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Comment by BugsJustFindMe | Hacker News Reader

I agree, but we can't talk about "over" without talking about where the line is.

Sure we can.

Some loaves of bread are worth a dollar. Some are worth ten dollars. The exact line is hard to pin down... but a $1,000 loaf of bread is probably excessive.

This is semantic nitting and wastes time when for all practical intents and purposes humans understand the assertion being made and find it agreeable.

You can talk about jetliners cruising over towns without discussing the height of a town's buildings. No one here seems to be in disagreement that the line is lower, which is all we need to know to describe the markup as over.

Fundamentally, you have a pretty good point here, since the system we have has two halves that are fundamentally at odds:

One part "free market -- maximize your profits as much as you can and get rewarded by a skyrocketing share price!"

And one part, unspoken except in the PR BS put out by the insurance companies, "Try to improve the health of patients and have them not die!"

The only way the two can coexist at all is if someone draws some lines like you are suggesting. I know that there are some (probably easily manipulated) laws stating that X% of premiums have to be "spent on care" and if they get too high overall margins on your group, they have to give your employer a rebate. Of course, who knows whether you'll see that money.

If we just say "maximize your profits" (and indeed, shareholders 'should' sue them if they don't) then it's obvious that morally bankrupt scum that runs all these insurers would 100% extort people for 1000% profits on lifesaving drugs. It's the most logical course of action! People will pay infinity dollars to save their own lives/their loved ones, so let's soak them!

If it's not obvious, I believe that overall the "free market" part of this system is a failed experiment that should be abolished immediately, and not just because I want all of these companies' sickening, greedy executives to go straight to hell (where Brian Thompson is burning today).

It ceased to be a free market when we enshrined employer-provided plans into the law. If it were more like auto insurance where I can fire my insurance company and receive a pro-rated refund or renegotiate coverage in the middle of the year then it would be more free. But my employer negotiates for me on my behalf, and their needs are often at odds with my needs. And the whole "open enrollment" period thing creates a situation where the insurance company gets to be absolutely terrible for an entire year and there's no recourse. And especially there's no recourse if my employer is generally satisfied, because my alternative is to take a massive pay cut to get good coverage.

I never understood why health care had to be so tightly coupled to employment. All it does is tie people down, obfuscate costs, and give insurance companies more leverage over everyone, companies and employees alike.

This is an example of what economists call path dependence. In principle there's no good reason for access to health care to be coupled to employment and we wouldn't design the system that way if we were starting from scratch. Originally it started during WW2 when the federal government imposed wage controls to hold down inflation, so employers took advantage of a legal loophole to offer free employee benefits such as health insurance in order to attract workers. At that time healthcare was pretty cheap because it couldn't really do much. That system stayed after the war ended largely due to inertia. It probably benefits large employers because it gives them a cost advantage over smaller competitors but overall it's a terrible burden on the country.

A better approach would be to mandate that everyone purchase individual or family policies directly from insurers on open exchanges using pre-tax dollars, with subsidies for low-income consumers.

Why mandate it at all?

It's essentially the free rider problem. If we want to make affordable healthcare available to everyone then we have to force everyone to pay into the system to spread the risk around and get the healthy to subsidize the sick. It kind of has to work that way regardless of whether we have a single public payer funded by taxes or multiple private payers funded by insurance premiums; in the end the money has to come from everyone.

Very long history I suggest you look into, because it's very interesting, but the oversimplified explaination:

after WW2, there was very obviously inflation. It was crazy in the EU and Japan, but the US still experienced some too. To fight this, the government made a then-common tactic of wage controls: basically cap off the maximum amount an employer can compensate workers, in order to fight the inflation spiral.

But there was an imporant exemption. This was only on wages and not any benefits given to employees in order to try and quell the inevitably angry employees. So when companies couldn't attract talent with more money, they offered more benefits. including employer sponsored healthcare. Perfect since these contributions were free from income tax.

And the modeled spiraled from there. a tax code passed in 1954 to let these contributions be business expenses, Medicaid came in the 60's, etc. It was great back then, but it was getting more expensive to navigate and companies started compromising to manage it. up to our favorite healthcare starting its vertical integration 20 years ago to come into what we know them for today.

I agree as well, just drawing some lines!

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