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Comment by k-mcgrady | Hacker News Reader

>> "The liberal would prefer to keep universal healthcare and food programs and put cash on top, making the total distribution to the poor larger."

I'd definitely say I look at it from a liberal (non-libertarian perspective) but I don't agree with your statement. I believe universal, free health care should be available but not a food program. The money you get as your BI should cover basic living requirements - rent, food, clothing, heat. I come from a country which has free health care (NHS) which I think should remain in place. If citizens had no choice but to pay for health care then the BI should be higher to cover that cost (although I think cost of health care would rise and people would end up screwed - hence why we should have a free system). So put simply your BI should be enough for you to live 'comfortably'. That doesn't mean with a nice TV and steak for dinner every night - it means clean, warm shelter, healthy home cooked meals, adequate health care etc. The essentials for living. If you want anything more you can work. We're putting more trust in people by giving them the money without any conditions on it but I believe if there aren't extra safety nets and BI is equal to or greater than current welfare payments people will learn quickly. Their financial position doesn't change, just the trust put in them.

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Health care is a fundamentally different kind of expense. Housing, food, clothing, basic necessities are pretty stable expenses in the short run. An income of a particular size could be judged to be more or less sufficient for the needs of that expense or not.

Healthcare is a lottery. If you're 30 years old, your healthcare needs for the year might be $0 or $1,000,000. Trying to make basic income cover that doesn't make sense.

OTOH, BI could be expected to cover minor healthcare costs plus insurance for major costs.

Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income.

(Which is not to say that I disagree with you, though I do think that there are actually three different cost categories of health care:

1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.

2. One-time catastrophes, like "I broke my arm" or "I got pneumonia." Probably best dealt with as insurance.

3. Long-term or lifelong large expenses, like "I have HIV" or "I have MS." Probably best dealt with as a government program.

But then you'll have a lot of problems with the boundary cases.)

> Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income.

We already have a national individual mandate for health insurance with specific coverage rules which has made decisions about this; essentially, a mature BI would cover expected out-of-pocket costs plus insurance premiums in that system.

(That's not to say further reform of that system isn't possible or desirable, with or without BI, just that, given the existing system, there seems to be a fairly natural way that healthcare within that system fits into BI.)

Sorry, I misunderstood your previous comment to mean that you thought we should go to an India-like "out of pocket" system plus (optional) health insurance to handle catastrophic costs. Rereading, your intent is clear.

(Not sure why I jumped to that conclusion, except that perhaps a basic income system appeals to the same economic minimalism that an out-of-pocket health cost system does.)

Just want to point out that making routine/preventative care an out-of-pocket cost is probably one of the worst things you can do. I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans. You can save a ton of money later by catching and treating issues early, and even a small personal cost can encourage people to ignore warning signs and not seek aid until the problem has become severe and expensive.

Yeah, this is deeply off-topic, but my reading of the evidence is that preventative or diagnostic care is typically not cost-effective or even outcome-enhancing, with a few specific exceptions like vaccinations.

Interesting. I'd love to see support for this view. Everything I've heard suggests the opposite. Especially if you consider worker productivity in addition to healthcare costs.

http://www.nejm.org/doi/full/10.1056/NEJMp0708558

http://www.reuters.com/article/us-preventive-economics-idUSB...

http://www.statcan.gc.ca/pub/82-003-x/2015012/article/14295-...

http://www.thehoopsnews.com/effectiveness-of-mammograms-vast...

It's a complex subject, and a few articles aren't the final word one way or the other. My opinion is based on various things I've read over the past couple of decades (most of which I can't summon up right now) and conversations with various medical professionals in my family and social circle, and my overall worldview (as anyone's must be).

Ok, this is interesting. Some of this fits my intuitions, and some was a surprise to me, so yes, this does modify my view, but only slightly.

It seems there are preventative measures that are cost effective, and there are others that are not. So really, this indicates a need to determine a threshold. Perhaps we determine that we can afford to pay up to $50,000 per QALY, and cover any care that falls within that limit. So, we'd have coverage based on its efficiency rather than whether it is considered preventative or treatment or maintenance. The idea being to get the maximum amount of healthy years of life out of whatever amount of money we as society are willing to put toward healthcare. This could also be extended to programs outside of direct care, like some of those articles suggest, which encourage and support healthy activity in a way that still falls within the $/QALY target.

Of course, I expect it would be a bear to fairly study every possible treatment and program to determine its efficiency, especially factoring in a changing environment which is bound to change the efficiency of any given treatment from year to year.

Still, at a minimum, we should be grabbing those low-hanging fruits, where we can gain healthy years for a very low cost.

It does not exactly answer your question but this study [1] had some relevant results.

[1] https://en.wikipedia.org/wiki/RAND_Health_Insurance_Experime...

I have heard this as well, but I think the point still stands. Things like annual physical's might not be a net positive, but you don't want to deter people from going to the doctor when they think something could be wrong.

I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans.

Yeah, it is called brainwashing. I worked in insurance and was all tickled to see them offering "wellness" benefits. I was all "Oh, yay, the world is turning into a better and more clued place!" Then I went to the meetings. These were purely a sales gimmick. That's it.

You encourage people to go to their annual check up and they feel like you actually care. It breeds employee loyalty. It mostly does very little for actual health outcomes. If you actually want better health, you are better off promoting exercise, healthy eating, sanitation, etc. in place of preventive medical screenings.

Theoretically, that's what your doctor is supposed to do at these "preventative checkups": convince you to exercise, diet, etc.

Since we don't see any benefits from annual check-up, that either isn't happening or is ineffective.

However, that small personal costs may very well help not fill up a queue to the doctor for mundane, trivial crap that would have gone away in a day or two. Care quality is improved when the doctors are less stressed and can spend more time with their patients.

Free-as-in-beer health care ensure more people going to the doctor for more crap, reducing availability and quality for the average person.

I'm going to say this because I'm in a similar situation now. For weeks, I've been having pains in my chest, back and sides. I know for sure something is wrong. And I fear I may be dying.

But being unsure where my next meal will come from, I can't even visit a clinic to get a test done.

I keep praying to get some money so I can go check myself before I leave my young family without a caregiver.

So yes, whatever you guys argue here today. Make sure people like me in future can be cared for. And that they don't have to worry about food, shelter, Healthcare.

Go visit a clinic. You obviously have the time to write this comment on HN on a computer, so you have the time to go to a clinic.

Like you said, you absolutely don't want to leave your family without a caregiver.

I wrote it on my phone. And it's not about time. It's about being able to afford the care.

When you live in Africa, you have different problems.

Either way, I was buttressing this point

> even a small personal cost can encourage people to ignore warning signs and not seek aid until the problem has become severe and expensive

> 1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.

This is a pretty terrible idea. Even programs in the current day that are trying to make consumers feel their healthcare costs (like HSAs and their required high-deductible PPO plans) often or always cover preventative care at 100%.

Preventative care is precisely the kind of care that people are most likely to skip to save on some money, and at the system-level this just means much more costly healthcare. Regardless of how you structure your healthcare system, increasing the cost of the actual care itself is a horrible idea.

> Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.

This seems like a terrible idea. If someone, for example, notices a new mole, they are much less likely to get it checked out if it is an out-of-pocket expense. Obviously, most of the time it'll be fine, but it could also be skin cancer that was easily treatable but has now metastasised and will be hugely expensive to treat.

Insurance companies are just a leech on the economy who collect rent. This would turn healthcare into an even more negative sum game.

> This would turn healthcare into an even more negative sum game.

How, specifically, would it do so compared to the actual system that exists now in the US?

The system that exists now in the US is broken and already exactly what is described.

Those with money pay too much for insurance because those without insurance are only covered at the last stages, when it becomes inhumane (by anyone's definition) to deny them care (which is also the most drastic and expensive level of care for a problem) which is then 'written off' and padded in to the 'prices' asked for other services.

A LOT of medical costs are actually sunk fixed op-ex. Big expensive machines that cost deferentially little to use or not (but always coast a lot to have the option of using), drugs and other supplies that have shelf lifes, etc.

Labwork presently requires a lot of humans, but much of it could also be converted to automation and human review, lowering the per unit cost; if there were incentive to make such technology.

It's also a major bit of administrative overhead to have to haggle with different insurance companies, hound patients for billing, and in general worry IF someone will pay and how much.

Sorry to basically just negate your post but I do believe that you missed answering the last question in explaining details. The poster asked, how would the provision of basic income further turn healthcare supply in the US to a negative sum game as compared to private insurance supplemented with corporate and government benefits? Your response does a fair job of detailing some of the current issues with the US healthcare system but does not mention how basic income would make these issues worse. Would you kindly link the two for those of us who are not making the connection?

You're correct, I was explaining why it was /already/ a negative sum game.

I suppose the closest parallel is what I recall hearing happened to auto-insurance rates when those became mandatory.

Another close parallel would be what would happen if everyone in the San Francisco Bay Area were to suddenly receive an additional 500 USD/month housing allowance for living in the area. I would expect occupancy prices to go up by ~500 USD and the general quality of housing anyone current has to remain the same otherwise.

Yes, pretty much.

(And incidentally, that's a great argument for replacing almost all taxes with taxes on land rent: any extra money people have left over after paying taxes etc goes to bid up housing costs. Lower taxes and you get higher housing costs. A land tax can recover the lost revenue---and it's really hard to hide land and evade the tax.)

The idea of insurance is great. Unfortunately, I agree with you about the actual, existing insurance companies.

I would suggest the idea of private insurance is actually completely non-functional without such heavy regulation that you might as well just institute public provision — which also has the benefit that it does not heavily incentivize over-provision.

With a competitive insurance market, you charge people a premium related to their expected healthcare costs. Some people have chronic diseases, and their expected healthcare costs are way beyond what they can likely afford.

However you regulate, insurance companies will always try to find a way to cream off the lowest risk customers to offer them the cheapest deal, progressively chipping away at the idea of collective insurance until it breaks.

Private health insurance is broken not only in practice but also in theory.

For sure - it's kind of absurd because healthcare costs are an inevitability.

With car and home insurance, the products can go their entire lifecycle without burning down, being robbed, or smashing into a tree.

With healthcare, a person is going to need it, and it incapacitates them when they don't get it. Personally I'm for treating healthcare as we treat most regional monopolies that everyone needs - make it a public utility. You'll need healthcare just like you'll need water and electricity.

> With healthcare, a person is going to need it [...]

Not really, at least not at the current stage of technology.

During most of your life, healthcare is more like a lottery, ie you might never need it.

When you are old, something will eventually get you. And a lot of health care costs are spend on these end-of-life conditions. Alas, our massive spending at the end doesn't actually help very much: they mostly give you a few more month of suffering. (For things like cancer etc.)

For a lot of people hospice care is both cheaper and provides a better quality of life. (Some in-law of mine went from hospital care to hospice care when the cancer treatments got worse than the disease.)

See eg http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medi... for a similar argument.

So you're saying that you don't eventually need healthcare, except for when everyone needs it then it's the most expensive?

That's like saying you don't really need electricity until later in the day, when it's more in demand for everyone. Should we treat electricity use as a lottery?

In fact, people should be using healthcare more, as a preventative measure (for reasons you just said), but because we treat it like car accidents and house fires and lotteries it's stuck in remedial mode.

The strawmen and me hold quite different positions.

See eg http://www.theguardian.com/society/2012/feb/08/how-doctors-c...:

> How doctors choose to die

>When faced with a terminal illness, medical professionals, who know the limits of modern medicine, often opt out of life-prolonging treatment. An American doctor explains why the best death can be the least medicated – and the art of dying peacefully, at home

To be clear, there are a few different kinds of health care along multiple dimensions, like

- price

- expected mean utility (as measured in quality adjusted life-years gained)

- variance of utility (which I am ignoring here)

I am saying that at current state of technology, if we exclude the expensive stuff with near zero or even negative utility, the remaining demand for big items fits an insurance model rather well.

Yes, I agree that we should probably do more preventive interventions---like exercise, decent nutrition, vaccinations, etc. These are mostly cheap.

And even though they are good for people already, the insurance company might very well decide to just pay for them (and perhaps even pay people extra on top with discounts etcs to nudge them even more) to save itself money in the long run.

https://en.wikipedia.org/wiki/Quality-adjusted_life_year

EDIT: There's of course also expensive treatments that provide a lot of quality adjusted life years, but the need for these are more like a lottery. (Eg treatment after a car accident or massive burn, or certain treatable cancers.)

So why not explicitly pass a subsidy (e.g. through the tax code) for the chronically ill? Disguising such transfers through regulatory costs is both inefficient and dishonest. It's also very unclear whether society would choose to subsidize all sick people. For example, those who are sick and rich enough to afford their insurance premiums (or who were lucky enough to obtain long-term coverage before they got an expensive medical condition, so their premiums are low), might not merit such transfers. If women have higher expected lifetime health costs due to pregnancy-related care, society might or might not want to have healthcare-related subsidies that amount to a transfer payment from men to women.

The proper way to make these sorts of decisions is by passing laws that make the transfer payments explicit, not disguising them in byzantine insurance regulations.

You are right in some theoretic sense.

Alas, politics is the art of the possible, and hypocrisy is a valuable tool.

And yet the margins for insurance companies is generally not at the high end when compared with other industries.

For example, using the data from: http://pages.stern.nyu.edu/~adamodar/New_Home_Page/datafile/...

and looking at the After-tax Lease & R&D adjusted margin, The software industry is at 24% (8th place) and the Insurance industry is at 11.51% (37th place).

You can drive the cost of healthcare up without having large margins

Just like Hollywood never makes a profit, you can't use profit margin to measure what the cost savings would be in moving to national healthcare system.

Healthcare for an individual is a lottery. For a population, it generally isn't. In other words, the total expense to provide healthcare for everybody is a pretty stable expense, which is why it makes more sense to handle at the national level, with the individuals who 'lose' the health lottery being subsidized by those who do not.

The common complaint I've seen against this (aside from general complaints against redistribution) is that it forces the general populace to pay for the poor health choices of smokers and other such bad habits. I think this is a relatively minor issue, but if necessary, penalty taxes/fees can alleviate the concerns of people legitimately bothered by this.

> I think this is a relatively minor issue, but if necessary, penalty taxes/fees can alleviate the concerns of people legitimately bothered by this.

It is not minor at all. Depending on how you look at it, smoking either costs the health care industry billions (in treatment of the living) or saves them billions (on premature death). Compound this by: diet, exercise, stress, and socialization problems and you see that the lottery has a lot of knobs and buttons, most of which will only be effective if people get effective health care their entire life.

That would be an interesting analysis: savings of premature deaths from smoking vs long terms costs of people that smoke and don't die and costs of treating those early deaths before they die. Intuition says the costs probably outweigh the benefits there. Even so it feels pretty macabre (and species threatening at the extreme [1]) to consider someone dying before they need medical care a savings.

[1] Considering killing someone before they're born saves the cost of them and any children they would statistically have. So if we wiped out everyone we'd save all the money ever spent on healthcare.

The high taxes for cigarettes (and similarly alcohol) should also be taken into account when considering net gains/losses. According to this [1] in the uk at least the taxes more than cover it for tobacco

[1]https://fullfact.org/economy/does-smoking-cost-much-it-makes...

Here in the US the taxes are much lower for a large portion of the country [1] so it probably doesn't come out so much in favor. Though long term health care is also more expensive here so it might all come out as even or similar enough.

[1] http://taxfoundation.org/blog/state-cigarette-tax-rates-2014

It creates enormous social pressure to increase cigarette and alcohol taxes. In Canada both are quite high and the general population supports it due to the public healthcare burdens.

For health issues I think this type of pressure is a positive social force.

How is [1] distinct from rational control of population (eg birth control by default), which will presumably be necessary to avoid food and resource waste (or war/starvation)? Health care seems to be just another factor affecting population cap.

[1] Differs from normal population control in it's extreme application of reducing costs by any means. Also population control has additional concerns beyond just reducing costs by not having people to deal with like sustainability of resource consumption and to me there's a large difference between a person never being born and dying early. Really my [1] wasn't meant to be seriously at all.

Another way to think about this is if a person comes into existence, then BI demands their immediate universal right to the resources to sustain their life comfortably without any contribution from that body.

So really, those who multiply the fastest win the resource war of the future? Or having kids is somehow constrained now through other hoops, like a "procreation license."

> Or having kids is somehow constrained now through other hoops, like a "procreation license."

Possibly, though better educated and better off people tend to have fewer children so there are other ways to limit population beyond strict China or Ender's Game style limits.

Or maybe asteroid mining will finally break and crash the whole materials economy making everything but space, food, and water extremely cheap.

My point is this: universal BI requires some level of population control (to prevent poverty and misery), and eventually some level of reproductive planning.

Universal BI leads to universal resource control.

Really we'll need either population control or (more likely and) to drastically limit consumption (or the impact of it maybe more closed cycle recycling) with or without BI.

> saves them billions (on premature death)

Smokers don't die healthy. The "saving money" bullshit is literal propaganda from the smoking industry.

Here's an actual meta study on the costs: http://www.tobaccoinaustralia.org.au/chapter-17-economics/17...

>Third, Collins and Lapsley estimate the net costs of smoking, taking into account both those costs that are made greater and those that are reduced because of current and past tobacco use. For example, smoking increases some health care costs because of the higher prevalence of diseases caused by smoking (in smokers and ex-smokers who are still alive). These are the gross health care costs attributable to smoking. However, certain other health care costs are lower than they otherwise would be because of the premature deaths of many people who smoked over the past 40 years. These people did not live to use health care that they otherwise would have, so Collins and Lapsley subtract the costs that would have been incurred from the gross health care costs attributable to smoking in order to estimate the net cost. Similarly, in terms of labour (production) costs first costs that are made greater by smoking are estimated. For example, the time spent undertaking domestic duties because a home-maker is ill or has died prematurely is costed assuming domestic help will be hired. Then, savings due to reduced consumption—for example, household spending on food and clothing—are subtracted because these costs will be lower when there are fewer people in the household as a result of smokers dying earlier.

>Collins and Lapsley estimated that in 2004–05 the total cost of smoking in Australia was $31.5 billion

A real lottery for a population isn't "a lottery" in that sense either. The lottery business is reliable just like the health insurance business and for the same reason.

The thing about having the government pay for healthcare at the national level is that it would also incentivize prevention of diseases, as a way to cut costs over the long term. At least that's what's supposed to happen without too strong Big Pharma lobbying that would prefer the population to be as sick as possible.

Just keep in mind that we will likely never reach the ideal balance between the voice of the people and megaphone of money. The impact of lobbyists and money is a necessary consideration in any discussion of political solutions to problems.

How does that happen? Doesn't this imply government interference in people's lives (eat this, eat that, exercise etc.,)? Given that such advice is frequently shown to be wrong, this is problematic.

The NHS doesn't seem to incentivize prevention of diabetes in the UK. To quote 'UK Diabetes': "Diabetes is the fastest growing health threat of our times and an urgent public health issue. Since 1996, the number of people living with diabetes has more than doubled. If nothing changes, it is estimated that over five million people in the UK will have diabetes.". This disease largely results from personal choices often made on the basis of misleading information.

> For a population, it generally isn't. In other words, the total expense to provide healthcare for everybody is a pretty stable expense.

The one does not follow from the other. Just because it's predictable does not mean it's stable: you can modulate demand by, for example, making people jump through bureaucratic hoops or wait in long queues to get care.

> The one does not follow from the other. Just because it's predictable does not mean it's stable: you can modulate demand by, for example, making people jump through bureaucratic hoops or wait in long queues to get care.

...as we have seen in far too many countries with universal healthcare (leading those with the means to seek healthcare from other, more market-driven systems...which in turn leads to those without the means to receiving sub-standard care, or quality care subject to bureaucracy and long queues.)

In short, it's a self-licking ice cream cone. (But this is quite the tangent from the BI discussion - wherever your opinion falls on the matter, universal healthcare is an entirely different thing indeed.)

> The common complaint I've seen against this (aside from general complaints against redistribution) is that it forces the general populace to pay for the poor health choices of smokers and other such bad habits.

If you want your 21st century healthcare, you also gotta let go of outdated notions such as that addiction is a "poor health choice" (seriously kind of makes me angry typing that).

Except that, on the whole, an individual in the US who 'loses' that lottery is going to cost themselves/their insurance significantly more than an identical individual in another country with the exact same condition, due to multiple levels of negotiation, backroom dealing, 'in-network', overcharges, etc.

That 30 year old individual with the $1m healthcare bill for the year in a for-profit system might well have only cost a public system (e.g. in Canada) $200k for the same standard of care, but with less additional financial stress impacting their ability to recover from their illness, and with no bills, phone calls, rejections, negotiations, and arguments after the fact.

It's just another example of how a uniform, public system works better.

Disagree. I had a valve replaced, and researched extensively what my experience was like vs. that in other countries. I received an unquestionably higher standard of care. I had my choice of valve, doctor, hospital, I had nearly zero wait (a few weeks from diagnosis to surgery, and only because I asked for the time -- in my circumstance there was a double digit chance of death, and I needed to ... process), and the nursing care that I received after surgery in the ICU was literally one-on-one - there was a nurse assigned to me. I had a bed that massaged and hammered the goop out of my lungs, I had tasty food (when I could eat again), and I had some say in when I would be discharged. The only thing that wasn't absolutely first-class was that I had a shared room with two beds post-ICU, but even that's becoming uncommon in the US.

After reading on the experiences of people from European countries and Canada in the 'OMG I had a valve replaced' forum (yes, there's a site just for that -- valvereplacement.org), the level of care that I received was significantly better than what is typical of public health systems.

Oh, and last week I needed to see the doc for a sore throat, and I was in the same day. Queues are a regular thing in public systems.

I think there are a lot of data points missing in this anecdote.

What do you pay for health insurance? How many people in the lower levels of society could afford to pay what you pay for healthcare? Do you have an employer that provides you with healthcare benefits?

I agree that healthcare in many countries could be greatly improved, but at least in many of those systems you could just walk into an hospital to start the process.

My employer offers a few options for health insurance. At the time I was a young and healthy 29 year old (or so I thought) so I was enrolled in the low cost high deductible option. It costs less than $200/month between both the employer and employee portion of the contribution for that plan today -- at the time (in 2009), it was less than $150/month, but our costs went up significantly with the advent of Obamacare. Total medical bill came to about $350k, down to $250k with insurance co's negotiate rates, of which I was responsible for approximately $5k. I was sitting on a pile of cashed earmarked for a mortgage downpayment at the time ... so I didn't have to go into debt over it, but even if I had, for most people $5k isn't a bankruptcy event type debt.

I'm from Europe and I know of a lot of people who wouldn't be able to front a $5K bill. With the US system I would still think there are many who would fall below that line as well. Free healthcare as exists in some european countries actually helps those people.

For a significant number of Americans, a $5k bill might as well be a $200k bill. A lot of people are living month-to-month on far less, and I wouldn't be surprised if most people couldn't actually afford that, or couldn't even manage to acquire $5k in debt, let alone pay it off.

The reality is that you're in a privileged position, and it may not seem like it to you but there are a huge number of people out there for whom your situation would be effectively a bankruptcy trigger. And that's even assuming that their company lets them off work long enough to get treatment and recovery, which, in at-will states, doesn't seem like a thing that's likely to happen for a lot of the working-class.

Queues are a regular thing in private healthcare also... Your anecdotal evidence is just that... Anecdotal.

More anecdotes: every single urgent care center I visited is 2hr+ wait; then I opened my Blue Shield CA online doctor registry and called some — do not accept new patients or available in a month.

For rich people/folks with wonderful insurances the other countries with public healthcare have private care in private hospitals, and it's of the same class — with one-on-one nurses and good food.

It's a lottery at most ages. Age 39 health care costs: $0. Age 40 health care costs: $45,000. Due to a single incident of slipping and falling on an icy sidewalk. I carry insurance because (1) you never know when something big might happen and (2) I have to just in case the Republicans ever get their wish to "repeal Obamacare" and suddenly my kidney donation to my dad becomes a pre-existing condition again.

#1 is a legit reason for insurance. I'm having a hard time with #2 though. You elected to have a condition that others might have to eventually pay for. Now this was an extension of your dad's condition, so really his insurance company (pool) should pay for your condition's expenses, but with the help of Obamacare, all insurance companies are going to share in these expenses and raise their rates, and they can raise the rates more than their actual costs, because with all the new regulations, how many plans can you really choose from? So we now see healthcare providers laughing all the way to the bank, and a new form of guaranteed income for the insurance workforce. #1 and #2 shouldn't be in the same system. That's what needs to be repealed.

The rules around "pre-existing conditions" are completely asinine. Under the old rules that Republicans would like to go back to, I'm covered as long as I don't have any period that I didn't have insurance since donating the kidney. However, if I temporarily lose health insurance and then get health insurance again, that kidney donation 16 years ago magically becomes a pre-existing condition again for a period of multiple years. Even though nothing at all happened in that short period I went without health insurance.

The kicker is, health insurance companies will use any pre-existing condition to get out of paying for just about everything. So, for example, if I wound up getting poly-cystic kidney disease, my insurance company would use the fact that I donated a kidney as a pre-existing condition to get out of paying for it. Even though it's completely unrelated and can't cause PKD. It's an out in their mind and they're going to take it.

Health insurance and medical care in the US is absurdly corrupt. That's why I wasn't allowed to leave the hospital without buying a walking boot from their provider. And their provider billed my insurance company $700. And the insurance company paid them $400. And then the provider billed me $100 and threatened to send me to collections if I didn't pay them. All for a walking boot that didn't fit, that I didn't use, and that I could have purchased from Amazon.com for $53 with free shipping.

> but with the help of Obamacare, all insurance companies are going to share in these expenses and raise their rates, and they can raise the rates more than their actual costs

Only if they are below the maximum premium profit-to-cost ratio (20/80), otherwise, they are going to have to refund the excess anyway, due to other provisions of the ACA.

I really think the MLR cap was the biggest improvement Obamacare brought. It means keeping a genuinely expensive patient might mean your shareholders get to take home more money, so the incentive is "keep their business" rather than "treat them well enough that they can't successfully sue you for more than you'd have spent on them anyway."

Healthcare can be universally provided via BI w/o having single payer government universal healthcare. Individuals can choose (not) to buy health insurance with their BI payments. Thus getting coverage or not as they see fit. Its a bit of a gamble because it turns everyone into an actuarial (do i feel lucky this year? should i buy insurance? Am I higher or lower risk than the cost of insurance?) .. But, it also allows market forces to drive down the cost of insurance and healthcare provision.

The problem with that is that it requires not treating people who are uninsured and unable to pay for care. "Sorry you got hit by a drunk driver, but we think that the risk is too great that you and the guy who hit you won't ever pay the $100,000 it would cost to fix you." That's pretty unpalatable.

Also people with pre-existing expensive conditions would need to pay a lot more.

Either, because insurance companies charge them more.

Or, if insurance companies are not allowed to charge them a special price, healthy people will be reluctant to pay for (now) overpriced (for them) insurance.

One clever technical way out is to have your parents buy insurance for you before you are even conceived. This way, because neither the buyer nor the seller of insurance knows what's coming, it's not a market for lemons. (And if the parents genes make this kind of insurance too expensive, because it's expected that you inherit some defects, perhaps they should rethink their decision to procreate with each other. (Just like couples with sickle-cell-anemia on both sides are already advised.))

But of course, people will not be that farsighted, and we don't want to penalize people for their parents making stupid decisions, like not to buy insurance, more than necessary.

So in actual life, a basic version of an NHS like system plus optional extra insurance you can buy seems like the most sensible policy.

I see what you're saying, but how can one get a market forces involved so that the price of care isnt super high and that users have some choice.

I have lived in a country with universal healthcare. Its not that cheap, my portion of taxes that went to healthcare was about the same as the highest cost Kaiser plan. But Kaiser (thus far) is leaps and bounds better than the care received.

Where I am from you make an appointment with a doctor, and they will almost certainly be 30-60 minutes late for it. Then when you do get in the room with them, they will give you 15 minutes max because thats all the government pays for. Similarly every person I know who needed something done is on a waiting list. For months and a small number for years.

People complain about the cost of US healthcare, but if you can pay for it then it does seem excellent.

I disagree on this. BI is not supposed to solve the healthcare issue. Right now most people have some money, but some of them still gamble with their life, or healthcare cost is still too high for them. That won't change if they have some extra money every month.

You can make the same argument about almost every government benefit/wealth transfer; food stamps fall under this category, as does a housing allowance, etc.

It looks like we went in to a fairly deep reply chain but never got back up to here.

Presenting, perhaps, a different take: basic income can cover insurance which does account for the 0-1mil total distribution via actuarial science.

Even the world's crappiest healthcare plan protects against the worst case. I know - I had a major health event at age 29, and I had absolutely garbage insurance. $350,000 in hospital bills later, with approximately only $7k out of pocket, I was all fixed up (as well as current medical tech allows, at least) and my heart was a click-click-clicking away. Insurance with deductibles in that range for a single (and ~double that for a family) is really relatively cheap.

only 7k out of pocket implies your insurance was not as garbage as you thought.

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