter-Schiff-was-right moment.

Obama said no one is losing their coverage. He didn't lie.

That is the one flag-waving thing they can say about this, that more people are eligible or covered (but that ≠ "no one lost their coverage"). Obama will wave that raw number flag hard to try to tout his legacy.
Literally everything else in all aspects of the American health care & health insurance industries is worse off because of it.

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