Comment by sanderjd | Hacker News Reader

Comment by sanderjd | Hacker News Reader

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The ACA isn't supposed to help healthy and financially secure people like your lawyer friend. It is supposed to help sick and financially insecure people, by forcing healthy people (who are in the majority) to subsidize the cost of their care (which is very expensive).

There's a moral question at the heart of this, the answer to which defines the solution space: do we, as a society, think it is important that all sick people receive care? If yes, there are a bunch of potential solutions, but they all involve healthy people subsidizing care for sick people. If no, there are, of course, a lot more options.

The thing that frustrates me about the current Republican approach is that they seem to want to answer "yes" to this question, while telling voters they will not have to subsidize care for the sick in any way.

Depending on your point of view, either the best feature, or the biggest failure, of the ACA was that it made this subsidy for the sick visible to anybody buying their own insurance, rather than hiding it behind taxes or complicated dynamics between governments, insurers, employers, and hospitals.

A little more succinctly: either we decide to let emergency rooms turn sick people away, or somebody will be paying for their care. There's no magical solution.

I think you've answered a question you'd like to answer instead of one you don't: WHY is healthcare in this country SO EXPENSIVE?

The way to make care available is to drive down costs. We haven't done a single thing with the ACA to improve the affordability of care, we've just made the un-affordability a problem borne by the people who were already doing a good job of taking care of themselves. That's not a scalable solution.

The ACA got us a lot of short-term benefit for a small group of people but set in motion a chain of events that will only drive UP costs while driving affordability down.

And I'd like to argue that until we do something to improve the market dynamics of healthcare we are very likely to see this sort of thing continue to get worse until it's so unsustainable that it's like trying to legislate away the force of gravity.

One thing I'd like to see in any future version of ACA reform is RIGOROUS price transparency by healthcare providers. It should be absolutely illegal for any healthcare provider to conceal, obfuscate, or otherwise obstruct the price discovery mechanism of the market.

Even if you argue that consumers aren't the best people to decide what services are necessary or needed, they can rely on the advice of trusted advisors and popular understanding to shop for healthcare at providers known for offering good value.

SO MUCH of health care isn't of the "emergent" kind but the kind that is for chronic issues that are the result of unhealthy living or plain bad genetic luck. We need to redouble our efforts to drive those costs of care down and start paying for results and not treatment. Paying for treatment encourages overconsumption. Paying for outcomes encourages optimizing for cures.

Well said. Can we also work on the supply of medical care? We keep giving more and more people insurance which increases demand without doing anything to increase supply and then wonder why prices go up.

Your second paragraph is not even close to true - if you do more research on the ACA you'll find that it does all kinds of things to try and improve the affordability of care, a lot of which has made real improvements. Incentives against fee-for-service, quality-of-care rules, medicare/medicaid rules, there's just a ton of that stuff in the ACA. The stuff in your last paragraph is directly addressed by many parts of the ACA. And, more can definitely be done, including price transparency etc. These things tend to be supported by Democrats and opposed by Republicans.

I think you should post some links to relevant sections of the ACA and show me where they take specific actions to drive down costs.

I will tell you that I've seen scant evidence that it's working.

A wishlist of initiatives isn't a plan for action that drives down costs. Allowing Medicare to NEGOTIATE prices for drugs is a plan to drive down costs.

The insurance companies wanted to GROW the per-capita spend on healthcare. That benefited them. It's really really unclear if it benefited the public right now.

Forcing people into a market they don't want to be in isn't reform. The way to solve this problem is to make being a part of the market ATTRACTIVE.

IMHO we really missed an opportunity to affect behaviors. For one thing, Romneycare incentivized people to skip insurance until they needed it. That was a recipe for adverse selection.

The way to help this is to provide incentives for people to get in WAY EARLY and pay for their OWN care long before they may need it while also providing a measurable benefit to those who get in early right away.

People are capable of responding to incentives and I'm convinced that there exists a Nash equilibrium in healthcare that helps everybody win.

Remember, the same people who gave you "the Internet is not a truck" are the same people you're expecting to solve healthcare affordability. Think about that.

I work for a company which operates in the Medicare Advantage space.

A provision of the ACA sets a minimum medical loss ratio for us. In simpler terms: it puts a legal cap on our profit margin, by requiring a minimum percentage of the money we take in to be spent on benefits to our members (such as paying their claims).

That is almost certainly going to get repealed.

In that scenario, are your interests served more by spending via medicare increasing or going down?

If your incentive is to maximize the absolute amount of actual profit you earn and the ONLY way you can do that is to push more money towards healthcare providers, then what do you think will actually occur?

Because once you have achieved that spend level on provider care, you're in the clear. The ONLY way for you to increase profit is to ensure that more procedures happen.

We don't profit from paying out to providers; we're an insurer.

We profit when people are healthy.

I think you misunderstand my question.

In a perfect world, you'd keep 100% of the premiums and never pay a cent to a healthcare provider because everyone is healthy, right?

In a terrible world, every single one of your insured has a chronic, long-term expensive to treat condition that requires you to pay tons of money to providers.

In the first/perfect case, premiums are zero, right? In the second/terrible/worst case, you're not making zero money because your (collected premiums - minimum payout) > 0.

See where I'm going with this? In a world with healthy people, there is little need for health insurance and spending trends towards zero. There isn't a need for an insurer. Your company can only exist in a world with sick people.

I don't see how that point has any value. It's kind of like calling Social Security a ponzi/pyramid scheme. It's only true if children cease to exist. Similarly here, your point only has value if sickness and accidents cease to exist. But that won't happen. The market for health insurance naturally exists already. And the incentives for increasing health care costs are very much what the ACA is about - those incentives are being affected by things like the ACA rewarding quality-of-care instead of fee-for-service, etc.

I'm for aligning incentives.

Quality of care is a good direction but doesn't go far enough. We need to get real price transparency into the market so people understand what it costs to treat lung cancer and what the probabilities are that they'll actually get better.

Do you think the average person on the street really knows what it costs to undergo a round of chemotherapy? Does the EXACT SAME procedure performed in different hospitals across town cost the same? These are important questions and there doesn't seem to be any political will to actually answer them.

And my suspicion for this state of affairs is that the interests of the players in this game is for nobody to really know what things cost because if they did the game would change.

And we can't have that, now, can we.

Interestingly, Medicare is a slight counterexample to your comments, because you can -- given motivation to sit down and collate the necessary public data sources and understand the rules -- calculate what rate Medicare allows for a given procedure. And since providers who accept Medicare have agreed to those rates, it means that for Medicare, at least, you can find out the price (or the ceiling of the price, which is what people often want to know anyway).

Note that this doesn't mean the same procedure costs the same at every provider, though; Medicare rates include a geographic adjustment, among quite a few other factors, but it does mean you can work it all out for yourself.

Interesting that you should bring up Medicare.

I'd encourage you to read pages 23-28 of the following paper from the Mercatus Center. You'll find that prices for Medicare reimbursement are set by a committee largely stacked by the AMA, a de-facto lobbying group for doctors. They aren't likely to support any schema that cuts reimbursement rates for their members.

https://www.mercatus.org/system/files/Feldman-Medicare-Role-...

Unless medical care is cheap enough for everyone to always afford all the care they might require with the cash in their pockets or the money in their checking accounts, I believe my fundamental question is relevant. Since some medical care currently, and for the forseeable future, requires the time of extremely smart, talented, and highly-trained individuals, I don't believe it's possible to make it that cheap.

I agree with everything else you said though. Costs are too high and are a major reason this is so hard to solve and price transparency is a big part of the problem. A related (because it distorts the market in a similar way) problem is that most people don't see the true cost of their insurance, because they get it as a benefit from their employer. I would be highly in favor of any credible attempts to fix these issues. But that's not what I've been hearing from the party that's about to be completely in power.

You see the lack of honesty on both sides of the aisle. You're right in that Republicans don't just come out and admit that they believe that healthcare is not a right and that people should have to deal with their own health issues.

Democrats don't just come out and admit that they want a wealth redistribution program that they can use to show voters how compassionate they are with other people's money.

They're politicians. They just aren't honest and voters aren't perceptive or concerned enough to call them on it.

> Democrats don't just come out and admit that they want a wealth redistribution program that they can use to show voters how compassionate they are with other people's money.

I want a wealth distribution program that means that thanks to a genetic condition I had no role in acquiring (if you're "doing a good job taking care of yourself" and never get cancer or some other nasty expensive disease, why don't you count your fucking blessings that you're healthy instead of bitching about having to subsidize others) means that I don't get a death sentence if I ever am sick enough to lose my job for long enough to lose coverage and get fucked over in the future on preexisting condition exclusions. Or fucked over due to lifetime benefit caps.

And I want one that protects other people in similar situations too.

So maybe not everyone's motivations are as cynical as you make them out to be.

You might want a redistribution program, just like I don't want healthcare to be a right, but none of that changes that no politician will speak about their support for some healthcare policy in those terms. It would be electoral suicide if they're from a competitive district.

I want a wealth redistribution program as redress for past injustices. Current concentrations of wealth and property are the result of force and fraud, and I do not see how anyone should support preserving those distributions, let alone enshrining their preservation as a moral imperative.

Personally, I thought the ACA was a very honest plan. The individual mandate is a very clear statement of: healthy people must get insurance so that we can offset the cost of requiring that sick people can get insurance. I never had any illusions that, as a healthy young person, this would do anything besides increase medical costs (including insurance premiums) for me, as a trade-off against the possibility that I may one day be one of the older and/or sick people that it would benefit. I hoped it would decrease costs because we would no longer need to subsidize the uninsured by making up for care providers' lost revenue, but I didn't think that would (especially in the short term) be anything besides shifting that subsidy from being included in the cost of care to being included in premiums and federal taxes.

I was pretty sure it was going to make things more expensive for me, and I don't think it was sold any differently than that. I was not in favor of it, largely because I didn't think it would survive politically long enough for me to switch from the "loses" to the "benefits" category. We're sort of seeing that now, except that I'm actually sort of optimistic that its 6-year (or so) survival has enshrined it or something like it.

I believe a repeal-without-replace plan will be completely disastrous for the incoming government and that whatever government is next will have popular support to backtrack, and that a repeal-and-replace plan will end up settling on something very similar, maybe even with some free-market-based improvements!

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