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Comment by reenorap | Hacker News Reader

Obama was hated by San Franciscan progressives because he came in with all of these promises and then backtracked on almost all of them. He basically turned into a Bush-lite, and he even maintained every single one of Bush's policies as well as deadlines. For example, he talked a lot about abortion and then immediately said it wasn't a priority for him once he got into office. He never closed Guantanamo and in both elections said he didn't support gay marriage.

ACA is a failure and the only thing it did was make it mandatory and unaffordable at the same time. Income inequality skyrocketed under him as well. Anyone who wasn't rich enough to afford some sort of asset like stocks or real estate was left behind and is now suffering.

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I'll give you one reason, among many, it wasn't a failure. It made it illegal to deny people health insurance coverage based on pre existing conditions. That was a big step forward in a broken system to restore some humanity to the system.

True (*)

They can't deny coverage for pre-existing conditions anymore, but insurers still have hundreds of other ways to avoid paying.

There's no silver lining in the U.S. healthcare system -- it's built to exhaust, confuse, and bankrupt patients. And it's only gotten worse in recent years. (Will only get worse with the addition of more AI.)

Joe Lieberman, a supposed Democrat, killed any real chance for reform we had in our generation. He then left Congress and quickly died -- his legacy is the broken healthcare system we have today, totally rigged against the very patients it's supposed to serve.

Joe Lieberman and basically every Republican ever, for decades.

And the Republicans on the Supreme Court that hobbled what the Democrats managed to narrowly get through the political process.

But sure, direct all the anger for that towards Democrats, that will result in better Healthcare any day now. I hear Trump has concepts of a plan that he's been working on for over a decade that he'll let us know about in just 2 weeks.

I'm so tired of "this plan wasn't perfect, it failed. Democrats suck".

And meanwhile the republican plan was to do nothing or actively make things worse than ignoring the problem. Why are some people seemingly hardwired to just blame democrats for any or everything? Because the plans they have don't immediately benefit them, the middle class person who was never down on their luck?

Even then, I fail to think of any policy that legitmately benefits the middle class either. Did abortion bans improve your quality of life? Do immigration raids help your 401k? Did that cut to EV credits get you better public transit?

Murc's Law

https://en.wikipedia.org/wiki/Murc%27s_law

> Murc’s Law is typically phrased as: "the widespread assumption that only Democrats have any agency or causal influence over American politics".[5] [6] It reflects a perceived journalistic double standard, where Democrats are held responsible for political outcomes regardless of context, whereas Republican obstruction or extremism is treated as a given. This framing, critics argue, absolves Republicans of responsibility and creates an unbalanced political narrative.

Like half this sub-thread is driving me insane. The deep hatred of Democrats (for decades) from the left is very frustrating to me. They may not be as left-wing as those people might like but they're in fact not nearly as bad as the Republicans.

>Murc's Law

Which, somehow is a weird outcome of the "Two Santas Theory[0]. I'm not sure why folks actually buy into it, but they apparently do.

[0] https://en.wikipedia.org/wiki/Jude_Wanniski#The_Two_Santa_Cl...

I'll throw in extending parental coverage to 26. I have a sibling with type 1 diabetes and it's impossible for me to describe the positive impact those two provisions have had on their life.

Just because a piece of a legislation includes painful compromises doesn't mean we should ignore its huge wins.

That has in part become the issue in modern politics, any compromise no matter how minor is seen as a loss.

Neither sides most ardent supporters was willing to accept anything that looked like a compromise and so you end up with things as they are now, with someone where compromise shouldn’t happen because there is no practical compromise.

US politics has collapsed down to the scorpion and the frog.

> That has in part become the issue in modern politics, any compromise no matter how minor is seen as a loss.

Because to those who are now getting hit with huge insurance bills as a direct effect of that compromise, and may have to go without insurance at all, it is a loss.

And nothing has been done to address the underlying reasons and bad incentives that have led to this outcome. Which is also a failure.

>Because to those who are now getting hit with huge insurance bills as a direct effect of that compromise, and may have to go without insurance at all, it is a loss.

Because the Republicans slashed the premium tax credits to pay for tax cuts for rich people.

The fact Republicans wouldn't repeal ACA but would repeal the tax credits just shows both sides prefer it to be broken. Democrats could shove through enough votes to repeal ACA to make health insurance cheaper for lower-risk groups without tax credits; Republicans could re-instate tax credits. Instead we are stuck in this bastardized half-socialized model that gets the worst of all worlds.

Politics in the USA has basically gridlocked to it being much cheaper to shit on the other guy than to fix things. In two party system you can actually win by only making the other guy look worse, which only requires breaking things in a way that can be pointed at the other guy, somehow we are stuck in this local minima.

And now the US is having the longest govt shutdown ever, millions of people losing their food stamps, millions of people potentially seeing their Healthcare costs skyrocket, and neither side seems willing to compromise, with the GOP blaming the democrats for the shutdown, which really is not productive.

This is nonsense. You have Democrats working to get more healthcare to more people, via increased taxation, and you are blaming them for Republicans holding them back.

It's both of their faults. Blaming one party or the other is what got us into this this hole and what keeps making it deeper.

The ACA was passed in 2014. Congress (both Republicans and Democrats) have had since then to get off their butts and do something to fix the serious flaws it came with. Flaws that made insurance too unaffordable for millions of people so they had to risk it and go uninsured.

    Years      Pres  Senate     House     SC
    2013-2015   D    D(+8)      R(+33)    R(+1)
    2015-2017   D    R(+10)     R(+59)    -(+0)
    2017-2019   R    R(+4)      R(+47)    R(+1)
    2019-2021   R    R(+8)      D(+35)    R(+1)
    2021-2023   D    D(+0.5)    D(+9)     R(+3)
    2023-2025   D    D(+2)      R(+9)     R(+3)
    2025-2027   R    R(+8)      R(+4)     R(+3)

When exactly were the democrats supposed to "fix" the ACA without compromising?

Dems haven't had solid control of all three legislative bodies since it passed, and Republicans have vocally made it their priority to oppose the ACA in any way possible, and are unwilling to give an inch. Even the hair thin margin post-2020 was unusable for this due to the handful of DINOs that all needed to vote in lockstep.

Meanwhile, R's had unilateral control of the government for four straight years, and they voted to make everyone's lives worse, as you're complaining about. They said over and over they were going to repeal it, like you suggest, and then turned around and made it obvious that was a blatant lie. Because despite its flaws, even the gutted ACA is still wildly popular and a vast improvement over the previous status quo. (It turns out keeping workers healthy is critical for the economy)

This is not a symmetric problem. It really is one party making it worse.

> When exactly were the democrats supposed to "fix" the ACA without compromising?

The Democrats did have full control when they first passed the ACA and they ended up getting in their own way.

But I never said that the Democrats were supposed to fix it on their own. I said both parties are to blame.

It shouldn't require one team have full control for something to happen. That's the real issue. They refuse to work together, and somehow this gets them more support (votes). Both sides. Total shit show.

> The Democrats did have full control when they first passed the ACA and they ended up getting in their own way.

They didn’t. They had to heavily compromise with an Independent.

> After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Senate Majority Leader Harry Reid focused on satisfying centrists. The holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat Ben Nelson. Lieberman's demand that the bill not include a public option[161][175] was met,[176]

> But I never said that the Democrats were supposed to fix it on their own. I said both parties are to blame.

This doesn’t make any sense, because 99% of Dems have tried to increase access to healthcare, and 99.9% of Repubs have tried to reduce access to healthcare. The sole exception being when McCain provided his vote to not repeal ACA.

> This doesn’t make any sense, because 99% of Dems have tried to increase access to healthcare, and 99.9% of Repubs have tried to reduce access to healthcare.

This is the problem. All conversations about policy lead to "it's the Republicans fault" or "it's the Democrats fault", never about the actual substance of the issue or any attempts to fix the underlying problems.

The fact that both parties think they're "winning the game" right now by shutting down the government is a joke.

I did point out the actual substance of the issue, Repubs don’t want to expand access to healthcare as it would require a wealth transfer, hence they have opposed all efforts.

The Dems (by and large) bring up bills to provide paid parental leave, increase minimum salaries for overtime exempt workers, fund education, increase access to healthcare, and here you are saying they don’t focus on the substance of the actual issues, whatever that means. Meanwhile, the only thing Repubs have done is cut taxes, and block all those efforts.

> The fact that both parties think they're "winning the game" right now by shutting down the government is a joke.

The fact that you would even bring up both parties when one has control of all 3 branches of government is a joke.

What am I reading?

@grok are more or pess people uninsured since the ACA was passed in the USA?

(The answer is obvious btw)

> The fact Republicans wouldn't repeal ACA but would repeal the tax credits just shows both sides prefer it to be broken.

It really doesn't. All it shows is that team R is following it's usual playbook of "The government is broken - elect me, and I'll make sure of it."

> Democrats could shove through enough votes to repeal ACA to make health insurance cheaper for lower-risk groups without tax credits

The only true part of that statement is that they could get enough votes to repeal it without replacement. But it wouldn't make anything cheaper.

The only way insurance would get cheaper is if it went back to not covering pre-existing conditions, which is contrary to the whole point of insurance.

It's wild that you're blaming the dems for... Not repealing without replacement, and pushing us straight into a completely broken shitshow?

> lower-risk groups

Oh, I understand now. You're are explicitly unhappy that the dems aren't agreeing to your plan to massively hike rates for anyone with a pre-exisiting condition, or literally any complication that would get them discriminated against prior to the ACA.

Sorry, that's a shitty thing for you to be fighting for, and they are in the right to not do it.

ACA without subsidies is a regressive tax due to the price differential cap from young to old. It's a wealth transfer from younger/poorer people to older/wealthier people still on private insurance. Health risks track most closely with being older and thus on average wealthier.

It's just the people that have tricked you, have used statistical correlation and cover of pre-existing condition to hide the fact what they're actually doing is robbing from the poorer to subsidize the richer.

It's a wealth transfer from healthy people to sick people. That's the whole point of health insurance.

Older people are sicker and older people are wealthier, but older sicker people on ACA plans are not wealthier than the median.

It's a sleight of hand to collate the two (old-rich and old-sick), but sure, if this is such a large concern, the solution is adding means testing, not just leaving sick people with care they can't afford.

Due to the way ACA works (disallows pre-existing condition discrimination) it's young-average[for age] vs old-overage[for age] with a cap on the ratio. Which functions as a regressive wealth transfer when the premium subsidies get gutted.

The original plan was for single-payer, but the Blue Dog democrats fucked it up, because they didn't want to lose their seats, so they pushed for a compromise solution.

They then all lost their seats to tea-party and proto-maga types who were screeching about FEMA internment camps and death panels killing grandma.

No that is a huge failure. That is perhaps the biggest failure of Obamacare.

That means I, as someone with healthy lifestyle habits, has to pay largely the same premium as someone who smokes, is obese, and doesn't exercise. And sure enough, life expectancy in the US immediately stalled after the law's implementation: https://www.macrotrends.net/global-metrics/countries/usa/uni.... Exactly what economics would predict would happen.

And what if you, despite being healthy, get diagnosed with cancer right one your employer fails, thus becoming uninsurable? This type of thing happened to people.

It’s nice the above can no longer happen. You could, at the same time, still allow insurers to charge a premium to smokers and obese and for other lifestyle risks within one’s control. They are not mutually exclusive.

The entire system of linking health insurance to one's current employer is bad. I should just be able to buy it with money I earn from doing anything that pays me, just like I do with my car insurance or any other type of insurance.

How about if that is diabetes, or something else that does not depend on lifestyle choices?

You're kidding right? Look up how many people have type 2 diabetes, greater than 90%

Assuming they mean type 1 yields a better dialogue.

I remember being denied coverage after aging out of my parent's healthcare plan. The cited reason was "pre-existing conditions", which were allergies and a congenital cleft lip and palate (I had a number of corrective procedures as a kid). I was a healthy and relatively normal young adult.

Life expectancy flatlining could be any number of things. Correlation != causation

Yes, everyone on insurance should be young and healthy. Fuck those sick people /s

That decline is mostly because of Covid pandemic, no? And it looks like the life expectancy picked back up after 2022.

Similar laws existed in EU countries long before US, and EU countries also saw a decline in life expectancy during those years: https://www.macrotrends.net/global-metrics/countries/deu/ger...

> That means I, as someone with healthy lifestyle habits, has to pay largely the same premium as someone who smokes, is obese, and doesn't exercise.

Do you live a healthier lifestyle than every single other person in your insurance plan or are you just a hypocrite who’s decided the line is acceptable when it includes you, but not one inch beyond that?

Look at this Ubermensch that will never have a stroke, develop cancer, or any number of debilitating conditions. Must be nice!

It is the basic duty of every human to do their best to make sure every other living human is afforded a life of simple human dignity. Full stop. We have the resources. Let's just do it.

Sadly we do not have, and will never have, the resources to help everyone, even to a baseline of human dignity. Surely we can't give people unlimited talk therapy, MRIs, and cancer treatment for free. But some people sorely need these things.

Preventative/propylactic care is orders of magnitude cheaper than treatment once a disease has manifested. It makes sense to me to punish people for not doing this care, thereby choosing to impose more strain on an already overburdened system.

Note that GP only mentioned things we have control over -- exercise, weight, not smoking. Of course I agree that it would be cruel to disadvantage pre-existing conditions.

That's the point of insurance. It's the idea that everyone pools together money and when something bad happens to one person, its finances are mitigated by the input of others. Some will benefit more and others benefit not at all. But no one can predict who is on what end.

Yes, if everyone gets cancer at the same time then Health Care is boned. But then again, so is society. So why worry about that worst case scenario?

>Note that GP only mentioned things we have control over -- exercise, weight, not smoking.

We couldn't pass laws to help control what companies put in food, and failed to subsidize healthier food options. I wish you the best of luck with healthcare trying to pull off that endeavor with punishments for obesity. I'm guessing it wouldn't be poolitically popular.

Since when do we not have the resources? Nearly every developed country on earth manages it ok.

Does every other country have a boarder that "allows" millions of people in every year? These EU countries are tightening hard on immigration as they have found that it crushes their social nets. Not to mention keeping defense spending adequate relative to allies.

If this was so easy, what is the plan?

Oh boy, here we go.

Several million people migrate to EU countries from outside the EU every year, yes. The number will be lower than a million for most individual EU countries, but then the individual countries also have smaller populations than the US.

Immigrants are easily exploitable labor. They aren't sucking up our resources. If anything, we're sucking up their resources.

I live in Texas. Look around me. Who's building these 500,000 dollar homes? Not fatass white people. And who is buying them? Not the people building them.

> Sadly we do not have, and will never have, the resources to help everyone, even to a baseline of human dignity.

This is really a matter of choice. There is a level of treatment that most people could have with far less friction. We just have decided to organize our economy otherwise.

Broadly, we need to stop seeing our economy as a zero sum game. It's dehumanizing. So what if there are a few bad actors that abuse the situation? Most don't. If everyone is doing something harmful, eg smoking, then we need strong public education, etc.

US policies wouldn’t affect the life expectancy in the UK, which has broadly the same trend: https://www.macrotrends.net/global-metrics/countries/gbr/uni...

This is despite no-one paying (directly) for health care.

Would you be willing to submit to invasive investigations into how you live to identify any risk factors you have (both under your control, like choosing to drive, international travel, and not under your control, like genetic predisposition to heart disease) to ensure your premium can be accurately calculated?

Blaming people for their illnesses is something we have historically gotten wrong a lot, and regardless, it’s pretty inhuman as a society to leave people to suffer and die because they can’t afford healthcare.

> Would you be willing to submit to invasive investigations into how you live to identify any risk factors you have

To be fair, there are insurance policies (at least in the UK) which give you discounts if you drive "safely"[0] or health insurance that rewards you for "being active"[1].

[0] https://www.which.co.uk/money/insurance/car-insurance/how-bl...

[1] https://www.vitality.co.uk/rewards/ "you earn Vitality points by getting active or attending your health check-ups [...] rewards, including a reduced excess and lower renewal premiums"

Example 1 is car insurance, not health insurance, so not really apples to apples. Being able to drive is not the same as being able to access healthcare.

Example 2 is private healthcare insurance, which does exist in the UK, but only about 10-15% of the population have it, and it's mostly about getting access to healthcare provision faster. These private providers can of course do what they like, same as in the US, with the caveat that everybody is entitled to free, comprehensive healthcare through the NHS if they don't have private healthcare insurance.

However, folks that can afford to sometimes like to skip the queue.

It's worth noting I suppose that the UK has significantly more in the way of 'sin taxes' than the US. For example, tax on cigarettes is 16.5% of the retail price plus £6.69 ($8.73) on a packet of 20, meaning on average cigarettes retail for around £15 (~$20). This compares to the US average of somewhere around $3 tax and retail of around $10 (varying based on state).

It's more complicated to calculate for alcohol, but again, the UK taxes alcohol more heavily than the US.

This additional tax revenue helps to fund the treatment of those who use those substances (although to be clear, it doesn't cover it fully).

I would be very surprised if taxes on tobacco did not cover the increased costs to the State from tobacco users. When I last looked at it tobacco users were dying early before they imposed huge costs on the State during their old age years and this produced an enormous saving to the State. This was ~20 years ago and we might be much better at keeping people alive and this has changed the calculus.

So it seems that the literal cost of treating smoking related illnesses is indeed fully covered (multiple times) by the tax revenue generated.

https://fullfact.org/health/farage-smoking-revenue-nhs/

However, net cost to the state when you factor in inability to work, etc is estimated at twice the tax revenue.

Your point that smokers die younger and so cost the state less is a contentious topic with lots of debate. One thing that is clear is that tobacco firms are actively pushing that narrative, which, given the industry’s history with regards to data and studies like this makes me instantly suspicious: https://www.wsj.com/articles/SB995230746855683470

> it’s pretty inhuman as a society to leave people to suffer and die because they can’t afford healthcare.

this is mostly about drawing a line between the tradeoffs of costs and the benefits of increased lifespan and better quality of life. almost no-one actually believes all of societies resources should be committed to healthcare to achieve some small marginal health gain. claiming people are inhuman because they want to draw the line differently is messed up.

That’s a fair point. But whether a person lives or dies should not be a function of their income.

The NHS for example today doesn’t spend infinite resources on any individual. In some cases, the decision is that the cost of treatment is not justified by the benefit.

Whether someone is a smoker is a factor in that decision: how much longer they may live, their expected quality of life. Also their lifestyle is taken into consideration when determining the order of a transplant list, etc.

But the decision is never made based on their ability to pay.

That's the point of insurance.

The obese and smokers actually cost less because they die early vs healthy people who live a long life and need a lot of care when they're aged.

"Smoking was associated with a moderate decrease in healthcare costs, and a marked decrease in pension costs due to increased mortality." https://bmjopen.bmj.com/content/2/6/e001678

The UK did a study and they found that from the three biggest healthcare risks; obesity, smoking, and alcohol, they realize a net savings of £22.8 billion (£342/$474 per person) per year. This is due primarily to people with health risks not living as long (healthcare for the elderly is exceptionally expensive), as well as reduced spending on pensions, etc..

Absolutely. We have this bad habit of hating policies and politicians that make things 10% as good at they tried to do, but shrugging and ignoring politicians and policies that actively make our lives worse. Perfect is ideal. Better than we started with is still better.

In my circles of news and friends, plenty of people are actively hating against politicians and policies that make our lives worse, or who spout dangerous rhetoric (and do nothing else but that).

Usually it's just Trump, but my local congressman gets a lot of hate too.

Sometimes it is just "orange man bad" but cmon building an opulent ballroom and remodeling a bathroom in marble and having a grand old Halloween party while millions of Americans have no idea how they're gonna have their next meal is some Marie Antoinette shit. Sure that's not really a "policy" per se but it sure makes it look like he doesn't give a shit about policies that actually help the American people.

The real problem is not politicians per se, its lobbyists. If you want blame the shortcomings of the ACA on anyone blame the insurance lobby. We need to get rid of lobbyists and put in term limits. period. It doesnt matter what party you support neither of them are looking out for your best interests. We should vote for people based on their individual beliefs and policies and not have to worry about what they are going to do in office because they get threatened by their party to vote this way or that way and hold the line ebcause if they dont they will primary you. If we have term limites, getting primaried doesnt matter as much anymore. It shouldnt be a career to be in DC. It should be a public service. The sooner we all realize this and quit picking a tribe the sooner things will get better.

Isn't it the same thing that made it unaffordable?

No, what made it unaffordable was scrapping the penalty on not having health insurance. If you force health insurance to cover everyone then you also need to force everyone to have health insurance to keep the system balanced. One way to do that is have everyone automatically covered in a public system: rejected. Another way is to tell people they don’t have to sign up for health insurance but they do have to pay into the system.

Obama care was not a Democratic win it was another Republican win in a long list of Republican wins, where the dems tried to work with the republicans in good faith and implemented their policies for them. Sadly they realised to late that you should never work with right wing fascists because if you give those people your hand they will take the whole arm.

This is a bit of an aside, but why isn't medical tourism more popular in the US? If you could set aside a couple tens of thousands of dollars, as a rainy day fund, you could get close to the very best possible care for even serious conditions from countries that have highly developed medical tourism sectors.

Granted, I acknowledge, that the US will likely still provide better care at the absolute high end, and asking most people to save that much can be quite a tall order, but from what I gather, a lot of people either bankrupt themselves, and end up paying much more than that and/or receive substandard care for conditions where treatment regime is established like treatable forms of cancer or congestive heart failure.

I remember Trump blasting Obama about Medicare, and proposing to 'open up' the system, introducing competition to drive prices down instead (which is the real problem of the US system, socially subsidizing it is just a bandaid fix imo). I guess not much has come off that.

> If you could set aside a couple tens of thousands of dollars

Non-starter for the vast majority of Americans.

The sort of people who can set aside a couple tens of thousands of dollars are also the sort of people who probably have good health insurance through their job. Generally, the US's healthcare problems _mostly_ impact low to middle income people, and they usually can't just magic up 30k or so.

100%. I have known a couple of people that did some form of "medical tourism", mostly for expensive dental work. In both cases they did some form of tech contract work as a sole proprietorship and bought their own health insurance (not through a partner). The overlap of people who can save up thousands of dollars for treatment abroad and have poor health insurance is probably not too large.

I know it's popular with the US transgender community, looking for gender reassignment surgery.

Cost of travel to Thailand < savings on medical procedures (with equivalent or better outcomes)

There are a lot of misunderstandings in this post. I'll try to explain a few of them, which maybe can help realign your whole understanding.

For starters, American insurance has a "maximum out-of-pocket" amount, which means the maximum you can possibly pay for healthcare costs. My plan, from just a regular unknown company doing boring things, has a maximum out of pocket of $5k for an individual. So there's no scenario where I'd ever benefit from spending "a couple tens of thousands of dollars" because even if I spend the whole year in an ICU bed at a cost of millions of dollars to the hospital, I only pay $5,000.

Also, "a lot of people either bankrupt themselves, and end up paying much more than that" doesn't make sense. Declaring bankruptcy means you don't pay the debt, you wouldn't pay a lot AND declare bankruptcy. You'd see the amount was too much to pay, declare bankruptcy, and have the debt wiped out.

Keep in mind that millions of Americans have essentially no assets that aren't protected in a bankruptcy (car, home and retirement accounts are generally safe). It's not like millionaires are going bankrupt from medical costs, it's people who had nothing to begin with declaring bankruptcy when they got hurt while uninsured and going back to zero (instead of negative).

The real problem of the US system isn't the subsidies for the poor, it's the opaque, convoluted billing system between insurance companies, pharmacy benefit managers, and providers. Billions of dollars are siphoned out of the system as profit to insurers and hundreds of millions are wasted on salaries for the bureaucracy of managing the billing system.

> Declaring bankruptcy means you don't pay the debt, you wouldn't pay a lot AND declare bankruptcy. You'd see the amount was too much to pay, declare bankruptcy, and have the debt wiped out.

Bankruptcy isn't a magic get out of debt button. First you have to prove your inability to pay, which generally means not having much in the way of assets. So you probably have to spend a significant amount of money on the debt before bankruptcy is even an option. Then once you have successfully declared bankruptcy it means, aside from a few classes of protected assets (e.x. your primary residence if your sufficiently lucky to be a homeowner) your creditors get to divy up what you have left amongst themselves. THEN the debt is wiped away. It's a last resort that keeps every penny you earn for the rest of your life from going to creditors, not a way to walk away with your assets and lifestyle intact.

It's fairly popular, especially for elective surgeries.

Had the ACA gone further and actually provided a single payer system, I'd consider the block on denials based on preexisting conditions a win.

As it is we have a system of private "insurance" that can't consider the risk level of those being insured. All that means is the companies charge everyone else more to subsidize the cost of those who are more at risk.

That bastardizes the whole point of private insurance. I don't want to pay more for my car insurance because the person next door bought a Porsche and the insurance company isn't legally allowed to consider the cost of repairing a Porsche.

Don't get me wrong, morally I don't want to see anyone denied health insurance. I also don't want this half-in half-out program where its no longer really private health insurance nor is it a centralized single payer system.

Blame Joe Lieberman for that one.

Health insurance that can discriminate against people based on pre-existing conditions rapidly becomes health insurance you can’t use. Sure, it’ll be cheaper for a few years. Then, with non-negligible probability, you’ll develop a serious condition. At that point the cost becomes anywhere between “high” and “infinite”. If the point is just “private insurance is dumb”, sure, I mostly agree.

It isn't insurance if the provider can't consider risk factors for the policy though.

If we don't want people's health to be dependent on insurance that's fine, but we should replace it with a system that isn't based on risk at all rather than bastardizing something that still sort of looks like risk-based insurance.

> It isn't insurance if the provider can't consider risk factors for the policy though.

Insurers are welcome to consider risk factors... for populations in aggregate.

It turns their actuarial models into population-subset models instead of individual models.

Which is easily the most "fair" (to individuals) option.

Allowing insurers to consider individual risk factors (preexisting conditions, genetics, etc.) would make the advertising data mining industry seem quaint. And I don't think any American wants to live in that world.

So we can talk about whether insurers should be able to offer lifestyle incentives (yes!), preventative care incentives (yes!), and be backed by catastrophic reinsurers (like mortgages, maybe)... but enrolling people blindly is one of the best things ACA did.

(Unless one happens to be young, rich, family-less, healthy, and have no moral compunction about fucking others over for ones own benefit)

Also, important unremarked benefit of ACA -- capping maximum insurer "administration" costs.

Firsthand from inside the industry as it was implemented, I can tell you that drove efficiency improvements inside insurers, as they couldn't bill for broken, slow, manual processes in additional premiums.

Granted, it caused other problems (attempts to self-deal and harvest profits through quasi-related provider / pharmacy entities or Medicare Advantage), but it did focus insurers on being efficient facilitators.

It's also quite convenient that the contributor group (youngest adults with very little time spent to acquire wealth) are basically subsidizing the richest groups (older adults but still young enough to be on private health care).

It's effectively a regressive tax, transfer from the poorer to the richer, due to the way ACA caps the price spread.

Where do you draw the line on individual vs population subset risk levels?

The insurer must decide what subset (s) of the population a person fits into, preexisting conditions are a factor that would almost certainly weigh heavily on the risk factor for that subset.

Are you proposing that it is irrelevant with regards to an individual's risk if they have diabetes, for example? Or are you simply arguing that we aren't comfortable with the costs it would require for an individual with diabetes to get health insurance if that factor is considered?

I fall into the latter personally and would prefer a real solution to health care that isn't some form of insurance. As long as it is insurance, though, the former seems impractical.

Insurance is a simple business: collect enough money so that in the long run you earn more than you pay out.

American health insurance generally does this in two broad ways. (1) Insure a large enough population group that averages hold and you can price based on actuarial/statistical probabilities. (2) Negotiate deals with provider groups so that they get something they want and you can bound their prices.

Neither of those things are contingent on knowing anything about individuals.

Insurers will generally pick {more randomly-selected customers} over {knowing more about each customer} any day of the week.

Maybe I'm misreading you, but you seem to want insurance that's accurately priced to exactly your circumstances and health (say, how custom high value property insurance is sold).

That doesn't solve insurer's concentrated tail risk problem though, and it means you're fucked if you ever develop a complicated condition, like cancer.

I have multiple actuaries in my family that work primarily in the insurance industry. I can assure you they are tasked with determining individual risk rather than risk of an entire pool of people with no regard for the individual.

And what do they use those individual models for, after they've built them?

>Had the ACA gone further and actually provided a single payer system, I'd consider the block on denials based on preexisting conditions a win.

Your other option was to continue as things were, with fewer people getting less healthcare. Would that have been more of a win?

Yes, either we have a risk-based insurance system or we have a single-payer system that isn't insurance at all. Being stuck in the middle is worse than both extremes in this case.

How is it worse when more people have received access to more healthcare? Or is that also in contention?

I'm not sure if it's in contention, but efficiency is also important. Life isn't an optimization for health care. At the middle class and below, people are already spending most their earnings on essentials.

Maybe you can alter healthcare so people are paying through the nose (either through highly regulated private entities coupled with incentives/mandates, or through taxes) but more people are covered, and so now they are less able to afford housing, good education, healthy foods, child care, and other stuff. Then they are not necessarily better off.

Is your only metric for success the number of people technically covered by a healthcare program? That seems easily gamed and doomed to fail.

Wonderful point of view to consider people as akin to cars.

It's an analogy. They are not comparing the worth of a human being to a car. They're saying that someone else's high risk should not increase your premium.

I stongly disagree with the premise that someone else's high risk should not increase your premium. How do you control your insurer? How do you know who's in their pool?

Why should your premium be tied to someone else's risk? There will always be some level of connection, the insurer has to stay in business, but that's very different.

Without preexisting conditions your premiums go up only because they can't charge the higher risk individual for that risk. That is no longer insurance at least at the individual level - you're effectively being asked to vouch for, and pay for, someone you never met.

> you're effectively being asked to vouch for, and pay for, someone you never met.

That is the basic premise of insurance. Collectivized risk. That you disagree with a specific detail in the implementation and that part, and that part only is vouching for someone else is undermining your point, not reinforcing it.

Everyone in the developed world has injected government heavily into healthcare, because its the lynchpin of a healthy and efficient workforce. That's the real solution.

No, it isn't. You'd have to define "developed world" here to make your argument more clear, but more importantly you'd have to define insurance in general if the government is stepping in to control those markets.

If we just want healthcare to be covered for the entire population that's fine, but don't call it insurance.

> All that means is the companies charge everyone else more to subsidize the cost of those who are more at risk.

Literally the purpose of insurance

Huh?

The purpose of insurance is to mitigate the risk of a very costly but unlikely outcome by paying a smaller amount over time, thereby spreading that risk among those of similar risk.

Not being able to consider individual risk means that insurance makes no sense for those with a low risk profiles, because they’re in the same cohort as those who will _definitely_ file claims.

Cohorts are based off of your employer, because we, inexplicably, tied health insurance to your employer. If you work for a very young and hip company then no, your cohort might not file claims.

There's levels of broken-ness to healthcare in the US. Even if you allow health insurance to discriminate based on health conditions, it will still be broken in other ways.

That's one way, true. I've mostly been considering the ACA here and those getting coverage that can't get it through an employer.

Employer health insurance rates fan still get wonky for small businesses though. It probably can't happen today, but I was at a small business where everyone's rates went up shortly after one person was diagnosed with cancer and another one or two with diabetes.

That is an example of it not really being individual insurance though. The insurance company is just lumping the employees together and setting rates based on the relative risk of the whole group, not dissimilar from getting an individual policy where the rates are based on a group of one.

How do you propose we address adverse selection in insurance markets then? That's the part you're overlooking and making you go "Huh?". It's clear to everyone else.

You don't.

Health insurance is intended to mitigate the risk of unexpected high costs, not pay for your normal healthcare.

You're thinking of a healthcare _plan_. Trying to make the insurance model fit where it doesn't work is the root of the vast majority of our issues in the US.

Not private insurance. We all pay into it obviously, but our individual rates in an insurance market are based on individual risk. My rate is only impacted by others in a relative sense, if I'm more risky than someone else I pay more.

With preexisting conditions off the table, my rates may go up only because someone else is a higher risk and the insurance company can't charge them for it.

I said this in another post, but morally I don't want others to be denied health care. I don't want health insurance at all in that case because insurance implies that you pay more for riskier coverage.

>As it is we have a system of private "insurance" that can't consider the risk level of those being insured. All that means is the companies charge everyone else more to subsidize the cost of those who are more at risk.

That's what social insurance/welfare systems do throughout the developed world -- make sure everyone's covered at some minimal level even if it wouldn't be profitable when evaluated individually; it's just using insurance companies as an arm of the state to pull it off.

If, as it seems, your only objection is to labeling it "insurance", that's not a substantive objection to the merit of the policy, only how it's marketed.

What you're describing isn't insurance. There's nothing wrong with that and maybe (probably) its better than what the US has today, but if it claims to be insurance than it must be allowing the insurer to consider the risk of each policy it writes.

I don’t see where I was disputing that point.

Your neighbor buying a Porsche was a choice they made. Nobody chooses to have a pre-existing condition. We're also talking about a luxury vs simple survival. I am not sure how you can compare them.

What insurers in some countries do is charge higher premiums for people who engage in high-risk behaviors, like smoking, drinking, or extreme sports. Those are all choices so it seems fair to charge a sin tax for them. Higher premiums would discourage risky behavior and improve the health of the country as a whole.

> Nobody chooses to have a pre-existing condition

Are you sure about that? Plenty of medical conditions are the result, at least in part, of decisions a person makes.

A person with lung cancer seeking health care could very well have smokes for decades. A person with type 2 diabetes may very well have eaten poorly for decades. Obviously those aren't always directly linked to life choices, but they often can be.

Nobody _intentionally_ signs up for a pre-existing condition.

Whether a past action caused a condition, sure, but where do you draw the line? If you become disabled in a car accident, despite knowing full well that accidents can happen, should you be denied insurance in future because you did something risky? What if you were a smoker for the decades when cigarette companies suppressed the research about how bad it was?

Also, how would you even prove that a condition was self-inflicted? My old dog had lung cancer despite (to my knowledge) never smoking (and nor did anyone else in the household). I lost a close family member to liver cancer despite being a lifelong teetotaller, but how would anyone even prove that? The moment you start means-testing people, you're adding a whole lot of extra cost to taxpayers and stress for patients.

Denying healthcare to the most vulnerable members of society is simply cruel. It is kicking them when they're down. Having the condition is punishment enough. We can do better than that.

That's simple though. For insurance the line is drawn at how expensive it will likely be for a private company to insure you over the course of your policy.

It doesn't matter if someone intended for a decision to lead to higher risk, the only question at the point of signing an insurance policy is how risky that private company views the policy.

The whole insurance debate often feels misplaced. Many people simply don't want healthcare to depend on an insurance system. And I get that, I also would rather people be able to get the care they need regardless of their individual risk.

As long as we have anything claiming to be insurance that simply isn't how the system works. If the game is insurance the insurer should be able to consider individual risk. If we don't want that, build a system that isn't dependent on an insurance scheme at all.

How do you address adverse selection then? There's no private insurance where you don't address adverse selection. Either you force everyone to have coverage: ie car insurance in US or universal health insurance systems or you force them to get insured in groups (US employer based insurance), or you accept outrageously expensive rates for it.

Healthcare already being expensive doesn't make it amenable to that last option unlike insuring your laptop where you might be okay paying 2-5x the expected loss for peace of mind. Criticizing the method of addressing adverse selection is fine, but not the existence of it. You need something. There's no such thing as completely free market of health insurance. Any economist can easily explain this to you.

So why not have just done that?

Writing as a conservative, the marketplace is also a huge win. I have an employer-subsidized plan I got through healthcare.gov.

How easy people take for granted the status quo and forget that it could be and once was much worse.

You see it all the time in the fight for everything.

I heard this somewhere and its true of every politician:

you campaign in poetry and govern in prose.

ACA is NOT a failure. It did address some really critical pain points but left others. There is no bill that can address every single pain point in a system that is as complex as the US healthcare.

> Obama was hated by San Franciscan progressives because

Because San Francisco progressivism doesn’t win on a national stage.

Times are changing. The pendulum swing back from MAGA is going to be interesting.

> Times are changing. The pendulum swing back from MAGA is going to be interesting

The pendelum swings in multiple dimensions. MAGA went mainstream in a way the Tea Party and conservativism did not by abandoning policy purity in favour of, first, messaging, and later, idolatry.

The preserved component between MAGA's messaging and Mamdani's rise is populism and, to a lesser degree, divisive politics. Where MAGA failed and Mamdani may deliver is in pragmatism (and not being corrupt).

There is an opportunity to unify "abundance" policies with inclusive progressivism or villanisation of wealth. (I'm not convinced you can do both. If you want to pursue growth and cost of living, you need to turn the capital spigots. Accumulated capital facilitates that. If you want to tackle inequality and billionaires, you'll need to temporarily destabilise those capital structures. You'll also, presumably, be increasing the lower and middle classes' purchasing power, which limits how much public spending you can do without spiking inflation.)

San Francisco progressives can influence national politics. But anyone insisting on copy-paste purism is a godsend to MAGA.

Main reason why MAGA will fail even harder is that you now see that there is basically nothing holding this movement together apart from Trump.

Next step in MAGA is the open inheritance war between the original 2016 spirit and the 2024 donor class.

Hopefully we don't add too much energy to the pendulum because eventually it will swing back again

> Because San Francisco progressivism doesn’t win on a national stage.

If the message that Democrats take from this is NY progressivism wins on a national stage, we'll certainly lose the next presidential election, and maybe even fail to gain a majority in either the House or Senate during the midterms.

That's my biggest fear.

> That's my biggest fear

Mamdani is a disciplined New York progressive. He’s left of the median voter. But the Mamdani that won the D primary was also left of the median NYC voter.

One can take a shallow policy lesson from this election. Or a deeper political lesson in the value of pragmatism and respect for the voter (versus the holier than thou crap that has polluted the far left).

> Mamdani is a disciplined New York progressive. He’s left of the median voter. But the Mamdani that won the D primary was also left of the median NYC voter.

I hope you are right, that he is more like Obama than Trump. Time will tell.

Personally, I haven't seen any evidence to support that hypothesis. If you have, I'd love to feel more assured you are right so please share.

>Mamdani is a disciplined New York progressive.

Also, who are these current or former elected officials that fit the description "disciplined New York progressive" you refer to?

I'm truly not sure.

> who are these current or former elected officials that fit the description "disciplined New York progressive" you refer to?

The guy named in the comment.

So an n of 1 that has yet to take office and prove that he will live up to the label?

The day after election day 2016 I recall trying to reassure myself that another candidate who won had to be more disciplined when governing than when campaigning. That the rhetoric his campaign put out was only because his supporters were to the right of him. How sad I was to find out that wasn't true. Hope I'm not let down again.

Frankly, the Democrats have done nothing but pander to people who hate them, who will never vote for them, and fucking LOVE their opposition for years now. If there is one thing to take away from the Trump campaigns, it's that pandering to an imaginary moderate is not nearly as effective as being really exciting to your base. All ceding ground to the opposition does is lead to disillusionment and apathy amongst the people who might vote for you. You win over no one with morally bankrupt, least common denominator bullshit.

What you are advocating for is the same bullshit that cost the Democrats the election in 2016, and in 2024. We've tried it your way and it is nothing but a losing strategy. People want progress, people want change. If a candidate can't at least have balls to lie about wanting that too, then they are unfit to win an election.

In that case, the base of the Democrats, as you seem to define it, is destined to be a permanent minority in national elections.

And maybe you are right. I'd love to see America move to 4 or more major parties. With the far-left and far-right of each separated out into their own parties. Would even settle for 3 parties.

They're really not a permanent minority, though. Obama's campaign promises (not to be confused with his actual politics once in office) demonstrate that positive, progressive change is a perfectly popular political position.

And frankly, that's all besides the point: The reason exciting candidates do so well (Trump, Obama) is because voter turnout in the US is abysmal. It's gotten better (because the Fascists are excited for Trump, and everyone else is at least a bit energized by "oh god we can't have the fascists win"), but it's still very true that if you could convince at a quarter of the nonvoters (half of the half that might vote for you) to show up to the polls, you'd have a blowout victory the likes of which haven't been seen since the Bill Clinton campaigns.

The Democrats have been playing a strategy that tries to win over the rational fringe of the Republican party, but it's becoming increasingly obvious to apparently everyone but the DNC that those people don't exist. The kind of person who can be convinced to vote for Trump (ESPECIALLY TWICE) are not the kinds of people the Democrats will ever win over without royally pissing off most of their voter base.

> Obama's campaign promises (not to be confused with his actual politics once in office) demonstrate that positive, progressive change is a perfectly popular political position.

But as you said, Obama didn’t govern the way he was perceived to have campaigned. And up and down this thread people express their disillusionment with him. Including you.

So I’m not sure how Obama campaigning to the left of how he governed makes the case that without Democrats moving to the center they can successfully turn out the number of supporters needs to win national elections. Unless we keep electing people then throwing them out next cycle because they didn’t govern like they campaigned (which is which I think we’re going to see for the foreseeable future)

Also this was almost 20 years ago. The country has gotten significantly more polarized since then. I’d make the case that since Obama the democratic part has failed to move to the center, but instead clung to identify politics. And in the case of presidential elections anointed the nominees rather than give citizens a real chance to choose them.

Hope I’m wrong, since Democrats don’t seem to be moving to the center and I also don’t want federal governments like this one. But I’m not convinced I am.

Obama won off his campaign. That suggests that enough people agreed with his platform to vote for him. He didn't win additional votes by shifting to the center: he shifted to the center after already having received said votes.

And polarization of the voter base helps that argument: people want real, radical change. On both sides of the political spectrum. The right is having their demands heard through the rise of Trump's fascist tendencies. The Democrats need to notice that the "moderate" Rebuplicans were more willing to vote for a fascist than for a moderate Democrat, and re-evaluate their platform.

But the change many people want is not immediately achievable, at least not without a period of intense suffering as a result of drastic upheaval (read: war). It defies basic laws of humanity.

You seem to suggest that politicians like Obama failed to achieve all their campaign promises, even though they could have. I suggest that they could not have. that it wasn't a bait and switch, but rather laying out an aspirational vision and then trying to achieve as much of that vision as reality allows for given the many needs and competing interests that co-exist in the world at any given time.

> pandering to an imaginary moderate is not nearly as effective as being really exciting to your base

The takeaway should be there is no one size fits all.

Under Biden, donors pushed climate and identity politics that don’t work outside far-left Democrat strongholds. Then Kamala clumsily tried finding a centre in a multidimensional policy space which may not have a definable centre.

Mamdani won New York. But “moderates,” i.e. politicians who spoke to economic populism and don’t get distracted by the base, kept Pennsylvania, Virginia and New Jersey. If we want to control national politics, we have to concede that West Virginia and Arizona voters don’t care about the same things as folks in Manhattan and San Francisco. That’s okay. We can embrace that diversity. But it also means we have to respect it and cut out the name calling because a promising candidate on the other side of the country doesn’t embrace your pet issue or identity language.

(Obama campaigned for Mamdani and Spannberger and Prop 50.)

> If we want to control national politics, we have to concede that West Virginia and Arizona voters don’t care about the same things as folks in Manhattan and San Francisco. That’s okay. We can embrace that diversity. But it also means we have to respect it and cut out the name calling because a promising candidate on the other side of the country doesn’t embrace your pet issue or identity language.

Very well put, I hope others see this as well.

“…the only thing it did was make it mandatory and unaffordable at the same time.”

That’s such a fraught statement, because the _opposite_ is claimed by supporters of the ACA after the repeal of the mandatory rule.

I’m old enough to remember the failed attempts for healthcare reforms under President Bill Clinton. The ACA felt like a miracle. It wasn’t what everyone wanted, but it was a start with principles. It has only been legislatively weakened over time, rather than improved.

Whatever alternative, employers should not be where we look for our healthcare. Can’t understand why anyone would trust their employer or expect good outcomes in the post-lifelong employment age.

>I’m old enough to remember the failed attempts for healthcare reforms under President Bill Clinton. The ACA felt like a miracle. It wasn’t what everyone wanted, but it was a start with principles. It has only been legislatively weakened over time, rather than improved.

I am also old enough to remember. And the health insurance companies spent heavily on lobbying and advertising ("death panels" and "healthcare rationing" and all sorts of other crap). It was sad.

Fast forward to the ACA and as I recall, insurers were spending USD1 million/day on lobbying efforts to block it.

I didn't think the ACA was a "miracle" though. Back then I used the analogy that it was like RFC 5386[0] ('Better Than Nothing Security'), as it wasn't single-payer and didn't even have a public option (thanks for nothing, Joe Lieberman -- I hope you're roasty-toasty in hell), but it was better than nothing.

I even have an ACA plan which costs me an enormous amount, but again, it's better than nothing.

[0] https://www.rfc-editor.org/info/rfc5386

> ACA is a failure and the only thing it did was make it mandatory and unaffordable at the same time

Isn't it because Republicans spent a busy decade destroying it?

>ACA is a failure and the only thing it did was make it mandatory and unaffordable at the same time.

Compared to what? Is it really better to just be uninsured and go bankrupt over an ambulance ride?

This point alone makes your entire post suspect, even though parts of it are indeed true (it's a real shame guantanomo was not closed down).

Unaffordability doesn't need a comparison - if you can't afford something it doesn't matter what the alternative is.

So your solution to something that every other cointry believes is a universl right is just "let people die on the streets"? Seems pretty uncouth.

Let's not forget, Edward Kennedy passing away really through a monkey in the political calculus early days for Obama.

He also bailed out Wall St.

I hope Mamdani turns out to be as good as Obama was.

What was so impressive about Obama was his incredible leadership skills and ability to get elected president DESPITE his racial and ethnic background. That the things the far left saw which drove them to support him were not the ones that led him to be such a good leader for the country.

In 2008, I spent most of the year backpacking through Europe before starting college in the fall. So I truly don't remember much of Obama's first campaign or the tone of it at the time. But there is very little evidence in my mind that Mamdani has any of Obama's abilities. Hopefully either I'm missing something again, or he'll rise to the occasion despite the lack of evidence to suggest it.

most importantly he made this 100 yard dash immediately after winning the primary, not when met with congressional objections as president elect.

> ACA is a failure and the only thing it did was make it mandatory and unaffordable at the same time.

This is absolute, unequivocal bullshit. I get that you aren't under 26, that you don't need subsidies, never were denied coverage for having had the audacity to get sick years before, and that you've never had to pay for expensive care, so you probably don't know what you're talking about in the first place, but suggesting it was a "failure" is absurd. The idea that actual coverage was less affordable after the ACA passed is such spectacular nonsense I don't even know where to start.

Sometimes it's ok to NOT have big, strident opinions on things you know you don't even slightly understand, and to ask questions or approach things with curiosity, instead.

I always called him a Bush-lite too, such a disappointment. Did everything I disliked about Bush and nothing about the things he said he'd do. If anything some of the things he did were worse, like executing a US Citizen with a drone without trial or crime to get a man that wasn't even there.

"He never closed Guantanamo" is missing a lot of context. See [0] for more context around Congress blocking his efforts[1].

(While searching for a decent article, I found [2] which has the hilarious-in-retrospect quote: "It just doesn't happen in, you know, traditional American justice that someone is essentially arrested and disappeared with no access to attorney" - oh the sweet innocence of 2017.)

[0] https://www.politico.com/story/2017/01/obama-congress-guanta...

[1] Which, to be fair, were hamstrung by his refusal to override the Republicans - a sensible approach (at the time) because a) the right wing would have gone mad (see: literally anything Obama did) and b) it opens the door for ruling by Presidential fiat which, sadly, was kicked wide open by Trump-1 and the entire wall removed by Trump-2 with the help of SCOTUS. On the whole, though, Obama wasn't as good as promised, definitely.

[2] https://www.pbs.org/newshour/show/obama-failed-close-guantan...

Americans are in charge whenever America fails.

Stop calling concepts like ACA a failure and look in the mirror.

Then ignore it all and go enjoy some TV, video games, grubhub any obligation to yourself away; you earned it.

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