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Comment by martythemaniak | Hacker News Reader

As an outside observer, sure, you don't strictly speaking need them in some theoretical America, but in the America I see there's a large group of people who do not believe government can or should do this work and will work very actively to make it happen. The last bit is crucial.

Suppose that you are disappointed that Obamacare did not contain a public option. Suppose that Obamacare did contain this provision in the law, it would most likely be implemented the way the cfpb was. The cfpb is great, except how good it is depends on how good the government in place is. If there's people in government that want it to fail it will simply fail. Thus merely incorporating the public option into law is not enough to have to have a dedicated political body that wants to make it work. I don't think that's the case in America.

I guess what I'm saying is, the specificity of the law doesn't seem to be as important as peoples dedication to making things work

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A majority of voters of both parties support Medicare for All policy proposals.

https://thehill.com/policy/healthcare/403248-poll-seventy-pe...

Voters were split on the ACA mandated carriage of private insurance.

I have my doubts.

The term ‘Medicare for All’ is a fairly new term that has only been exposed to public discourse (of the sort that reaches the average unengaged voter) within the bubble of Democrat primaries.

It’ll be instructive to see how these numbers stand up to scrutiny during the general election—assuming the Democrats elect someone who supports it as advertised.

It’s pretty well documented by political studies the delta between what voters broadly want and what political leadership in the US generally delivers. That poll covered Democratic, Republican and independent voters. Independents being the unorganized third party in similar size to both other main parties.

On the plus side, the recent Democratic debates have delved into the subject in impressive detail, with candidates grilling each other over differences, as well as the moderators. It's a remarkably nuanced discussion within the party. Not that most voters care about nuance, but for those who do, the information is there.

In addition, the "Medicare for All" branding is deceptive, as the plan on offer is nothing like Medicare.

Some candidates are trying to jump onto the brand without supporting the core proposals, but the Sanders/Jayapal senate and house bills for Medicare for All are the core proposals by which the others should be judged.

Yes, the Sanders and Jayapal bills are the ones I meant are nothing like Medicare. I was trying to say that those "Medicare for All" bills are nothing like the current Medicare program.

In my state at least, the ACA bankrupted the smaller participants and allowed for the Blue Cross to eat up that market, all while increasing their price 50%-100% year-on-year. Forcing someone to purchase these products, combined with our campaign finance problems in the US, I wonder if this wasn't a submarine corporate welfare bill.

More charitably one might call it a half-measure when one needs a full.

For better or worse, those same anti-government people do functionally support social programs from which they directly benefit. They may pay lip service to their ideological stance on the subject, but the money is green and they will happily continue to take what they are "entitled" to.

Their major opposition is to social programs they don't benefit from.

Exactly. Which is so strange when you see which states are against government involvement and which states need the most government assistance.

Maybe we should take them up on their offer.

My neighbor is a good example. He is on Medicare but he is violently opposed to socialized health care and Medicare for All.

This is extremely common in middle America where I live. People using social services but opposing it for others. They believe they have earned and deserve it, and the others are abusers who haven't.

There is nothing ideologically inconsistent or hypocritical about saying "I don't think this government program should exist" and also making use of the program that currently exists. There's a game-theoretical issue here: you might want everyone to stop, but unilaterally stopping hurts no one but yourself.

Along the same lines, from a different political perspective: many people advocate higher tax rates, but few people will unilaterally send in a higher tax payment or decline to take a deduction.

The Netherlands has mandatory private insurance and it works well for them. The insurers are heavily regulated though.

"Mandatory" is the key thing, though. The system doesn't work if all the healthy people opt out until they have a crisis and show up uninsured at the emergency room.

See: https://www.kff.org/health-costs/issue-brief/how-repeal-of-t...

Do the Netherlands also have doctors who expect to make $300k-$1M/yr and drugs that cost 10x what they do in any other country?

No but they are high up on a recent list of doctors salaries[1]. US is #3 and the top spots are the usual European countries for top salaries.

[1]https://www.careeraddict.com/top-5-countries-with-the-highes...

Before clicking on the link, I guessed Switzerland would be ahead of the US, and I was right. Switzerland has ACA-like mandatory insurance that's even more expensive than ACA.

Notice how for the US the article doesn't even mention the upper bound for specialists. That's because there is none, and they expect that.

GPs are quite affordable, if it was just the GPs I wouldn't mind paying them $200-300 directly for a visit. But the specialists can really get you crying for mercy, especially if there's no insurance company between you and them.

I broke a leg a few years ago, and if I did not have insurance, the cost to me would be $55K (probably more, this doesn't count the follow-up visits). Surgery alone was $30K+ for about 2 hours of work, not including cost of anesthesia ($5K). Insurance got the total down to about $7K, which is still a lot of money for a relatively run-of-the-mill surgery. Cost to me was my deductible: $1K.

As a Canadian, it just baffles me reading these kinds of posts. Like, I could break my leg on the way home from work today and any surgery I needed would be completely covered other than a $45 ambulance charge and maybe $50 for painkillers or whatever was needed afterward. (And prescription drug coverage is on the radar going into this fall's federal election, see: https://www.ndp.ca/pharmacare, https://www.greenparty.ca/en/our-vision/health-care)

No drama, no discussion, no appeals or scary forms to fill out. Is this really what Americans mean when they talk about "freedom of choice"?

As a US citizen, your tax rates and multi-month waiting lists baffle me as well.

Well, that is the perspective that is preventing the situation from improving. However, if you take the time to look into it, you may find that the situation is not as dire as conservative talk radio pundits would have you believe.

For starters, nobody waits in an emergency. If you need urgent care, you get it— with no second mortgage needed. Waiting times vary a lot across the provinces and depending what kind of care is needed. Cancer treatment, for example, is very fast.

Generally speaking, wait times are a function of overall funding, and funding has been cut repeatedly over the past three decades, as Canadians have consistently voted for tax cuts over investing in health care. See the decline as reported by the Fraser Institute: https://www.fraserinstitute.org/studies/waiting-your-turn-wa... (Although of course, they're a right-wing think tank, so their agenda is further tax cuts and privatization... take from it what you will.)

As far as taxes, again beware of what you hear from US-based commentators about how bad it is. In fact, the income tax we pay is almost identical: https://en.wikipedia.org/wiki/Comparison_of_Canadian_and_Ame...

Getting into a doctor in the US requires long waits, too! The last time I bought insurance, I decided to get a long-overdue checkup, so I went hunting for a doctor in-network. There goes one afternoon, just calling around to GPs to see if they were accepting new patients. Nope.

A few weeks later I tried again and found someone could see me three months from then!

And I'm paying $400 a month to get this with a $6500 deductible??

The "long wait times" critique of Canadian health care makes no sense in the face of actual American health care access. It's the same here, except we pay coming and going for it.

Don't look at doctor salaries. Look at per capita costs. And by that measure, the US is far more expensive than Switzerland, the Netherlands, or any other country.

It's not that there's something uniquely good about those countries' models. It's that there's something uniquely bad about ours.

> Don't look at doctor salaries. Look at per capita costs.

Per capita costs are in large part (though not completely) determined by how much providers charge. Why shouldn't we look at "doctor salaries"?

Because when you look at doctor salaries out of context, you get a misleading answer.

I looked it up. The US health care system costs 25% more than Switzerland (the second most expensive in the world). That's not because of doctor salaries.

The Netherlands expenditure per capita is also quite high. I cant believe how high it is actually in Western European countries. If you compare it to South Korea or Singapore the Netherlands looks just as expensive as the US of A, just on a different scale.

What also works in The Netherlands is that insurance is not tied to employment.

I've heard that many American workers quit in the early days of the month, so that their ex-employer is still covering their health insurance that month, and their next employer (presuming they have another job to go to) picks it up in the next month. I can't imagine how many people are stuck in jobs they hate just because they are afraid to be without insurance. It can't be good for anyone.

> I can't imagine how many people are stuck in jobs they hate just because they are afraid to be without insurance. It can't be good for anyone.

It seems like it is good for employers for employees to be more precarious and dependent on them.

I really doubt anyone times their quitting to the start of the month. People just up and quit because they don't want to work.

Also, many health insurance plans from your employer don't start immediately. Sometimes you have to tiptoe around for 90 days until you get coverage.

Source: American, and it's always funny to hear what people in other countires 'think' about the USA

Actually it's worse, I've done much more involved backbending and hoop jumping to make sure I was covered between jobs than just quitting around the beginning of the month.

I've most definitely timed my job changes to insurance coverage. And luckily in the software industry, insurance tends to kick in on day 1.

>I really doubt anyone times their quitting to the start of the month. People just up and quit because they don't want to work.

I won't defend the specific scenario given but the second sentence there is a huge generalization. You're correct that insurance plans don't start immediately, but that also leaves people in a difficult, even if temporary, situation.

Europeans however are correct to think that the healthcare system in the US is abysmal, because it is. All this goes without saying that employment-tied insurance puts people in precarious positions, which is obvious.

My (family) insurance plan carries a $2,000 monthly premium charge (which is far cheaper than the care we've received in the last year). I timed my last two departures to maintain coverage for the month, as its the only way I can get time between jobs without having to (immediately) purchase health insurance.

It would be nice to not have to do that, but in the grand scheme of things (less than) a month is not a very long period of time.

N=1 I 100% quit the first of March such that I was covered for that month. Pretty much my only option to keep my perscriptions and scheduled blood tests affordable. And Im a tech worker with piles of disposable income, imagine if the potential 1000$ medical charge wasn't something I could absorb.

The US systems is royally fucked; sardonically quipping about "those crazy foreigners" doesn't make it better.

I have both done this and advised other people to time their departure like this. I take a few weeks off between jobs and I only had to get screwed the one time before I learned I had to take that into account.

Nevermind ..

> Just pass a law making it illegal for teens to smoke

Did anywhere do that? I see laws making it illegal to _sell_ cigarettes to teenagers, and I see laws making it illegal to _advertise_ cigarettes in a way that will attract teenagers but I don't see any laws that jail teenagers for smoking.

https://tobaccocontrol.bmj.com/content/12/suppl_1/i6

This goes into more detail - yes, in some states it is illegal for teens to possess tobacco, but the penalty is usually something like a small fine, or you have to attend a class.

No teenager has been to jail for smoking a cigarette. Underage possession laws have penalties like (usually small) fines. People might go to jail for selling tobacco to minors, but that is different!

Nevermind ..

Not all legislation has the citizenry as its subject, or creates criminal offences. Legislation can also bind the actions of government, or establish rights which must then be fulfilled by a government.

Public healthcare is typically not provided by creating criminal offences for citizens.

Nevermind ..

That's just not true:

Page 131 of the ACA bill:

"In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure."

For a codified citation, this is 26 USC § 5000A(g)(2)(a), an is accompanied by a provision also ruling out tax liens and levies at § 5000A(g)(2)(b), so neither criminal penalty nor the usual compulsory fallback civil collection methods are permitted by the ACA.

https://www.law.cornell.edu/uscode/text/26/5000A

Those same people oppose all sorts of existing social programs too, and those programs continue to function anyway.

The CFPB was a special case as a small agency with little visible impact that few people even knew existed. Messing with people's health care is quite another matter. See also: “keep your government hands off my Medicare.”

> Those same people oppose all sorts of existing social programs too, and those programs continue to function anyway.

Sorta, barely.

When I was unemployed a few years ago, it took me months to get basic state medical coverage in Kentucky. I had to spend hours waiting in line at the office because the phone service simply didn't work, and then had to jump through endless bureaucratic hoops.

As a single guy who's fairly bureaucracy-savvy, I eventually managed it. If I'd been a harried and undereducated single mom, I might never have made it through.

That was the second time I had to sign up for Kentucky Medicaid. Five years previous, it was a breeze. Then a Republican governor cut funding to the bone, and now it's awful. That's not an accident.

Most Americans vote with their feet to avoid this sort of governance.

The kind of people who need Medicaid don't always have the luxury of relocating themselves and their family to another state.

> I see there's a large group of people who do not believe government can or should do this work and will work very actively to make it happen

do you have any numbers to back that up? There's a very 'vocal' minority holding that opinion but don't assume that group is large enough to matter when it comes to voting for/against it.

You can see Gallup's historical polling results on this question here: https://news.gallup.com/poll/4708/healthcare-system.aspx

Since 2000, the percentage of respondents who have said that providing healthcare coverage "is not the responsibility of the federal government" has fluctuated from a low in 2006 of 28% to a high in 2013 of 56%. (In their most recent survey, it's 42%.)

I've always wondered why people seem to think it should be "the responsibility of your employer". As someone who didn't grow up in the US, who is now a US business owner, it seems totally insane but everyone just nods..

This is the crux of the problem. Sometime ago- the wise people in power decided to push the responsibility of medical coverage onto employers. Funny they chose that instead of housing or food- but thats what it is. Now everyone has to find a job that has health benefits- but employers are finding ways around it

That’s not what happened. The federal government capped wages during WWII, and in response the unions threatened to strike, which would have shut down the war effort. To mollify them, the health insurance that unions had negotiated as a fringe benefit from their employers was temporarily made tax-free (normally you pay taxes on the cash value of fringe benefits).

After the war, it was supposed to go back to normal — but people had gotten used to not paying taxes for their insurance benefits, and it became politically impossible to go back to the way things were pre-war.

Not only that, but there's also the problem of how you ask people the questions. When you ask, "Do you think we should have socialized medicine" a large percentage will freak out and say "NO! We don't want socialism here!" But if you ask them, "Should we defund Medicare?" they'll also loudly scream "NO! We need our Medicare to stay alive!"

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