Hacker News Reader

Comment by 2OEH8eoCRo0 | Hacker News Reader

This right here. Benefits shouldn't be tied to employer. Pay me more and let me control my money.

If folks are losing their jobs (assuming they don't have a nest egg which the majority of Americans do not have) how will they be better off being personally unable to pay for health care instead of losing access to their employer provided insurance to pay for healthcare?

Also - a lot of these benefits are things we'd generally consider "necessary" - if that's the case why would we open the door wider to allowing folks to continue being paid 7.25/hr and now not even have a chance at ever seeing a doctor?

Or, if that money is personally controlled is it going to be secured against debt repayment? Will individuals have a guaranteed right to pay for medical care before any paycheck garnishing?

We already have unemployment insurance, it’s easy to imagine something like government assisted cobra for recent job loss.

We already have Medicaid for people who are chronically poor.

It’s possible to decouple healthcare from a specific employer without moving to single payer or similar. I often like to point to Germany to show there is are much more varied solutions that can be tried than people are likely to say.

Conflating all these different ideas makes it harder to find an optimal solution, IMO.

It's possible...

Single bidder though. A reverse dutch auction in each market region for qualified providers to offer services, and if the price in that market isn't desired then short term bring in the military docs, and longer term fund the education of more doctors with the provision that they resettle among the target areas needing coverage.

The problem with USA's private healthcare system is that it refuses to train enough doctors. You're supposed to overproduce doctors to drive prices down.

Medicare for all: individuals shouldn't be paying for healthcare personally.

Medicare has premiums, deductibles, co-insurance and co-pays you realize?

It doesn’t have to, that’s simply a policy decision. Policy can and does change.

The why call it “Medicare for all” if it’s not Medicare?

Is this like “defund the police” where we aren’t trying I actually defund them?

Marketing and branding. "Medicare" is what most are familiar with, even if there are some tweaks to make.

So does my PPO plan, that’s not the point. The point is that my healthcare doesn’t become more expensive when I’m unemployed.

Yet the cost per head in the US of Medicare is higher than the UK’s health system.

That’s kot cost per head covered. That’s dividing government health spending by the US population.

The US pays enough in taxes to provide great healthcare to every citizen. It chooses not to.

I don't mean to speak for the parent but I'm pretty sure it's implied in this scenario that you'd move to universal health care.

I don't think so - the implication I read from "Pay me more and let me control my money." was an entirely private individual insurance market. If I misread the comment my apologies.

I had the same impression, which is an insane idea. The reason people should have universal healthcare and universal pensions and so on is to use society's size to shield everyone from individual risks.

> which is an insane idea

Swiss American here. It's not insane [1]. The state of healthcare in America is so poor, I would caution us from referring to anything as insane without empirical evidence.

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

If people are arguing over what I meant, this system is the one I was thinking of.

The US already implemented tax penalties on no-coverage and could adapt them to be auto-enrollement in basic coverage at a high deductible.

I have nothing against single payer, but I don't think it is worth fighting for the details of it in the US system when it can be emulated like it is in Switzerland.

(But for pricing to be fair, the more important problem in to reverse the incentive for removing lower risk individuals into group plans and make sure everyone is considering the actual price of their insurance.)

It's not too unreasonable if we could also have a transparent, competitive, reasonably priced healthcare market. Doing that would require a lot of changes to how we conduct medical school admissions, residency, and medical licensing that'd be fought tooth & nail by the healthcare industry, though.

I don't believe a transparent healthcare system is realistically achievable without essentially moving over to full government control - I wrote up a thing above[1] if it's of interest.

1. https://news.ycombinator.com/item?id=26187260

Part of the issue is that the insurance pool needs to include low risk individuals to work.

If everyone under 30 says “I won’t shell out for private insurance, and if something catastrophic happens, fuck it, I’ll declare bankruptcy”, the system falls apart for everyone. Unpopular as it is, this is the logic behind the ACA mandate.

It’s a terrible outcome, unless you’re rich enough not to care about insurance to begin with. You get coverage that’s unaffordable for higher risk people who need it, and uninsured “healthy” people one stroke of bad luck away from disaster.

That isn’t insurance. You don’t need low-risk people in the pool for insurance to work. Insurance premiums are technically derived from individual risk, not the risk of an arbitrary pool. Pooling is only done to reduce the tail risk of the underwriter, it doesn’t materially change individual premiums.

You do need low-risk people in the pool if you want low-risk people to subsidize the insurance premiums of high-risk people. That is not insurance, that is just socializing the premiums of high-risk individuals. These distinctions matter when discussing policy. Socializing medical costs may be the appropriate policy choice but lets not smuggle it in by abusing a term of art like “insurance” which means something very different.

That is how your employer provided plan works, however. They negotiate a rate for the whole group, not an individual medical workup and premium for each individual.

If you want to move away from that to “just pay me the equivalent comp directly and I’ll get my own insurance”, rates are going to get ugly.

If you only get insurance once it is too late it is not insurance either. Insurers have a financial incentive to avoid paying for expensive care. If early or preventative care is cheaper they will administer it while you are "healthy".

> Pooling is only done to reduce the tail risk of the underwriter,

Which, in the case of an universal service, is also the insured.

Was hoping a Republican Congress and President would at least attempt health care market reforms, but that didn’t happen.

Would be happy with a government run plan, too, just want our government to make some attempt to address the problem, whether from the left or the right.

A competitive market reduces costs and profits. Why would the Republicans do that?

If you use a market to reduce cost of healthcare, it'll reduce cost for easy to treat conditions by extracting maximum profit from more difficult or rare conditions.

Healthcare being a fundamental right, this fails by not ensuring people with rare conditions get it.

I don't know the details so I appreciate your comment. You cannot have privatized healthcare while simultaneously restricting the supply of medical professionals. That's not a free market. It's welfare for specific individuals.

The biggest drivers of health care cost have little to do with physicians, their training, or licensing although they do all contribute a bit. So to make any impact you'd need a much bigger list of things to change.

What are the biggest drivers? It feels like death from a thousand cuts.

I was maybe underemphasizing the labor costs - it's a real contribution. But you are right that everything is more expensive, and it's pretty interconnected. Big contributors: fee for service incentives, administration overhead, end of life care, inefficiencies due to fragmentation and licensing, insurance inefficiency (not the profit margin, but the tracking/coding level of detail), over subscription of expensive (e.g. capital heavy) procedures, pharmaceutical costs.

I'm reminded of https://slatestarcodex.com/2017/02/09/considerations-on-cost... when these discussions come up.

It already exists, visit healthcare.gov.

Pretty slick website too.

I agree - but the comment above was, AFAICT specifically advocating for removing both Large and Small Group insurance pools provided by employers from the equation. Folks currently get insurance from a variety of sources, Medicare, Medicaid, Military Tri-care, Fed/State/County Insurance, Self-funded plans - there's a lot of variety here. I believe the comment above was advocating for closing Small and Large Group coverage (and probably self-funded pools as well) in favor of those customers being dumped on the Individual market which does exist - and does definitely have it's own problems.

Oh, and the Individual insurance market predates the ACA and healthcare.gov - it was much harder to navigate before the ACA due to the pre-condition exclusions but there were a variety of plans on offer to individuals.

>I believe the comment above was advocating for closing Small and Large Group coverage (and probably self-funded pools as well) in favor of those customers being dumped on the Individual market which does exist - and does definitely have it's own problems.

The only problems I know of in the individual market are due to the fact that so many healthy lives are locked up in the government/small/large business group plans. If everyone, and I mean everyone was dumped onto the market, then there would be sufficient healthy lives to balance the whole situation. Basically, it would be the same as taxpayer funded healthcare, except you get to choose your insurance company.

>Oh, and the Individual insurance market predates the ACA and healthcare.gov - it was much harder to navigate before the ACA due to the pre-condition exclusions but there were a variety of plans on offer to individuals.

The individual market pre-ACA and the one that exists now are completely different. It's actually possible to compare different insurances in the one that exists post ACA due to standardization and certain stipulations for being ACA compliant.

>so many healthy lives are locked up in the government/small/large business group plans

Well, that and the fact that many young individuals who don't have health issues, aren't making much money, and aren't covered by employer plans are often opting out of paying $7K/yr or whatever for health care.

Employers require employees to pay for health insurance and subject them to deductibles and copays just like healthcare.gov. The government even pays for a portion of most of the health insurance premium under certain income amounts, so it’s not any different than people with health insurance via employers.

Also, bronze level health insurance is closer to $300 per month for young people, or $3,600 per year.

https://www.nj.gov/dobi/division_insurance/ihcseh/ihcrates20...

Of course, the deductible is massive but it’s the same with any employer sponsored bronze plan, just like a healthcare.gov bronze plan.

I don’t disagree. But the basic point is that a lot of younger people in poorly paying jobs still consider, whether one agrees or not, health insurance as being more than they’re willing to pay for.

Obama promoting the site on Between Two Ferns might be the most astute PR move by a President in the 21st century (35m views as of today)

I'm not only talking about healthcare. To get matching contributions to retirement accounts you have to use theirs.

Yes, I agree that there should be no tax benefits for employer's providing matching contributions to retirement accounts they can restrict investment options for.

I recently hit this up in Canada with a matched group RRSP which has a heavily restricted panel of options for investment and while contributions are matched and the transfer fees aren't too steep they are there and intended to capture clients within their spread of options.

I would prefer if group retirement plans had more flexibility on in/out flow and had to legitimately compete with the open market.

I'm not sure if you meant it this way, but way benefits work you'd actually be getting paid less (total compensation), as one of the driving forces behind benefits packages is it costs the company less than it would for you to get it on your own.

If you are happy with cash salary + (what benefits cost the company ) rather than the bigger cash salary + (nominal value of benefits) then this can work, but you have also be happy with the idea that some of the benefits you are used to become less (or un) affordable to you.

You're assuming that those "benefits" aren't something that can could leverage the scale of an entire country's government. The biggest example of a benefit that's cheaper for a company to provide in bulk is healthcare, and basically every developed country has demonstrated that it's cheaper to let the government handle that. Pensions, paid days off, childcare, and others all make sense to provide at a societal level rather than relying on a company to do right by its employees.

I’m not assuming anything, I’m talking about what you could reasonably expect today of your company if you made this tradeoff.

What you were able to do with that cash is a separate issue. Over time it could become better, sure.

I hear this point a lot about the power of group purchasing. If everyone purchased their own insurance the market would be larger and be able to offer larger discounts.

Doing it at the company level doesn't make sense. Companies with larger sizes have better leverage under this model.

Would the purchasing power be greater at the state level or federal level?

I don’t think it’s purchasing power so much as risk pool. Or really a bit of both, it’s number of healthy vs unhealthy people in the pool. Employees of a company tend to be healthier. People on ACA tend to be part time / low wage, and have more health issues. Insurance companies pass that through by charging based on risk. I imagine what would happen is this would average out, the total cost(including employer contribution) would go up for most of the hn crowd who can afford it, but down for others who currently can’t

Reply on news.ycombinator.com