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Comment by jhulla | Hacker News Reader

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.

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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?

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.

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.

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

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.

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.

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.

" 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)?

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 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".

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.

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)

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

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.

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.

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.

>"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?

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.

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

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.

"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.

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.

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.

"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.

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?

Cite?

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

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?

> "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.

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.

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

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

> 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.

> 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/

>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.

>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.

> 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).

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.

> 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 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.

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

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

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.

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.

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/

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.

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...

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.

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.

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.

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.

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.

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.

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-...

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.

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.

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.)

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.

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.

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

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

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.

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

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.

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.

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).
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.

> 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.

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.

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?

> 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.

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.

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.

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.

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.

> 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.)

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.

> 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.

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

"Insurers routinely pay out over %100 of premiums in claims."
Because there's zero controls around costs.

"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)

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.

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.

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.

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...).

'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.

"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...

>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?

> 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?

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