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Comment by tzs | Hacker News Reader

Several countries with universal healthcare use the "you have to buy private insurance" model, such as the Netherlands and Switzerland. There doesn't seem to be anything inherently wrong with that system.

ACA has survived 12 years and enabled a lot of people to obtain health insurance that would not have been able to otherwise, with Republicans wanting to kill it that entire time but failing to do so. Do you think there was any other system Democrats could have passed instead that would have lasted that long?

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> Do you think there was any other system Democrats could have passed instead that would have lasted that long?

You're buying into the paradigm wherein sandbagging it was necessary for pragmatic reasons, and justifying within that. While this is true to an extent, it doesn't really change my overall point.

I do get that the ACA was a significant piece of legislation that has helped many people. And if you want to talk system design, such a mandate might make sense in a system with much much more regulatory bandwidth than ours, where it's not just forcing people into a corrupt system. But as it stands, they didn't even address the antitrust issues of bundling healthcare plans with employment or price fixing between insurers and providers. So I stand by my characterization of the dynamic as brazen regulatory capture.

Switzerland has a “public option”, price controls, and IIRC private insurers have to be non-profits (and possibly that designation means more in their system than the US, I dunno about that).

ACA mandates that ~80% of insurance co. revenue must go back towards medical service. So not "non-profit" per se but there is some kind of restriction there.

1) Not for "self-funded"—many plans are managed by big insurance companies, but funded by employers. No restrictions there.

2) Not for plans that are (IIRC) two years old or newer. I'd be shocked if there aren't a bunch of shenanigans going on with this loophole.

also 3) many "insurance" companies are in the provider game, meaning they can preferentially shuffle surplus to their other arm

(2) and (3) were part of what I meant by a lack of regulatory bandwidth in another comment. There are rules that could be enforced to promptly impose steep penalties for a company that tries to skirt them. But they just aren't, so after one company starts doing it the rest inevitably follow suit.

which will never fly in the US in a million years.

take a look at the Fortune 500 list and notice how many health and pharma companies are in the top 50 (and/or top 10)

Add to it that all our retirement accounts are invested in these companies, and it kinda looks indistinguishable from a really roundabout way to have a very-regressive redistributive retirement scheme that also has crazy-high fees (whatever part of the overpayment to healthcare companies that doesn't make it to shareholders is basically part of the account management fees)

Yes, I'm suggesting that like 10% of our nominal GDP is actually a deeply fucked up regressive wealth redistribution scheme that doesn't buy tangible productivity, but is essentially a tax-like drag on the economy, but way less efficient than most government-run redistribution schemes. Because it is.

I don't think squinting and framing things that way is particularly productive on its own, and you didn't go anywhere with the idea. One could also characterize it as big jobs program. But these framings belie that the structural "inefficiency" is the crux of the problem - both resource-consumption wise, and also in terms of (not) providing good healthcare. For example, how many full time skilled doctor equivalents are flat-out wasted by being spent jumping through "insurance" company bureaucracy? Or how many nurses is the "insurance" industry wasting directly?

I agree that the core problem is that we’re simply spending far more than necessary for the level of care we receive, but the side effects like being a white-collar makework jobs program (the upscale counterpart to the military, sort of) and redistributing (a little of the) money toward retirement accounts are what make the problem “sticky”. There’s a lot of temporary collateral damage if you fix it.

But does that framing have predictive utility? Which would you say resonates more with voters, especially the middle/upper-middle class voters with skin in both games - "Healthcare reform is going to make your retirement account shrink" or "Healthcare reform is going to take away your employer plan and replace it with the same option the poors get" ?

Also my additional point is that nobody really thinks we need to create additional jobs for doctors, as we've currently got a dire shortage of healthcare. I just inquired about rescheduling a primary care visit for my aunt and the office told me they're scheduling out an entire year from now. That's obviously not the same as how soon they could see her for something urgent, but the sheer magnitude of that delay does highlight a problem. I've also seen many 4+ month waits for specialist appointments.

>ACA has survived 12 years and enabled a lot of people to obtain health insurance that would not have been able to otherwise, with Republicans wanting to kill it that entire time but failing to do so.

My insurance is more expensive than ever and quality of care lower quality than ever.

>Do you think there was any other system Democrats could have passed instead that would have lasted that long?

Medicare for all. Or lower the age gradually (cover kids and elderly first). They should have voted on it during the pandemic but Pelosi blocked it and AOC wouldn't do anything. They're all fakes.

You'd probably have the rising cost issue no matter what had happened, because that problem affects pretty much all first world health care systems. The US is way more expensive than others, but the ratio of US costs to the costs of others has stayed roughly constant over at least the last 40-50 years.

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