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Comment by flexie | Hacker News Reader

Thank you. It beats me that Americans when looking for alternatives to their current system(s) or the lack of systems in third world countries overlook the European models where "socialized medicine" in various forms works well and has done so since around WW2 (different from country to country).

My experience in Europe is limited to living in Denmark, Spain and Bulgaria, and in each place health care could certainly be improved. But most citizens don't worry as much about health care as they did when I lived in the US.

Having seen hospitals in those European countries and what is supposedly a top class Manhattan hospital, I would not trade the European model for the American. Just the humiliation of asking a woman in severe pain for her insurance before treating her; it's undignified.

But whereas the European models could - and in my opinion should - inspire in the US, they are not easily transposed to third world countries where you lack a strong government without too much corruption to collect taxes. Here, a private model might work better.

Anyways, kudos to anyone trying to improve healthcare in the third world or ours.

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What are your thoughts on wait times? I was very ill in Barcelona and was told by relatives there wasn't a point in going to the hospital unless I wanted a 6 hour wait for ibuprofen.

Switzerland: if you're ill, you don't go to the hospital. You go the a doctor near you, that already knows your medical history (family doctor), or you call a free hotline (Sanatel), or you just go to a Pharmacy, as the personnel there has medical training and they can also find the nearest doctor and make an appointment for you. And then, bigger public transport stations and airports have doctor stations that are reasonably staffed where you can just walk in ~24hrs. Hospitals do have walk-in for illness as well, but in relation to other stuff going on in the hospital you don't have a high priority and wait times can be more than you'd expect.

That's if you go to the emergency room - they will keep you waiting (closer to 2 hours than 6), when you have no apparent life threatening condition.

If you have a serious issue, like a heart condition or a broken bone or vomiting etc, you will be processed much faster.

I know that because I've been in both situations - once with pain in my left ear (waited 2 hours, got a prescription to ibuprofen) and another was chest pain and high blood pressure - processed immediately, all blood work done in minutes, etc.

I guess a lot of people go to the emergency room because they just need a doctor to confirm that they're all right.

Same here in Italy. I waited 8 hours to be visited at ER when I had a foot injury while climbing, but in the meanwhile I saw a lot of way more serious patients to go first.

My daughter broke her nose while playing and she had nose surgery and she had to stay a couple of nights in the hospital.

In both cases everything has been completely free (AKA paid by high taxes). Our current system has a lot of issues, but I wouldn't trade for a more private one. For sure I wouldn't trade it for the american system.

> I guess a lot of people go to the emergency room because they just need a doctor to confirm that they're all right.

This is correct and an issue all over the world; without a proper network of local doctors and whatnot (with reasonable waiting times), people will jump to the ER, which is 10x as expensive as a local doctor. But when people have a pressing need for care, they don't have much other options.

Healthcare is hard and expensive.

Recent UK NHS Scotland experience - went to "Minor Injuries" unit with what I thought was a minor injury (infected cat bite). Was immediately taken to A&E and saw a doctor almost immediately (within 5 minutes) - got an X-ray (which took < 10 mins) and was admitted to a ward where I got multiple intravenous antibiotics. Responded very well so no need for surgery and I was out two days later.

Food was decent, care by staff was very good and WiFi was excellent!

Edit: Turns out that a deep cat bite can be very nasty!

Edit2: This was lunchtime on Wednesday - I know that if I had went at midnight on a Friday it wouldn't be quite so simple...

What makes you think it would be any better in a US hospital? Unless you're literally dying, emergency room treatment is not known for its short wait times.

Side note: does the concept of "urgent care" exist outside the US?

Yes of course 'urgent care' exists outside the US (assuming that you mean A&E).

One of the most baffling things about this whole debate is the assumption by some Americans that socialised medicine is somehow lacking. It really isn't. It's just better and cheaper.

No, I don't think A&E is the same. "Emergency care" in the US is what emergency departments are for. I think this is the equivalent of A&E: go here if you are literally dying. "Urgent care" is for severe cases that don't have risk of imminent death: broken arm would be a great example. An ER will treat your broken arm, just probably not quickly. An urgent care facility is not equipped to handle anything life-threatening.

I'm not saying that the fact these things are separate implies it's worse than the European system, just different.

In the UK there is the distinction between 999 (emergency services) and 111 for "urgent but not life threatening". 111 is staffed by nurses trained to triage and will escalate if necessary and get you an ambulance.

Similarly there tends to be walkin clinics if you don't think you can wait for your GP, but don't think it's something you should go to A&E/ER for. Most of them will not be equipped to handle surgery of any kind, but whatever decisions they do as part of triage will certainly be passed on if they believe you need to be sent to hospital.

I think the big difference is that in most European countries the default is to triage everywhere, unless you pay extra to go private, while Americans seem to be more used to triage being somehow mostly restricted to emergencies.

Triage sucks when you have a minor problem and want quick attention without paying extra for private care, but it's quite great when you have an urgent problem and don't have to wait behind people with much less pressing needs.

Well, some level of triage takes place anywhere you go in the US. If you're at the doctor's office or urgent care for chest pain, you're probably getting a ride to the ER. But, nobody's going to send you away from anywhere because you come in with a broken arm (assuming they're equipped to handle it) or the sniffles. It's just a matter of how long you will wait and how much you will pay.

There's a clue in the name - accident and emergency - that these departments handle urgent but non life threatening care too.

Really, it's a fucking stupid question. Of course Europe's socialised medicine will treat broken arms.

If the question is about the time taken to treat these problems: England is going to through a bit of a scandal at the moment about missed waiting time limits in A&E departments.

The maximum time from arriving at A&E through to either being treated and discharged, or admitted into the hospital for further treatment, is 4 hours. And that time limit must happen for 95% of patients.

And we're currently worried because at the moment it's over 90% (but less than 95%) of patients get treated and discharged or admitted to hospital within 4 hours.

We have the advantage of free or low cost primary care, so most people don't need to leave minor problems to fester until it's turned into a severe problem.

> Really, it's a fucking stupid question. Of course Europe's socialised medicine will treat broken arms.

Seriously, WTF? Where did I ever say broken arms don't get treated? Are you seeing a dumb American in my post because that's what you want to see?

The only thing I even wonder is where the appropriate place to go to get it treated would be. In the US, you can go to an emergency department or an urgent care facility. The urgent care facility is the most appropriate place: you will get seen promptly and they are equipped to handle it, and it will cost less than an ER visit (even after insurance, typically). You will get seen in the ER, but not quickly, and you will probably pay more.

"does the concept of urgent care exist outside the US?", someone else mentions A&E and you say that doesn't count because broken arms.

To answer your point: in England we have:

NHS Choices, a website that provides evidence based advice

NHS 111: a free telephone helpline where health care professionals offer advice, or arrange a call back from a doctor, or recommends a visit to an doctor (and arranged an out of hours doctor if needed), or recommends minor injuries or A&E (and arranges ambulance treatment if needed)

Pharmacy: all pharmacies offer health advice

GP surgeries have GPs but also nurses who can provide a range of treatment including minor surgeries

Minor Injury Units provide treatment for minor Injuries

Accident and Emergency provide treatment for life threatening and other severe accidents - bit they're also misused as walk in treatment centres for a range of mild conditions. Some injuries would mean you get transported to a different hospital after being stabilised -- severe chemical burns would be one example.

I've missed out midwife-led birth units, and all the mental health stuff.

For a broken arm you'd go to A&E. They have to treat it and discharge you within 4 hours. Or you could go to minor injuries, where you'd probably get treated within 4 hours. A&E would have better scanning imaging options.

All of these are free at the point of delivery.

They will also escalate you pretty quickly of you go to a Minor Injury Unit with something that turns out to be reasonably serious (see comment elsewhere)!

You're using a bunch of US-specific names and I don't know how they translate. But of course anywhere will have a variety of facilities appropriate to different severity issues; the specifics vary from country to country. And of course if you go to the wrong place you might end up waiting longer, but will still be treated or at worst referred to somewhere that can treat you appropriately, and anything urgent will be treated appropriately quickly.

I was very ill in Barcelona and was told by relatives there wasn't a point in going to the hospital unless I wanted a 6 hour wait for ibuprofen.

Same in USA, unless you still have a knife stuck in your chest. IN USA, that ibuprofen might cost you $250, along with the $XXXX for the doctor's visit. Maybe I'm exaggerating with $250, but having some outrageous bills, I wouldn't be surprised if they bill you separately for the pill AND for opening the bottle and getting one for you.

https://www.google.com/search?q=emergency+room+visit+cost

Yea the situation in America is different - they'll charge you thousands of dollars for tissues after your hours long wait time.

https://www.vox.com/2016/5/13/11606760/emergency-facility-fe... "Colette turned out to be completely fine. A doctor ran her finger under the tap, stuck a Band-Aid on her pinky, and sent the family home.

A week later, something else showed up at home: a $629 hospital bill for the Band-Aid and its placement on Colette's finger."

I'd charge someone the same if they required immediate service for something silly. People in the USA will go to the ER for the common cold

This attitude silly, it is not always obvious to non-doctors what is an issue. For instance my 2 year old son got his finger caught in a reclining chair, it looked terrible but there was no real issue.

I am sure the opposite may apply to head injuries.

Having lived many years in the US and Europe, wait times in Europe are shorter. This includes emergency room visits, doctor office visits, and physical therapy. Just for example if I was more than 5m late for my physical therapy in the UK, they wouldn't see me. So zero wait time for that. At the doctor I would make a phone appt ahead of time and I usually had to wait 5 or 10m. Also no insurance forms to fill out or any of that annoying extra work.

I live in Madrid and my experience hasn't been even near that bad.

I have only gone to emergency services once, luckily, and it was a very brief wait. For more routine procedures, waiting times are even shorter.

On the other hand. I have had some trouble when I've needed certain specialities which have less available staff. Some relatives of mine have had to wait months for surgeries (not too urgent ones, luckily).

It's an imperfect system. Some hospitals are in terrible shape or overwhelmed, and some services or specialties have long waiting times. Many doctors are overworked and underpaid. But still I think the experience for most people is very positive.

I live in Catalonia, the same region as Barcelona.

If you only need ibuprofen you should not go to the hospital, you must go to a CAP (Centre d'Atenció Primària, Primary Assistance Center). My experience, in a small catalan city, is that sometimes you wait ten minutes, sometimes a couple of hours.

Hospitals can be croweded in Barcelona during flu epidemics or similar, but it is not often the case.

Do you need a prescription for Ibuprofen in Spain? Strange. In Germany, go to the drugstore and buy it yourself. € 10 for 100 400mg pills. And if you are ill, usually you go to a doctor near you. Only in real emergencies, go to the hospital.

I assume the parent's point wasn't that you need a prescription, but that you're unlikely to receive anything more than ibuprofen.

In Japan a a normal person will pay a little bit over $100 per month for an insurance card that can be used at any clinic or hospital. People under a certain level of income don't have to pay.

Since a visit to the doctor and medicine is rarely over $10-20 it means basic healthcare is something people don't have to worry about, and keeps people out of the ER (since it costs the same anyway).

Anecdata: Can be at least 15x faster in Europe (NL) than US.

I moved from the US to NL. I've had a (similar) knee operation in both places, on the same knee. Both times involved an ER visit, referral to specialist, planning an MRI, getting a diagnosis, consultation with specialists, surgery, and physical therapy. The Dutch system was approximately 15x faster than the US system (Kaiser): 10 days from ER to OR, vs 5 months in the US. My brother is currently going through a different problem which is following the same trajectory as my knee, when I ask my Dutch doctor friend he is astonished at the hoops my brother has to go through to get action taken.

US:

* ER - unable to straighten knee (incredible pain). Happened before but never for this long. After many hours and extreme pain, it finally clicked into place in the ER.

* Schedule GP visit for referral to specialist (can't go directly!) Took forever.

* Schedule Specialist visit. Took forever.

* Specialist said it happens sometimes, could be several things, best to wait and see.

* 2nd ER visit required. Scheduled a specialist (not available for 30+ days). Talked to a out-of-plan specialist, said the problem was clear: it's the meniscus, you need an MRI to confirm, and will probably need surgery to remove parts or stitch it in place.

* Specialist appointment. Still wanted to delay an MRI. Lots of foot-stomping, finally scheduled an MRI (30 days later).

* In the meantime, another ER visit.

* Quite some time between MRI and specialist consultation. Diagnosis was clear. Surgery scheduled for a month later.

* Operation. Gives me some crutches and tells me to schedule PT for 30 days from operation.

* PT can't be scheduled, 30 days haven't passed! Once 30 days passes, PT can be scheduled. First availability is 30 days in the future (AAAAAAH).

NL:

* ER visit (same issue again out of the blue).

* Specialist sees me the same day. MRI is busy with higher-priority issues, schedules me for 2 days later. No GP approval. Doesn't need or want my info from the US, doesn't want to 'wait and see', just get and MRI and we will probably see the problem clearly!

* MRI. I wait in the hospital, discuss the results with the specialist 2-3 hours later. Plans an operation less than a week away.

* Operation, immediately discusses PT. Two In-plan PT organizations that the surgeon recommends are not available (fully booked), so she schedules me with an (also recommended) out-of-plan PT, and writes a letter to my insurer. They cover it.

So yeah, socialized medicine rocks.

> Schedule GP visit for referral to specialist (can't go directly!) Took forever.

I can go to a specialist without referral on my PPO.

> Specialist appointment. Still wanted to delay an MRI. Lots of foot-stomping, finally scheduled an MRI (30 days later).

I got my shoulder MRI within 2 days after doctor visit.

> PT can't be scheduled, 30 days haven't passed! Once 30 days passes, PT can be scheduled. First availability is 30 days in the future (AAAAAAH).

Not sure what this is, I had surgery for my shoulder and was doing PT after 4 days post op. why did you have 30 day restriction?

> doesn't want to 'wait and see', just get and MRI and we will probably see the problem clearly!

MRI's often have high false positives, in my case a torn labrum would be seen in > 70% adults over 45 with no symptoms or pain. Scheduling surgery within a week merely from MRI sounds scary and irresponsible. Why would you want to jump to surgery first when its always available as a last resort. Wouldn't you want to see if something else would do the trick without surgery.

Also, did you research how experienced the doctor is in doing this particular type of surgery, is he upto date with latest techniques, whats his malpractice rate ect. Jumping into surgery with some doctor that you just happen to meet is scary. A botched up surgery is something you have to live with for rest of your life, its irreversible decision.

I'm not sure what the general point is you're trying to make. Mine was to answer, in my experience, whether or not wait times and general 'hassle' is higher in places with more socialized health care than the US. My (limited) experience in NL, and that of those I know here and in the US, is that wait times and hassle are much lower.

It could be that this is due to irresponsible MRI'ing and unneeded operations. If that were true it would be very interesting, since that's the opposite of what people assume when they think of socialized medicine.

I would also assume that it would be more expensive per capita, which it doesn't appear to be: https://data.worldbank.org/indicator/SH.XPD.PCAP?end=2014&lo...

It could be that all these super-fast decisions are more expensive, but kill a lot of people sooner, thus saving everyone on healthcare. This also doesn't appear to be the case (life expectancy at birth is higher). https://data.worldbank.org/indicator/SP.DYN.LE00.IN?location...

Anyway, to answer your specific points:

- PPO vs HMO: Nice that you have a PPO. That option wasn't available to me. In the Netherlands, I can pick my insurer freely, my employer has no say in the matter (costs are 100-150 euro a month). Some insurers have in-group agreements, some do not.

- On getting MRIs: I can't tell you when it's correct to order an MRI or not. All I can say is that both MRIs were hits for a torn meniscus, and both operations also bore out evidence of this. Both times it was also a textbook case of a torn meniscus based on my symptoms. Both

- Researching Surgeons: Yes, I researched both surgeons (and hospitals where the surgery was performed). In the US I had fewer options (Kaiser only), in the NL the specialist gave me a list of other specialists who I could get a second opinion from, should I want to.

>I'm not sure what the general point is you're trying to make.

Point I was trying to make is that you are comparing HMO to NL insurance that allowed you to see specialist directly. I don't think thats a fair comparison unless NL requires all insurance to cover self referral to a specialist.

I know nothing about NL healthcare but according to their website

https://www.govt.nz/browse/health-system/gps-and-prescriptio...

" In most cases, you need to visit your General Practitioner (GP) first so they can refer you."

What kind of insurance did you have that allowed you to self refer ?

You seem to have compared apples and oranges and came to the conclusion that oranges rock.

My girlfriend had an emergency while I was in UK and we had to wait around 5 hrs to see the doctor and had to go through series of rooms each getting progressively smaller than the pervious one. First room had hundereds of people. This was a smallish town near london.

Why would you go to the hospital to get an ibuprofen in the first place? Go to a doctor.

Why would you go to a doctor to get an ibuprofen in the first place? Go to a pharmacy.

Is ibuprofen actually not OTC in some countries? It's like one of the safest painkillers ever.

I think the heavier doses require a prescription, but you're right. You can just get it OTC at your pharmacy most of the time.

Why would you go to a hospital for ibuprofen? Isn't it over the counter there? I've waited at the ER in the US for hours because there was limited staff and more serious cases were handled ahead of mine.

Exactly. Most gov healthcare result in rationing an long wait times and sucks up massive amounts of resources.

We need better private solutions. We need yelp for medical comparative price shopping, with consumer and expert reviews.

Really well executed gov care can be OK but is rare and usually does nor stay good long term.

The current "free market" in healthcare is completely hamstrung by regulation and unspoken anti-competitve practices and broken intermediation via medical aid funds and gov medicare and other programs.

> Most gov healthcare result in rationing an long wait times

Most private health care avoid visible rationing by letting people pay to skip ahead in the queue based on economic means instead of urgency and clinical need. That the rationing and queuing isn't visible doesn't mean it's not there. Only that in the US people sit at home wondering how to afford treatment instead of wait in line based on triage based on urgency.

So yes, the US system is superior if you're one of the lucky ones that can afford to pay your way past those who need treatment more than you.

> and sucks up massive amounts of resources.

US healthcare is vastly more expensive for the users than most socialised options..

Why not allow queue jump payments in socialised care, to subsidise the rest of the queue?

Effectively many countries do allow this to some extent.

E.g. a significant portion of private care in the UK is provided in NHS hospitals by NHS staff either outside of their normal shifts arranged by private companies who pay the NHS for access to operating theatres and the like, and by NHS trusts themselves who are allowed to provide private services on top of their socialised care.

A market exception is Norway, which as one of very few countries have very strict limitations on what private services can be provided at all on the basis of an argument that as long as healthcare resources are limited (e.g. there is a practical cap on number of doctors - train too many and they don't get enough experience on real cases to gain the necessary skills), it is seen as immoral to allow people to queue jump.

All healthcare involves "rationing"; that's what we call scarce resources divided out along some kind of priority basis.

"Free market" healthcare is "rationed" on the basis of ability to pay.

>> We need yelp for medical comparative price shopping, with consumer and expert reviews.

I'm sorry, this is the stupidest thing I've heard in a long time. What you need is being able to go to any doctor, any hospital, at any time, and knowing you won't pay for it at all, ever, as it is in many countries around the world. Not competitive comparative pricing. If you are in pain you don't want to be shopping around for a good price.

I(as a European) think the difference is that at least in my country nearly all hospitals are public, there's very few private hospitals and they are not very good. So the government can afford to give everyone great healthcare because they are using their own hospitals to do it - they set the rates for operations and hospitals don't have billing departments because they don't need them - even if someone is technically not covered by our national health insurance(say, a non-EU visitor) they are usually treated for free anyway because finding out how to bill them is more hassle than it's worth, unless it's a major operation. If you just need an xray and a cast they will do it and send you home. In US almost all hospitals are privately run, so corporations dictate prices - even if the government wanted to pay for everyone's care it would end up paying a lot more than Europeans are paying, because once again, the money would go straight in corporations pockets.

I mean, I'd be more than happy to learn more if I'm wrong about this, but at least this is my impression.

> In US almost all hospitals are privately run, so corporations dictate prices - even if the government wanted to pay for everyone's care it would end up paying a lot more than Europeans are paying, because once again, the money would go straight in corporations pockets.

This is not at all how medical billing works.

First of all, many hospitals are structured as nonprofits. Whether or not they are, most hospitals are also barely staying afloat - a hospital that's turning 2 1-2% profit these days is doing astoundingly well. Many are going under and getting bought out by larger chains or by insurance companies.

The reason that they are doing so badly financially is because, in general, they are legally forced to lose money on half of their patients. Medicare sets its reimbursement rates unilaterally, and it reimburses about 7% less than COGS. In other words, if a vaccine costs the hospital $100/unit to purchase wholesale in bulk, Medicare pays them $93 for it. That means they've already lost money, even before they have to pay their doctors and nurses and building maintenance, etc.

Providers make up for this by over-billing the private insurers. That's why you see these stories of people who go to the ER and got charged an absurd amount for something. The hospital was presenting them with the same price they charge to private insurers (by law, they have to, at least on the initial bill). They don't actually expect individuals to be able to pay that, and in fact, an uninsured person is almost always able to negotiate that bill down if they know to try.

In short, yes, medical billing is totally fucked up. But it's not fucked up because the money goes to line corporations' coffers - it's fucked up because Medicare abuses the system to effectively pad its own budget instead of going to Congress to increase their budget.

And that's why, ultimately, Medicare will fight tooth and nail to prevent single-payer healthcare or any meaningful reform whatsoever in the US - they're the ones who stand to lose the most from it.

The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland. Standardized, subsidized insurance with some mechanisms to increase subscription.

The problem is that it also mixed employer mandates and Medicaid with that stuff. In principle Medicaid is good, providing care to low income people, including millions of children. The problem is that it is a huge off the books tax scheme, mandating care that it doesn't fund. And with guaranteed issue individual insurance available, employer requirements should have been reduced, not increased.

> The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland.

It did not, because it still kept private insurance companies in control and still made it impossible to negotiate drug prices. It seems better than what came before it, but I'd argue it may have even done some damage, (in terms of the debate towards universal health care), since its failures are now ascribed to 'socialised healthcare' by its opponents and equated to a single payer system, whereas in reality it is in may ways the polar opposite.

Germany has private insurance companies and all US insurance companies negotiate drug prices. Even the specific drug prices that the talking point says Medicare should be able to negotiate are negotiated (by the private companies that administer that part of Medicare...).

Most Germans are covered by "sickness funds" but those with higher incomes have the option of buying private insurance. And the sickness funds aren't really single payer, spending is negotiated regionally, not at the national level.

> Germany has private insurance companies

Yeah, practically every country does, if you want it. The problem in the US is that it is practically the only option for many, not a choice.

> and all US insurance companies negotiate drug prices

But that's the problem, it should not be done by private companies, but by a state/national body with more power.

> Even the specific drug prices that the talking point says Medicare should be able to negotiate are negotiated (by the private companies that administer that part of Medicare...).

Yeah, private companies...

> Most Germans are covered by "sickness funds" but those with higher incomes have the option of buying private insurance.

I am not saying anything about the option of buying private insurance, I am saying it should not be a requirement for basic coverage.

> And the sickness funds aren't really single payer, spending is negotiated regionally, not at the national level.

That is semantics, the principle is the same.

In Germany private insurance is the only option for self-employed. It is precisely a mandated requirement for basic coverage. The two "public options" are not available to freelancers, and anyway the public options are more akin to competing non-profit insurance companies than state-administered health care like in France, the U.K., or Canada.

Buying insurance is also a pain because unlike in the US under ACA, German insurance companies are able to charge higher premiums for pre-existing conditions up to a mandated Basispreis (approximately 3x a healthy person's rate - somewhere north of 600€ per month). Pre-existing conditions can include a hospital visit with a null diagnosis.

There's a lot more to it, but I get frustrated when people talk about European-style health care as if it means something concrete, when there are such a wide range of policies across Europe.

Abusive drug pricing would go away nearly instantly if the Medicaid formula considered the lowest effective price paid (by accounting for rebates when calculating Average Manufacturer Price).

It's really only patented drugs where it matters, most generics in the US are all but free (the exceptions to that pattern mostly have few users).

What? AMP accounts for rebates.

Add in the Medicaid rebate and Medicaid pays almost the lowest price in the US for drugs. I think the VA is the only org paying a little less than that.

The Swiss system has mandatory private insurance. It's very ACA-like.

Drug costs are 10% of health expenditures in the US. Not sure this is a critical issue for controlling costs.

> The ACA ("Obamacare") did a lot to make the US system look more like Germany and Switzerland.

In Germany you're automatically enrolled in public insurance unless you opt out and choose private insurance, no? That's completely different from the ACA, which has no automatic enrollments (if you're application gets stuck at the exchanges, good luck), no option to keep public insurance (if you're on Medicaid and you're income rises, you might have a month long gap between being kicked off Medicaid and getting a new health plan), pushes people into employer provided plans, and generally has a host of problems and complications that lead to 10.9% of Americans still be uninsured (and those who are insured still facing massive problems with healthcare costs).

I said "look more like". I even listed the things I thought were similar.

Automatic enrollment is rather obviously going to be more effective than a tax penalty, but the tax penalty is at least a mechanism designed to increase subscription.

There are a bunch of bad compromises in the ACA, but the comment I replied to was mystified that the US apparently isn't even trying things that have worked elsewhere, which is just wrong.

> There are a bunch of bad compromises in the ACA, but the comment I replied to was mystified that the US apparently isn't even trying things that have worked elsewhere, which is just wrong.

I'd say that they are right. The ACA is completely different from the German system. I mean, I could argue that the Republican healthcare plan is similar to the German healthcare system since it would have a public Government run system (Medicare and Medicaid) and subsidized private insurance (vouchers), but that's not a particularly compelling argument. When two systems are completely different, talking about a couple of ways they're slightly similar if you squint and don't look at the details doesn't seem particularly useful.

I guess I think that guaranteed issue of a plan with minimum standard coverage is a lot more important than the details of how payments flow through a system.

I'm certainly more concerned about the possible repeal of the federal insurance standards, the "essential health benefits" than I am eager for a public option to start competing with insurers (which I don't think insurers are doing a whole lot to either control or drive medical costs). I wouldn't mind a public option, I just don't expect it to matter much.

The ACA is a huge failure.

it massively increased everyone's premiums and deductible, and made it more or less impossible for many poor people to afford private insurance. If you ask many americans here how much they pay per month and how large their deductible is, you'll realize Obamacare actually wound up being absurdly expensive catastrophic insurance instead of universal coverage.

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