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.
Just because a piece of a legislation includes painful compromises doesn't mean we should ignore its huge wins.
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.
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 the Republicans slashed the premium tax credits to pay for tax cuts for rich people.
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.
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.
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.
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.
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)
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.
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.
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 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.
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.
@grok are more or pess people uninsured since the ACA was passed in the USA?
(The answer is obvious btw)
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.
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.
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.
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.
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.
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.
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.
It's effectively a regressive tax, transfer from the poorer to the richer, due to the way ACA caps the price spread.
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.
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.
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.
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.
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.
Literally the purpose of insurance
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.
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.
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.
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.
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.
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.
Your other option was to continue as things were, with fewer people getting less healthcare. Would that have been more of a win?
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.
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.
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.
If we just want healthcare to be covered for the entire population that's fine, but don't call it insurance.
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.
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.
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?
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.
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...
You see it all the time in the fight for everything.
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.
Cost of travel to Thailand < savings on medical procedures (with equivalent or better outcomes)
Non-starter for the vast majority of Americans.
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.
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.
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.
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.
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...
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.
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.
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.
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.
If this was so easy, what is the plan?
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.
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?
"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..
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.
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 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).
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
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.
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.
Life expectancy flatlining could be any number of things. Correlation != causation