The ACA was originally designed as a "three-legged stool" of nondiscrimination (insurance companies can't charge higher rates to sick people), the individual mandate, and subsidies.
If you remove one of legs of the stool, the market becomes unstable and you see price spirals like this.
Jonathan Gruber (MIT econ professor, and one of the designers of the Affordable Care Act) gave a fairly detailed talk about how and why they designed the ACA the way they did, learning from a similar law in Massachusetts:
https://youtu.be/2fTHqARiV_Q?si=SRC6Np-rjgUgAe4Z&t=679
Mitt Romney took the plan from the Heritage foundation (yes, the conservative neocon think tank). Hard low-controls capitalist plan.
Heritage foundation made this plan after Hillary Clinton pushed universal healthcare in 1994, as first lady. Howls of 'death panels' were heard all over republican talking points and radio shows.
(The 'death panels' aka rationing was seen as bad for government to do. However, we see a new type of rationing, based upon how much patients cost, and then denying care. That lead to the UHC execution, then approving more procedures, then getting sued by shareholders for that. Personally, government death panels are preferred to capitalist death panels.)
Put simply: Obama passed republican legislation put forth by a republican governor and a republican thinktank, and was deemed a socialist. And now, the program is basically destroyed.
I'm somewhat hopeful with Gavin Newsom's posture making an example, I wouldn't vote for him, but I like the aggressive PR position he's taken, his willingness to gerrymander just as the other side has been doing forever. That's what I mean by bipartisanship is dead. You can't negotiate with the other side, they do not want to negotiate, they want to win at all costs for ideology, so you can only do your best to disempower them. If you try to play fair with a counterparty who does not believe in acting in good faith or playing fair, you have default lost. You can't have a functional democracy when one side rejects democracy (massive efforts to disenfranchise voters, gerrymandering, etc) because they can't win democratically. There is no reason you can't have empathy while punching down at bullies, because if the tables were turned, the bullies would put their boot on your neck ("paradox of tolerance"). So, start punching down.
Edit:
In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves (considering how dependent red states are on the federal government [1] [2]); Oregon is up first [3]. You can increase state taxes to fund this, reducing tax dollars sent to the federal government, if properly engineered.
> In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves…
The risk here will be sick people (and their high costs) moving. As with how Chicago's illegal gun problems mostly come from Indiana.
We already deal with this problem in higher education by having out-of-state tuition and in-state tuition priced at different levels. A period of residency is required to access in-state tuition.
Does residency fraud exist? I'm sure of it. Despite the UC and CSU systems not publishing residency fraud statistics, such fraud is universally described as being extremely difficult to execute. I cannot overstate this point. Students routinely depict residency fraud as being more difficult to do than simply paying out of state tuition. The high cost of committing residency fraud makes cancels out any expected payoff. Furthermore, most instances of detected fraud appear to be technical and clerical errors, not intentional deception.
What are in-state residency requirements, and how difficult is the requirement? Evidence for residency includes:
- Obtaining a California driver’s license or ID card
- California vehicle registration
- California voter registration
- California state tax returns
- California bank accounts
- Employment in California
- Lease, mortgage, or property ownership in California
- Severing residential ties to your former state (e.g., closing out-of-state bank accounts, surrendering non-CA licenses)
Additionally, one year and one day of residency is commonly the required threshold to qualify for in-state tuition.
The question becomes, is this effective enough at reducing fraud rather than can fraud be eliminated. I'm sure, like with any system, fraud detection and remediation are part of the operating costs and measured in terms of recovery rate/rate of return - the KPI we're discussing.
It is fraud to move to California for the sole purpose of education[1]. Likewise, genuinely moving to California for the sole purpose of benefiting from universal healthcare is also, in my opinion, fraud.
People genuinely moving to California would presumably pay out of state healthcare fees until their residency was established. Don't you agree that these fees could be set in a way that served as a barrier to doing what you suggest?
Is there a case that isn't covered by this that you're thinking about?
1. Cal. Code Regs. Tit. 5, § 54022 - Physical Presence. "Physical presence within the state solely for educational purposes does not constitute establishing California residence regardless of the length of that presence." https://www.law.cornell.edu/regulations/california/5-CCR-540...
That just means college students living off-campus don't suddenly get in-state tuition rates after a year or two.
Sick people are allowed to like California's weather enough to move there. The ADA would also apply when trying to restrict residency in a way it would not for education.
> They shall pay out of state rates until they meet the threshold.
I'm not arguing they'll move and obtain residency on day one. I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.
The ADA's Title II would seem to forbid "you can't be a resident, ever, if you've got expensive healthcare costs" sort of rules at the state level, yes? That would clearly not be equal treatment for people with medical disabilities.
> I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.
It's trivial to construct a threshold and out of state pay structure which cancels this case out. What number of days and out of state pay structure do you feel would cover these cases? How many of these cases do you suspect will occur annually and what is the projected cost? It's a relatively easy problem to solve once we get down to the specifics.
> "you can't be a resident, ever, if you've got expensive healthcare costs"
Great! I'm not arguing for "ever". I think we're in the clear here.
Edit: Let's estimate the volume of this effect using migration after Medicad expansion as a proxy. Over 10 years (2009 to 2019) we find 56,659 interstate moves after Medicaid enrollment growth[1]. In other words, 0.23 percentage points greater annual population growth in the target population. Another study found an in-migration rate(to CA) of 1.4% for medicaid recipients. Being generous and taking the higher of the two, and multiplying it by California's net immigration of 500,000–600,000 annually, gives us an estimated 7000-8400 medicaid migrants a year a fraction of which are migrating primarily for medical purposes. What would you estimate the annual medical expenditures for this group would be and if an "new arrivals" insurance pool was formed, what would the marginal monthly premium cost be to its members?
I estimate that a CA new arrivals insurance pool would have $4B in annual disbursements, and $4-20M in annual residency fraud. Using averages, we can estimate a monthly premium for this group would be about $667/month.
This is roughly on par with unsubsidized ACA premiums for adults in many states. For comparison, ACA benchmark premiums for a 40-year-old in California in 2024 are about $450–$600/month.
Absolutely. While it was unsurprising to find that housing costs are now one of the biggest reasons for CA emigration. It's those who are lower income, and have just a high school education. Among high earners, working from home has a huge influence on emigration from California. Conversely, higher earners are least likely to move out of CA.
If blue states can build enough housing to welcome refugees from collapsing red states then great. Caring for people and building bigger concentrations of healthy people is a good thing, especially as the House is proportional to population.
This would be far more likely to concentrate non-healthy people, and all their costs. The needy in red states will move for access to care; the red states will see a healthier and cheaper population as a result.
I am willing to bet $10k to a 501c3 charity of the winner’s choice this doesn’t happen and that the thesis is deficient. Let me know if you want to take the bet, we’ll use Longbets.org to officiate.
Gonna gently suggest to you that someone who can go "I'll put $10k in escrow for a few decades over an internet comment" perhaps may struggle to understand the desperation of someone with a disabling chronic illness to get access to medical treatment. (And their lack of means to match such a bet, no matter their confidence in the position.)
On the contrary, I financially support several people who are disabled and will never work again (to bridge them until they qualify for age tested benefits). I bought a piece of land in the Midwest, and am building tiny homes for them one by one. I previously did a short stint as a Guardian ad Litem in Florida for disadvantaged children who needed an independent advocate, and I act as a patient advocate today for folks who need healthcare and have a hard time accessing it. My deceased mother could not claim Social Security disability while genuinely disabled, and I was first hand involved in the process to see how the system is built to prevent entitled beneficiaries from claiming disability benefits up to her early death at 60.
I am resourced (out of luck), but also high empathy and intimately familiar with the struggles you mention. The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right. This is why I am for universal healthcare, see no other path forward, and I hope this better explains the mental model my arguments in this context are based upon.
> The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right.
I mean, same position here. I just don't have $10k to sit in escrow for years. I've similarly got plenty of first-hand experience; one on Medicare and one on Medicaid in the family due to disability, and even with those and a reasonably well paying job we'd absolutely consider moving for a program as described.
Data-wise, we've already got quite a bit demonstrating that California's better-than-average social services are more attractive to homeless folks, to the point where they have ~25% of the country's population of them.
I'm also for universal healthcare. I just don't think doing it unilaterally at the state-level is likely to work very well with freedom of movement between states, as with gun control.
Most people cannot afford to move. 60 percent of Americans cannot afford a basic quality of life. Those who can move will move to states that can afford this, and are the economic engines of the US economy (California is the world's fourth largest economy, for example). Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want. I support the rapid reduction of healthcare services in those areas [1].
I pay taxes (>$100k/year total state and federal tax burden), I support universal healthcare, and I am willing to pay more for everyone to be covered.
That calculus gets a little different for some folks if the move comes with subsidized universal healthcare and better social services.
> Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want.
If you can’t change their mind, and you can’t change their vote, and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes. Until then, we are held hostage by the irrational and unsophisticated with votes, which is unfortunate but the reality of the situation.
It’s exhausting being dragged by low empathy unsophisticated humans frankly, I am personally over it. I was naive about human nature, hard lessons learned.
"and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes."
Is there any evidence that universal healthcare would address the facility and physician shortages in rural areas? It won't make much difference if you give people coverage if they still can't exercise that coverage, or just get subpar care in many rural facilities. It seems that many rural hospitals have turned into glorified helipads to transport many patients to bigger cities.
For example, the uninsurance rate for urban vs rural is only 1-2%. It seems like that wouldn't explain the larger gaps in health outcomes. It seemsbother factors would be more important.
Rural hospitals close because they lack funding. When they have funding, they can stay open and continue to retain medical staff. When they close, mortality rates increase. Can I prove universal healthcare would keep these hospitals open? Highly speculative based on what that solution would look like. I can only prove stripping Medicaid funding is going to close them, with the consequences enumerated.
Medicaid reimbursement rates tend to be lower than the cost to treat in many instances. Only preserving Medicaid funding will not prevent hospital closures. We already know that with or without Medicaid, rural hospitals continue to close. The only difference is the speed at which they do.
The question was about some universal system preventing rural deaths. If the coverage difference is only 1-2%, then coverage doesn't seem to be the driver. If it's a provider and facility shortage, then we would need some strategy to address the provider shortage, even if we assume we can fix the facility issue by providing higher reimbursement rates or grants.
Can I give my perspective as a Canadian? In our political system, we rarely talk about bipartisanship. First, because we don’t only have two political movements. Second, because we do nonpartisan politics. Examples include judges and district boundaries. Those two things are qualified as nonpartisan in Canadian politics. Another very telling example: parliamentary tour guides. The US Congress hires tour guides that are meant to reflect the political party that is responsible for their hiring. The Canadian Parliament insures their guides are nonpartisan.
Of course if you dig you will find problems, it’s far from perfect. However, the fact that what is collectively outside the realm of partisan politics is not decided by two partners who need to agree is what’s important here. There is a collective tradition. With our judicial system able to give binding decisions on unwritten parliamentary traditions, you even have legal protection for nonpartisan politics.
The US system counted way too much on the kindness of political adversaries. You need to find a new way to do politics, because American conservatives have decided that they will abandon democracy rather than give up power.
> However, we see a new type of rationing, based upon how much patients cost, and then denying care.
This is not at all new. It's how every other market operates.
For healthcare, which is not a normal market by any means, it might make sense to approach rationing differently because most people refuse to accept that rationing occurs at all, but cost will always be part of the picture.
Company, against contract, refuses to cover medication/procedures.
Company waits out patient to die.
The person is demonstrably wronged, but these companies can just wait sick people out. And that's precisely what happened with UHC. You know, Delay Deny Defend.
People need to take a step back and take the red/blue team fanboy emotion out of it.
It wasn't "destroyed" because it was "deemed socialist". It was destroyed because it used tricks of law to get something that didn't have broad enough support at the time done and those regulatory tricks were not durable. Same exact story as Roe v Wade but in a much more compressed timeline.
Unfortunately, the whole debacle has likely hardened the resolve of everyone who is against it even though a functional Romneycare system would likely be satisfactory to them (and needless to say an improvement over the status quo).
Turns out "the perfect is the enemy of the good, ship it" isn't how you run a society. This is a common theme. Stuff that's 50-50 either gets gutted or repealed with time. Something needs to be truly popular, like will lose you votes if you undo it, in order to stick around. For example no amount of pothead deadbeats or drunken wife beating is bringing weed or alcohol prohibition back at the state level.
We're 15yr on from the ACA and with very few exceptions things are worse. The nation likely would have been better served by letting the states that were inclined to run such systems continue doing so without federal meddling.
And where did they get the political capital to do that?
They got it from the approximately half of society that they could pander to by saying "look, we did that, vote for me and I'll take it even farther" at the next cycle.
The ACA is going to go down in history as something that caused some yet unknown number of decades of suffering because it was just barely too much just barely too soon. If they'd have kept it in their pants another decade or maybe even less, or legislated a more incremental solution at the time we'd probably be 5yr into something workable by now.
And some of us remember that asshole, Lieberman, was the one who blocked the Public Insurance option (aka universal insurance fund, a type of single payer). And he also blocked having medicare/medicaid from again negotiating for drug costs.
I keep saying, cause its true: this is a republican plan, pushed by republican governor, and by a republican thinktank, branded as socialist because a black democrat had the audacity to push it.
Romneycare wasn't really Republican , which was why it was it only passed in the overwhelmingly blue state of Massachusetts. Nixon signed OSHA, but nobody calls that Republican. The healthcare marketplace was proposed by the Heritage Foundation, but the state legislature added a lot of regulations and government assistance.
Yes, we know. It's not truly Republican unless it leaves the poor to die in a corner of bootstraps-itis. However, at the time the Heritage Foundation was still wearing the mask of caring because they hadn't pushed Single Payer out of the Overton window yet. It's bad optics to admit that you want the poor to die in a corner, so they had to pretend to have a solution and assistance was a cornerstone of the solution they pretended to have. The mask is off now, but history is history: it was part of their proposal.
My hope, perhaps naive, is that 95% of what happens in this Rube Goldberg machine basically amounts to the government paying private insurance companies to pay doctors, which is inefficient but ultimately straightforward.
I was going to push back against this, but when I googled "what percent of American health care is administrative costs" I got back numbers ranging from 15-34%, which is pretty darn high. Much higher than the last number I heard, which was something like 8%. The factor of two variance is kind of disturbing in itself.
All this means is that for insurance companies to maximize their administrative costs they push up the overall price - from their perspective making 10% of $10M is way better than 10% of $5M.
Drives me up the wall that the same people who can correctly identify when nominal nonprofits like rich people's charity organizations universities or even hospitals are pissing away money on officer salaries, perks, facilities, etc. because "nonprofit" think that somehow being a 10% or X% profit capped organization can't do the same thing with whatever expenses they aren't capped on.
In my country, social security and universal healthcare administrative cost are 8-11% depending on the year.
Compare that to Swisslife, my previous private healthcare insurance: for every 100€ I gave them, 66-72€ were paid to insure in need while I had them. Of course the mandatory dividends were pretty high before COVID, and reinvestment/marketing/sales has to take a bite of that, so perhaps only half of the 30% they take from customers are admin costs, but still, I'd rather give more to my country national healthcare if I could.
Probably the variance you have could be caused by non-admin costs being counted as admin costs.
Unfortunately there's a fraud problem, NOT by patients but by various entities claiming for unnecessary or never-performed procedures. https://pubmed.ncbi.nlm.nih.gov/25068880/
> Now that those subsidies are going away for next year, premiums are going to spike. For example, if someone paid $60 a month for their health insurance this year, they might be looking at $105 a month next year.
I was on the exchanges, unsubsidized, until this year. Last year's premium went from $3,000/month to $3,600/month. I had to buckle and get on a company plan with less coverage this year.
Meanwhile, every other piece of spare real estate in town is a new medical facility. Urgent cares, palatial orthopedic facilities… There's a crash coming.
I'll see your anecdote with another anecdote. Around where I live, for the past few years there was a sudden massive ad campaign for a new orthopedist complete with billboards featuring the presumably founding doctor's smiling face, and various other print and sponsored ads. Their main building is a giant gaudy marble, glass and brass clad building, but there are others that have taken up more mundane buildings. I don't know how such a business launches so quickly with so much $$, but it must be PE. They've certainly got a lot of debts to pay off now, and I can imagine the assembly-line level of care with more focus on low-margin patient satisfaction, encouraging reviews about how nice and friendly everyone was, rather than actual effective care. This is of course my cynical uninformed take after seeing mucho $$ spent on advertising. Maybe they are actually great and effective doctors, for all I know.
Platinum plan (which winds up most fiscally responsible for us - we max out the low out-of-pocket-max reliably), four people. Something like a bronze plan wouldn't save us any money; lower premiums trade for high deductibles and copays. Good if you're healthy.
Either you have a high deductible, or you're just being subsidized by everyone else.
The unsubsidized cost of a standard PPO plan for a family can easily reach $3000 a month. This is situation normal, people just don't see it because their employer is responsible for the cost.
We're likely to lose a lot of rural hospitals due to Medicaid cuts. We might need those new urban facilities, as those patients who do have insurance travel to the places still open.
For sobering data, check out the link below and look what happened in just 20 years. Unfortunately it stops at 2013, it's probably a solid orange blob today...
> Meanwhile, every other piece of spare real estate in town is a new medical facility. Urgent cares, palatial orthopedic facilities… There's a crash coming.
Consolidation of hospitals/medical facilities/practices and the rapid spread of PE firms is absolutely destroying our already cracking healthcare industry. A crash is definitely coming. And just like with the financial crisis, we’re going to be the ones footing the bill and/or just dying on hospital steps.
Combined with so many doctors fleeing states with strict abortion/anti-LGBT laws, as well as the dismantling of programs encouraging doctors to work in under-served (often rural/low income/isolated) areas, it doesn’t take a genius to figure out who’s going to be hit the hardest.
Does “ACA health insurance” classification used here include everyone who buys insurance on their own who are not employed by a large-enough company or on Medicare/medicaid?
The job-based insurance system in USA is so bogus.
Yep the biggest problem with the ACA was that it doubled down on health insurance as a benefit of employment, when it should have taken steps to transition everyone off of employer provided plans.
With a small tweak it would have the opposite effect. Just mandate that employers must add what they previously paid in health insurance to people's salary. So it would look like significant pay raises to a substantial portion of the populace. I bet that would be popular.
I don't know if you would even need to mandate it. Stop mandating it, and start taxing all benefits as income, and you remove the biggest incentive for employers for pay for them.
That would suck for employees. They just effectively got an effective decrease in pay.
A switch from employer-pay to government-pay should be a no-op for employees with employer health insurance. But in a naive scheme, it isn't. The burden for paying for health insurance moves from the employer to the employee (through increased taxes). The employer benefits because they stop paying for health insurance, the employee pays the costs.
Voters, who are mostly employees, would hate it.
OTOH, an on-paper pay raise for employees that doesn't cost the employer anything? That'll be much more politically palatable. "Both your taxes and your salary go up 10%" is a lot more palatable than "Your taxes go up 10%".
It's kinda hard to tell in the article but it seems specifically to apply to subsidized ACA purchases. There are market rate purchases on the ACA site too - I don't expect those will go up. They're already ruinously expensive.
Subsidies are going away but they're raising the unsubsidized rates because of that. This is the key paragraph:
> If healthy people opt out, the insurance pool is left with those who cost insurance companies more — people who can't go without health insurance because of chronic conditions or expensive medications. "That's why insurance companies are going ahead and charging a higher premium, with the expectation that the market is going to get sicker next year
Every plan is market rate. There is no distinction between subsidized plans and market rate plans. The individual subsidies simply reduce the cost of the marketplace plan for those who financially qualify for subsidies.
Premiums for all plans have been going up basically every year, even for those who don't qualify for any subsidies.
No, not everyone. For example, you can buy health insurance from Kaiser either through the ACA marketplace or directly. But the ACA has tax credits that you wouldn’t get if buying directly.
Prices are rough these days, because Republicans later removed the individual mandate. The system was never gonna survive that; it changes the economics entirely.
> “Pretty much every insurance company is talking about the expiration of enhanced premium tax credits in the ACA markets“
If I understand this correctly, enhanced premium tax credits were extended to 400% federal income poverty level during COVID. (e.g: federal income poverty line for a household of 1 is 15k), right?
For someone like me who is considering quitting their job for an extended period of time, and whose financial situation will not qualify for any subsidy on the ACA, how much is the cost expected to increase? The article doesn't seem to say, since it talks about "average" (i.e. heavily subsidized I assume).
Last estimates from a few weeks ago were ~$500/mo premiums for a bronze plan (+ deductible of course).
From a more informative article[1] linked from TFA:
"The expiration of the enhanced [premium] tax credits is expected to cause ACA enrollees’ out-of-pocket premium payments to increase by over 75% on average, with people in some states seeing their payments more than double on average."
"The enhanced premium tax credits were originally passed by Congress in the American Rescue Plan Act (ARPA) and extended under the Inflation Reduction Act (IRA), but they are set to expire at the end of 2025."
> Now that those subsidies are going away for next year, premiums are going to spike. For example, if someone paid $60 a month for their health insurance this year, they might be looking at $105 a month next year.
If you payed $60 a month you were mega subsidized. I'm at about $500 a month (50s, single, bronze). There's no way I'm suddenly going to be around $900. This is either clickbait or a NPR scare tactic.
> For generations, members of the Beers family of Canton, Ohio, have used Christian faith to sell health coverage to more than a hundred thousand people like Martin. Instead they delivered pain, debt and financial ruin, according to an investigation by ProPublica based on leaked internal documents, land records, court files and interviews. They have done this not once but twice and have faced few consequences.
Even the legit ones don't have to cover stuff; they aren't health insurance. Even if they do, many facilities and docs won't take it, because they aren't required to cover things and they don't want the fight.
I’ve never understood why America doesn’t have a decent health care system. And then America voted for Trump, and everyone appears shocked at what he has done…
There is something very wrong with American attitudes.
America arguably offers the best healthcare in the world. If you can afford it.
The quality of care, technology, and expertise are top-tier for those with excellent insurance or deep pockets. But the system is neither free nor particularly efficient. For many, access is limited by cost, bureaucracy, and inequities. So yes, it is best care available, but not best care accessible.
I don't think we (Americans) have a solid understanding of political cause and effect. You see this in low turnout for local/state elections (vs federal), and just a lack of understanding of how the various political mechanics work.
My mother is an elementary school teacher in a conservative Michigan town. She generally doesn't talk politics at work, but a coworker mentioned that the school's "no questions asked" free breakfast and lunch policy was ending next year due to federal education cuts. My mom's co-teacher, who voted for Trump, expressed surprise, saying she didn't realize that was something likely to be cut, or that the states would make up the shortfall.
Anyone remotely following US politics wouldn't be surprised, and would know that most states are fairly strapped for cash. (Whether that's societally optimal is besides the point.) This is a pattern I see over and over again, on both sides of the line: you see Trump voters surprised that cuts to the FDA result in higher food recalls, and you see Democratic voters saying that nothing got done over the last four years.
It baffles me. I have more awareness of the local politics in our small Canadian town than I did when I lived in Chicago, and it all just comes from listening to my friends talk about current events. It's a wild feeling.
Most people vote based on pre-established party identity or single issues. The main problem is that a two party system ends up with the parties being opposed to each other, providing voters with only 2 real choices. If you don't agree with your party's stance on every issue, then you inevitably end up voting for someone who will do things you are opposed to.
There's a lot of media disinformation goes into keeping people that way.
It's a weird scenario. American politics is so loud and omnipresent that I, as a Brit on the Internet, end up following it involuntarily because it ends up in every discussion everywhere. But so much of it is just weird things made up by right wing talking heads.
The US oligarchy runs the biggest propaganda operation in history. From think tanks that sell neoliberal policy narratives, to captured journalists in the MSM, to Fox News and its imitators, to podcasts, megachurches, conventional media content, carefully curated addictive social media algorithms, paid SM influencers, troll and bot farms, normalised work ethics and workplace dynamics, adtech and the ad industry, and "edgy" sites like nChan - it's all managed messaging.
It's targeted across all US demographics. Sometimes covertly.
And increasingly it's fine-tuned towards individual interests and psychological triggers.
Hard to pay for a health care system when the population is incentivized to live absolute unhealthy lives.
Encourage not sleeping, advertise and manufacture processed garbage, encourage drinking poison, and most of all encourage working long hours over getting any physical activity.
Yeah, good luck with that. It’s an every man for themselves environment, the government and American society is fine with throwing your body into the meat grinder for more profit.
Ironically we’d be much more productive if we incentivized a healthier lifestyle for the population.
It is cool to be uneducated and to instead believe unchecked made up bs in the US, as long as said bs maintains the status quo. It is the saddest part of this country.
Depends where you look, but most of his voters don't know and/or don't care. I think the only thing he's done to rile them up so far this term is his recent comments on the Epstein case.
I don't think they'll enjoy a price increase, but I also don't have confidence that the average Trump voter will blame him for it. Most of them are already distrustful of government and this will just validate that. Of course Obamacare failed, Trump was right all along, it failed because too many illegals, etc.
The right wing media ecosystem they have created obscures the fact that Obamacare is the thing these people are using.
Then, once it fails, they will just lie and again blame Democrats for it instead of circling back to their talking points about how they wanted to kill Obamacare.
This is just some people. I have met a fair number of people who just think it is too bad, so sad if you are too poor or do not have a good enough job for good healthcare. I was visiting Canada once, and the folks at the company I was visiting recounted the last American who rolled through who espoused the "well, I guess they die" talking points - to their horror.
Spend a bit of time talking with tradesmen and you'll change your mind on that.
These people aren't stupid - far from it! I work with electricians all day and they're sharp as tacks. But most of 'em have been lied to so long they buy it all, hook, line, and sinker. Quite a few of them get drawn in by the social conservative outlook and then just go along with the rest of it.
Yes, but only about a third of voters are hard-core MAGA. There's a big group in the middle that pays less attention to politics, and swung for Trump mostly for economic reasons.
Why not? They're already primed to hate Obamacare. All you have to do is say that prices went up because of the law, not these changes, and they'll believe it.
Well their supporters are, quite frankly, unrepentant morons that have believed literally anything broadcast on their absolutely enormous propaganda machine for two decades.
I'm not exactly holding my breath that they'll suddenly grow a brain to connect cause and effect against the word of Dear Supreme God King.
America does have a decent healthcare system for the vast majority of its citizens (people with full time jobs and their dependents, plus the elderly).
That's a large reason why there is no major change in this area, even though one is sorely needed.
Personally, I'd just open Medicare up to anyone who wants it by paying some additional fee each month and see how that goes, but that's too simple for most politicians I think.
"Personally, I'd just open Medicare up to anyone who wants it by paying some additional fee each month"
The big question is how big the fee is. Even with Medicare you have plenty of costs, and that's after paying 5.6% of pay into the system for 30+ years. My guess would be that the cost will be similar to what we're seeing on the ACA market with $500-3000 premiums depending on your deductible.
The problem is it costs what it costs. To reduce individual cost you have to reduce the cost of service or pay for it from some other source.
"Of the subtypes of health insurance coverage, employment-based insurance was the most common, covering 53.7 percent of the population for some or all of the calendar year, followed by Medicaid (18.9 percent), Medicare (18.9 percent), direct-purchase coverage (10.2 percent), TRICARE (2.6 percent), and VA and CHAMPVA coverage (1.0 percent).
While the private coverage rate was statistically unchanged between 2022 and 2023, the employment-based coverage rate declined by 0.7 percentage points to 53.7 percent in 2023. At the same time, the rate of direct-purchase coverage increased by 0.3 percentage points to 10.2 percent in 2023."
It's kind of amazing that majoritarian democracy is as good as it is at addressing problems experienced by small minorities. It is pretty bad, but it could be much worse.
America's healthcare system is basically a house of cards. Yes for people with jobs and benefits, it works, for now.
But so so so much is wrong financially for hospitals, clinics and pharmacies.
This administration is poking the house of cards with a really large stick.
Pharmacies are so fucked by PBMs( that politicians only pay lip service to dealing with) that they _owe_ money to the PBM everytime they fill many prescriptions. Negative reimbursements.
Many small time pharmacies now play games to refuse prescriptions because of how bad it is. PBMs have tried to counter by having distributors write contracts that bar refusals. Chain pharmacies aren't doing much better and are where the negative reimbursement customers end up.
"Mom & pop" doctor offices simply are going extinct. Due to both polticians lumping on requirements for digital records, infinite insurance games and cost of real estate going to the moon, every new doctor just joins a mega-hospital-network because they are already 2 million in debt after schooling. Old doctors just sell out their clinics to those hospital networks. Suddenly doctors that work there get put under strict quotas. This is something I've seen happen in real time in my suburban part of NY. My doctor's office that also fell under the growing blob of a mega-network, now has numerous signs saying "new concerns brought up during the appointment must be done under a new appointment for billing purposes".
Most Americans can get pretty good care. It also tends to be painful to get. You don't just go to the doctor. You visit some horrible web site clearly built by someone who doesn't have to use it, go through the list of in-network providers, pick one, call, find out that the list is out of date and they don't accept your insurance.... And then come the surprise bills. The office coded your lab work wrong so it doesn't count as preventive, pay up, or spend an hour on the phone correcting it. You offhandedly told the doctor you're feeling tired lately during your annual physical, and they give you some tips on getting better sleep. Then you get a bill because that counts as a consultation for a specific medical problem, so your free annual physical now requires you to pay a copay.
God forbid you have a major incident. Nobody can ever tell you how much things will cost. You'll be dealing with bills for months, and you won't be able to trust that any of them are legitimate.
The actual health providers are usually OK. The health insurance is godawful.
I think the system is a disaster and has actually gotten much worse over the last several years, but polls show that most people are satisfied with their care.
Maybe they're differentiating their care providers and insurer, but that's a level of critical thinking I wouldn't expect.
Israel is a special case. Obama made some "maybe we should consider what the Palestinians have to say" noises and you see the political blowback he got over it.
Entirely anecdotal: most Americans don't really get it. When people sign up for health insurance through HealthCare.gov, they're just picking a plan and paying their monthly bill. The website doesn't really make it front and center that it's ACA.
People may think they're paying full price because they make some monthly premium payment... which isn't true, as either the government subsidizes a portion of the premium, or you're getting group rates that are way cheaper than if you tried to buy insurance on your own. So even "full price" is receiving a form of subsidization through the operation of the program.
The disconnect is that the media and politicians talk about Obamacare like it's this free healthcare giveaway, so people who pay anything assume they're not on it. They could literally be using the ACA marketplace with 0 understanding that it's "Obamacare". Most people just perceive ACA as government overreach into healthcare, not realizing they're benefiting.
Most people don't talk about ACA / Obamacare on a regular basis (re: popularly). And I think empirically we can say many people don't know they're the same thing.
Also it's technically Romneycare. The political right got everything it wanted with it, similarly to when Nixon passed HMO funding that tied insurance to work, basically forcing a work requirement in order to get healthcare:
This might be the biggest thing that caused US healthcare to double in cost vs the rest of the developed world, which provides universal or single payer healthcare to their citizens for free or nearly free.
Also the article got the numbers wrong. To be accurate, they should have said $400 or more, roughly $5000 per year for working adults pushing 40. More for families. That was 10 years ago when I was applying, I'm sure it's more now.
I'm surprised that a startup isn't providing transportation for medical tourism. A friend of mine lived in Costa Rica for a while decades ago, and care was covered even for noncitizens. So a round trip ticket and living abroad for weeks would still be cheaper than insurance plus deductible here.
It's to the point where half of you will block nationalized healthcare for the other half, even though we would continue paying double to cover you for free too. So much for objectivism.
Edit: I forgot my point, which is that I believe that healthcare may be a natural monopoly, which is when something that everyone needs must be regulated, or else it becomes a monopoly where the vendor charges as much as possible because people have no choice:
A great deal of people do not, in fact, recognize that Obamacare == ACA.
It even shows up in poll data. This poll from Oct 2024 shows a 15 point difference when the wording changes. +34 favorable when asked how people feel about the ACA, but only +19 favorable when asked how they feel about Obamacare.
Labeling the ACA as Obamacare was an incredibly effective tactic to leverage the American public's racist tendencies against the public's own interests.
Figure 1.12 shows average annual premiums from 1999 to 2023. The ACA was passed in the middle of that range. It's a sustained upwards march, before and after its passage.
For all that cost - 2-3x as much as the other OECD nations spend, inclusive of taxes - we get shitty outcomes.
Prior to ACA all my colleagues in my peer group had employer provided health insurance that cost us very little, and it paid for virtually all medical bills except prescriptions. A HDHP was an option, but it only saved maybe a hundred or two a month, if that.
Today for most employees a HDHP is the ONLY option, and the cost is much higher than the old standard health plans were.
Your company is passing the ever-increasing costs (which, again, have been on a steady sloped increase both before and after the ACA, since the 1970s; https://ourworldindata.org/grapher/health-expenditure-and-fi...) along to you, yes. This is a significant problem with our system; people think they get healthcare for $50/month, but it's really coming out of a reduced salary.
You're getting fucked (as am I!), but the ACA isn't what's doing it.
> The Affordable Care Act requires employers to report the cost of coverage under an employer-sponsored group health plan. Reporting the cost of health care coverage on the Form W-2 does not mean that the coverage is taxable. The value of the employer’s excludable contribution to health coverage continues to be excludable from an employee's income, and it is not taxable. This reporting is for informational purposes only and will provide employees useful and comparable consumer information on the cost of their health care coverage.
So, it went from "I pay $50/month for healthcare" to "my paycheck says they're taking $2k/month! what the fuck?!" in folks' minds.
Your peer group consisted of working people who could generally wake up in the morning. Generally healthy people.
Your insured pool now includes people who don't take care of themselves and treat the emergency room like a private doctor's office.
Other countries with government-controlled healthcare introduced wait times to encourage people to consider whether eating that extra donut was worth the health risk. I suspect we'll follow that path, too.
"According to a recent study by the Consumer Choice Center, the average wait for a GP appointment in the United States in 2023 was around three weeks, two to ten times longer than in Europe. For example, in that year, the average waiting time for a medical consultation was two days in Switzerland, six days in France and ten days in the United Kingdom and Italy."
Don't forget the third option: let people die from treatable conditions if they can't pay, which includes you if you ever end up unconscious without proof of insurance on you.
Of course, this is so heinous that Ronald Reagan outlawed it and there's zero discussion of repealing that law. We've had universal health care in the US since 1986. All subsequent debate has merely been about how it should be done.
IMO participating on HN is a privilege earned through good faith discussion over time.
If they want to make a point they can do it without being smart aleck and wasting peoples' time.
There are two options: you pay for health care for the poor through taxes, or you pay for health care for the poor through higher insurance rates.
Reagan was the one who brought socialized health care to America. He passed a law saying that hospitals couldn't refuse emergency treatment due to inability to pay. So uninsured people wait until their conditions are bad enough to be considered an emergency, and then show up at the ER. So hospitals have to jack up their rates for everybody to cover the cost of emergency treatment of the uninsured. Expensive treatment that would likely be much cheaper if treated before it became an emergency.
So this Trump move won't save you money, it just changes how you pay.
The Biden administration started to heavily subsidized some
health care plans with Covid as the backdrop, and now
those temporary measures are ending.
In so far as I have found and I might be wrong,
congress never voted to fund and subsidize those medical plans
indefinitely.
Now health insurance companies are raising their rates
on those specific plans since the government is no longer
partially funding it, or perhaps not funding them as much.
Then I am convinced the insurance companies raised their
rates more then strictly required as they nearly always to
to make even more money.
The ACA was originally designed as a "three-legged stool" of nondiscrimination (insurance companies can't charge higher rates to sick people), the individual mandate, and subsidies.
If you remove one of legs of the stool, the market becomes unstable and you see price spirals like this.
Jonathan Gruber (MIT econ professor, and one of the designers of the Affordable Care Act) gave a fairly detailed talk about how and why they designed the ACA the way they did, learning from a similar law in Massachusetts: https://youtu.be/2fTHqARiV_Q?si=SRC6Np-rjgUgAe4Z&t=679
In this case they removed 2. Subsidies and mandates
And they also added requirements what must be insured and maximum out of pocket.
So you cannot have a cheap insurance with 20k max out of pocket.
You still can in some limited situations (like being under 30 years old) through “catastrophic” health plans.
Yep, the ACA was originally RomneyCare.
Mitt Romney took the plan from the Heritage foundation (yes, the conservative neocon think tank). Hard low-controls capitalist plan.
Heritage foundation made this plan after Hillary Clinton pushed universal healthcare in 1994, as first lady. Howls of 'death panels' were heard all over republican talking points and radio shows.
(The 'death panels' aka rationing was seen as bad for government to do. However, we see a new type of rationing, based upon how much patients cost, and then denying care. That lead to the UHC execution, then approving more procedures, then getting sued by shareholders for that. Personally, government death panels are preferred to capitalist death panels.)
Put simply: Obama passed republican legislation put forth by a republican governor and a republican thinktank, and was deemed a socialist. And now, the program is basically destroyed.
Bipartisanship is dead. If you want to win, play to win.
Playing to win is dead. Current climate is play to kill yourself, so long as your opponent also does but suffers more.
I'm somewhat hopeful with Gavin Newsom's posture making an example, I wouldn't vote for him, but I like the aggressive PR position he's taken, his willingness to gerrymander just as the other side has been doing forever. That's what I mean by bipartisanship is dead. You can't negotiate with the other side, they do not want to negotiate, they want to win at all costs for ideology, so you can only do your best to disempower them. If you try to play fair with a counterparty who does not believe in acting in good faith or playing fair, you have default lost. You can't have a functional democracy when one side rejects democracy (massive efforts to disenfranchise voters, gerrymandering, etc) because they can't win democratically. There is no reason you can't have empathy while punching down at bullies, because if the tables were turned, the bullies would put their boot on your neck ("paradox of tolerance"). So, start punching down.
Edit:
In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves (considering how dependent red states are on the federal government [1] [2]); Oregon is up first [3]. You can increase state taxes to fund this, reducing tax dollars sent to the federal government, if properly engineered.
[1]. https://time.com/7222411/blue-states-are-bailing-out-red-sta...
[2] https://usafacts.org/articles/which-states-contribute-the-mo...
[3] https://www.hcfawa.org/oregon_s_path_to_universal_health_car...
> In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves…
The risk here will be sick people (and their high costs) moving. As with how Chicago's illegal gun problems mostly come from Indiana.
We already deal with this problem in higher education by having out-of-state tuition and in-state tuition priced at different levels. A period of residency is required to access in-state tuition.
Does residency fraud exist? I'm sure of it. Despite the UC and CSU systems not publishing residency fraud statistics, such fraud is universally described as being extremely difficult to execute. I cannot overstate this point. Students routinely depict residency fraud as being more difficult to do than simply paying out of state tuition. The high cost of committing residency fraud makes cancels out any expected payoff. Furthermore, most instances of detected fraud appear to be technical and clerical errors, not intentional deception.
What are in-state residency requirements, and how difficult is the requirement? Evidence for residency includes:
- Obtaining a California driver’s license or ID card
- California vehicle registration
- California voter registration
- California state tax returns
- California bank accounts
- Employment in California
- Lease, mortgage, or property ownership in California
- Severing residential ties to your former state (e.g., closing out-of-state bank accounts, surrendering non-CA licenses)
Additionally, one year and one day of residency is commonly the required threshold to qualify for in-state tuition.
The question becomes, is this effective enough at reducing fraud rather than can fraud be eliminated. I'm sure, like with any system, fraud detection and remediation are part of the operating costs and measured in terms of recovery rate/rate of return - the KPI we're discussing.
I'm not talking about fraud, though. I'm talking about genuinely moving.
It is fraud to move to California for the sole purpose of education[1]. Likewise, genuinely moving to California for the sole purpose of benefiting from universal healthcare is also, in my opinion, fraud.
People genuinely moving to California would presumably pay out of state healthcare fees until their residency was established. Don't you agree that these fees could be set in a way that served as a barrier to doing what you suggest?
Is there a case that isn't covered by this that you're thinking about?
1. Cal. Code Regs. Tit. 5, § 54022 - Physical Presence. "Physical presence within the state solely for educational purposes does not constitute establishing California residence regardless of the length of that presence." https://www.law.cornell.edu/regulations/california/5-CCR-540...
That just means college students living off-campus don't suddenly get in-state tuition rates after a year or two.
Sick people are allowed to like California's weather enough to move there. The ADA would also apply when trying to restrict residency in a way it would not for education.
> Sick people are allowed to like California's weather enough to move there.
Perfectly fine. They shall pay out of state rates until they meet the threshold.
> The ADA would also apply when trying to restrict residency in a way it would not for education.
Can you elaborate? In the best case, it's difficult to predict how courts would rule on this. Any relevant case law? Legislation?
> They shall pay out of state rates until they meet the threshold.
I'm not arguing they'll move and obtain residency on day one. I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.
The ADA's Title II would seem to forbid "you can't be a resident, ever, if you've got expensive healthcare costs" sort of rules at the state level, yes? That would clearly not be equal treatment for people with medical disabilities.
> I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.
It's trivial to construct a threshold and out of state pay structure which cancels this case out. What number of days and out of state pay structure do you feel would cover these cases? How many of these cases do you suspect will occur annually and what is the projected cost? It's a relatively easy problem to solve once we get down to the specifics.
> "you can't be a resident, ever, if you've got expensive healthcare costs"
Great! I'm not arguing for "ever". I think we're in the clear here.
Edit: Let's estimate the volume of this effect using migration after Medicad expansion as a proxy. Over 10 years (2009 to 2019) we find 56,659 interstate moves after Medicaid enrollment growth[1]. In other words, 0.23 percentage points greater annual population growth in the target population. Another study found an in-migration rate(to CA) of 1.4% for medicaid recipients. Being generous and taking the higher of the two, and multiplying it by California's net immigration of 500,000–600,000 annually, gives us an estimated 7000-8400 medicaid migrants a year a fraction of which are migrating primarily for medical purposes. What would you estimate the annual medical expenditures for this group would be and if an "new arrivals" insurance pool was formed, what would the marginal monthly premium cost be to its members?
I estimate that a CA new arrivals insurance pool would have $4B in annual disbursements, and $4-20M in annual residency fraud. Using averages, we can estimate a monthly premium for this group would be about $667/month.
This is roughly on par with unsubsidized ACA premiums for adults in many states. For comparison, ACA benchmark premiums for a 40-year-old in California in 2024 are about $450–$600/month.
1. https://pubmed.ncbi.nlm.nih.gov/39893838/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4011649/?
I think there is a lot of time to flesh this idea out, California apparently has more people moving out than moving in at the moment.
Absolutely. While it was unsurprising to find that housing costs are now one of the biggest reasons for CA emigration. It's those who are lower income, and have just a high school education. Among high earners, working from home has a huge influence on emigration from California. Conversely, higher earners are least likely to move out of CA.
If blue states can build enough housing to welcome refugees from collapsing red states then great. Caring for people and building bigger concentrations of healthy people is a good thing, especially as the House is proportional to population.
This would be far more likely to concentrate non-healthy people, and all their costs. The needy in red states will move for access to care; the red states will see a healthier and cheaper population as a result.
I am willing to bet $10k to a 501c3 charity of the winner’s choice this doesn’t happen and that the thesis is deficient. Let me know if you want to take the bet, we’ll use Longbets.org to officiate.
Gonna gently suggest to you that someone who can go "I'll put $10k in escrow for a few decades over an internet comment" perhaps may struggle to understand the desperation of someone with a disabling chronic illness to get access to medical treatment. (And their lack of means to match such a bet, no matter their confidence in the position.)
On the contrary, I financially support several people who are disabled and will never work again (to bridge them until they qualify for age tested benefits). I bought a piece of land in the Midwest, and am building tiny homes for them one by one. I previously did a short stint as a Guardian ad Litem in Florida for disadvantaged children who needed an independent advocate, and I act as a patient advocate today for folks who need healthcare and have a hard time accessing it. My deceased mother could not claim Social Security disability while genuinely disabled, and I was first hand involved in the process to see how the system is built to prevent entitled beneficiaries from claiming disability benefits up to her early death at 60.
I am resourced (out of luck), but also high empathy and intimately familiar with the struggles you mention. The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right. This is why I am for universal healthcare, see no other path forward, and I hope this better explains the mental model my arguments in this context are based upon.
> The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right.
I mean, same position here. I just don't have $10k to sit in escrow for years. I've similarly got plenty of first-hand experience; one on Medicare and one on Medicaid in the family due to disability, and even with those and a reasonably well paying job we'd absolutely consider moving for a program as described.
Data-wise, we've already got quite a bit demonstrating that California's better-than-average social services are more attractive to homeless folks, to the point where they have ~25% of the country's population of them.
I'm also for universal healthcare. I just don't think doing it unilaterally at the state-level is likely to work very well with freedom of movement between states, as with gun control.
Most people cannot afford to move. 60 percent of Americans cannot afford a basic quality of life. Those who can move will move to states that can afford this, and are the economic engines of the US economy (California is the world's fourth largest economy, for example). Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want. I support the rapid reduction of healthcare services in those areas [1].
I pay taxes (>$100k/year total state and federal tax burden), I support universal healthcare, and I am willing to pay more for everyone to be covered.
[1] https://ruralhospitals.chqpr.org/Overview.html
> Most people cannot afford to move.
That calculus gets a little different for some folks if the move comes with subsidized universal healthcare and better social services.
> Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want.
We agree, but "The Only Moral Abortion is My Abortion" rule applies. https://joycearthur.com/abortion/the-only-moral-abortion-is-...
If you can’t change their mind, and you can’t change their vote, and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes. Until then, we are held hostage by the irrational and unsophisticated with votes, which is unfortunate but the reality of the situation.
It’s exhausting being dragged by low empathy unsophisticated humans frankly, I am personally over it. I was naive about human nature, hard lessons learned.
"and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes."
Is there any evidence that universal healthcare would address the facility and physician shortages in rural areas? It won't make much difference if you give people coverage if they still can't exercise that coverage, or just get subpar care in many rural facilities. It seems that many rural hospitals have turned into glorified helipads to transport many patients to bigger cities.
For example, the uninsurance rate for urban vs rural is only 1-2%. It seems like that wouldn't explain the larger gaps in health outcomes. It seemsbother factors would be more important.
Rural hospitals close because they lack funding. When they have funding, they can stay open and continue to retain medical staff. When they close, mortality rates increase. Can I prove universal healthcare would keep these hospitals open? Highly speculative based on what that solution would look like. I can only prove stripping Medicaid funding is going to close them, with the consequences enumerated.
https://www.nbcnews.com/news/us-news/rural-hospital-closings...
https://www.nber.org/papers/w26182
https://pmc.ncbi.nlm.nih.gov/articles/PMC9633454/
https://ruralhospitals.chqpr.org/
https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-r...
https://www.kiplinger.com/taxes/medicaid-cuts-and-your-local...
Medicaid reimbursement rates tend to be lower than the cost to treat in many instances. Only preserving Medicaid funding will not prevent hospital closures. We already know that with or without Medicaid, rural hospitals continue to close. The only difference is the speed at which they do.
The question was about some universal system preventing rural deaths. If the coverage difference is only 1-2%, then coverage doesn't seem to be the driver. If it's a provider and facility shortage, then we would need some strategy to address the provider shortage, even if we assume we can fix the facility issue by providing higher reimbursement rates or grants.
Can I give my perspective as a Canadian? In our political system, we rarely talk about bipartisanship. First, because we don’t only have two political movements. Second, because we do nonpartisan politics. Examples include judges and district boundaries. Those two things are qualified as nonpartisan in Canadian politics. Another very telling example: parliamentary tour guides. The US Congress hires tour guides that are meant to reflect the political party that is responsible for their hiring. The Canadian Parliament insures their guides are nonpartisan.
Of course if you dig you will find problems, it’s far from perfect. However, the fact that what is collectively outside the realm of partisan politics is not decided by two partners who need to agree is what’s important here. There is a collective tradition. With our judicial system able to give binding decisions on unwritten parliamentary traditions, you even have legal protection for nonpartisan politics.
The US system counted way too much on the kindness of political adversaries. You need to find a new way to do politics, because American conservatives have decided that they will abandon democracy rather than give up power.
> However, we see a new type of rationing, based upon how much patients cost, and then denying care.
This is not at all new. It's how every other market operates.
For healthcare, which is not a normal market by any means, it might make sense to approach rationing differently because most people refuse to accept that rationing occurs at all, but cost will always be part of the picture.
Its not JUST cost.
Insurance company covers person.
Person gets chronic ill, with covered disease.
Person is now 'less profit' or a cost.
Company, against contract, refuses to cover medication/procedures.
Company waits out patient to die.
The person is demonstrably wronged, but these companies can just wait sick people out. And that's precisely what happened with UHC. You know, Delay Deny Defend.
People need to take a step back and take the red/blue team fanboy emotion out of it.
It wasn't "destroyed" because it was "deemed socialist". It was destroyed because it used tricks of law to get something that didn't have broad enough support at the time done and those regulatory tricks were not durable. Same exact story as Roe v Wade but in a much more compressed timeline.
Unfortunately, the whole debacle has likely hardened the resolve of everyone who is against it even though a functional Romneycare system would likely be satisfactory to them (and needless to say an improvement over the status quo).
Turns out "the perfect is the enemy of the good, ship it" isn't how you run a society. This is a common theme. Stuff that's 50-50 either gets gutted or repealed with time. Something needs to be truly popular, like will lose you votes if you undo it, in order to stick around. For example no amount of pothead deadbeats or drunken wife beating is bringing weed or alcohol prohibition back at the state level.
We're 15yr on from the ACA and with very few exceptions things are worse. The nation likely would have been better served by letting the states that were inclined to run such systems continue doing so without federal meddling.
"The Democrats weren't able to stop Republicans from killing it, therefore it's the Democrats fault that Republicans killed it."
Instance #234535 of "the bar is never too high for Democrats and never too low for Republicans."
The regulatory tricks were upheld by SCOTUS.
Republicans just zeroed out the penalty in the individual mandate after that decision. They knew what that would do; that's why they did it.
And where did they get the political capital to do that?
They got it from the approximately half of society that they could pander to by saying "look, we did that, vote for me and I'll take it even farther" at the next cycle.
The ACA is going to go down in history as something that caused some yet unknown number of decades of suffering because it was just barely too much just barely too soon. If they'd have kept it in their pants another decade or maybe even less, or legislated a more incremental solution at the time we'd probably be 5yr into something workable by now.
And some of us remember that asshole, Lieberman, was the one who blocked the Public Insurance option (aka universal insurance fund, a type of single payer). And he also blocked having medicare/medicaid from again negotiating for drug costs.
I keep saying, cause its true: this is a republican plan, pushed by republican governor, and by a republican thinktank, branded as socialist because a black democrat had the audacity to push it.
I don’t see how anyone can seriously suggest society must only use “perfect” policies. They don’t even exist. How does that help anyone?
Romneycare wasn't really Republican , which was why it was it only passed in the overwhelmingly blue state of Massachusetts. Nixon signed OSHA, but nobody calls that Republican. The healthcare marketplace was proposed by the Heritage Foundation, but the state legislature added a lot of regulations and government assistance.
Yes, we know. It's not truly Republican unless it leaves the poor to die in a corner of bootstraps-itis. However, at the time the Heritage Foundation was still wearing the mask of caring because they hadn't pushed Single Payer out of the Overton window yet. It's bad optics to admit that you want the poor to die in a corner, so they had to pretend to have a solution and assistance was a cornerstone of the solution they pretended to have. The mask is off now, but history is history: it was part of their proposal.
The Heritage Foundation pushed a plan with the same key features. Get it straight from the horse's mouth here: https://www.heritage.org/health-care-reform/commentary/dont-...
That article purports to disprove the idea that the ACA is based on their proposal, but it actually does a good job proving it.
My hope, perhaps naive, is that 95% of what happens in this Rube Goldberg machine basically amounts to the government paying private insurance companies to pay doctors, which is inefficient but ultimately straightforward.
>which is inefficient but ultimately straightforward.
That's an understatement on the order of saying WW2 was a rebalancing of geopolitical power.
Healthcare is what? 20% of GPD. Likely half of that is paper pushing compliance checking rubber stamping that likely ought not to exist.
I was going to push back against this, but when I googled "what percent of American health care is administrative costs" I got back numbers ranging from 15-34%, which is pretty darn high. Much higher than the last number I heard, which was something like 8%. The factor of two variance is kind of disturbing in itself.
All this means is that for insurance companies to maximize their administrative costs they push up the overall price - from their perspective making 10% of $10M is way better than 10% of $5M.
Drives me up the wall that the same people who can correctly identify when nominal nonprofits like rich people's charity organizations universities or even hospitals are pissing away money on officer salaries, perks, facilities, etc. because "nonprofit" think that somehow being a 10% or X% profit capped organization can't do the same thing with whatever expenses they aren't capped on.
In my country, social security and universal healthcare administrative cost are 8-11% depending on the year.
Compare that to Swisslife, my previous private healthcare insurance: for every 100€ I gave them, 66-72€ were paid to insure in need while I had them. Of course the mandatory dividends were pretty high before COVID, and reinvestment/marketing/sales has to take a bite of that, so perhaps only half of the 30% they take from customers are admin costs, but still, I'd rather give more to my country national healthcare if I could.
Probably the variance you have could be caused by non-admin costs being counted as admin costs.
Unfortunately there's a fraud problem, NOT by patients but by various entities claiming for unnecessary or never-performed procedures. https://pubmed.ncbi.nlm.nih.gov/25068880/
According to: https://fiscaldata.treasury.gov/americas-finance-guide/feder...
22 % Social Security
14 % Net Interest
14 % Medicare
13 % Health
13 % National Defense
10 % Income Security
5 % Veterans Benefits and Services
2 % Education, Training, Employment, and Social Services
2 % Transportation
1 % Natural Resources and Environment
3 % Other
That's the budget of the federal government, which thankfully isn't 100% of GDP.
> Now that those subsidies are going away for next year, premiums are going to spike. For example, if someone paid $60 a month for their health insurance this year, they might be looking at $105 a month next year.
I was on the exchanges, unsubsidized, until this year. Last year's premium went from $3,000/month to $3,600/month. I had to buckle and get on a company plan with less coverage this year.
Meanwhile, every other piece of spare real estate in town is a new medical facility. Urgent cares, palatial orthopedic facilities… There's a crash coming.
>palatial orthopedic facilities
I'll see your anecdote with another anecdote. Around where I live, for the past few years there was a sudden massive ad campaign for a new orthopedist complete with billboards featuring the presumably founding doctor's smiling face, and various other print and sponsored ads. Their main building is a giant gaudy marble, glass and brass clad building, but there are others that have taken up more mundane buildings. I don't know how such a business launches so quickly with so much $$, but it must be PE. They've certainly got a lot of debts to pay off now, and I can imagine the assembly-line level of care with more focus on low-margin patient satisfaction, encouraging reviews about how nice and friendly everyone was, rather than actual effective care. This is of course my cynical uninformed take after seeing mucho $$ spent on advertising. Maybe they are actually great and effective doctors, for all I know.
> I was on the exchanges, unsubsidized, until this year. Last year's premium went from $3,000/month to $3,600/month.
I want to know details of your situation, because my exchange premiums are like $300/month.
Platinum plan (which winds up most fiscally responsible for us - we max out the low out-of-pocket-max reliably), four people. Something like a bronze plan wouldn't save us any money; lower premiums trade for high deductibles and copays. Good if you're healthy.
https://imgur.com/a/SC3DNTf
Curious what the details of your situation are and how often you use healthcare?
Either you have a high deductible, or you're just being subsidized by everyone else.
The unsubsidized cost of a standard PPO plan for a family can easily reach $3000 a month. This is situation normal, people just don't see it because their employer is responsible for the cost.
We're likely to lose a lot of rural hospitals due to Medicaid cuts. We might need those new urban facilities, as those patients who do have insurance travel to the places still open.
The medicaid reimbursement rates are so low that hospitals have been closing anyways. This might speed it up, but the outcome was already in motion.
What I read is that the big beautiful bill includes subsidies to keep those hospitals open, just not for them to treat patients.
It's pretty sickening, to be honest.
For sobering data, check out the link below and look what happened in just 20 years. Unfortunately it stops at 2013, it's probably a solid orange blob today...
https://www.bls.gov/opub/ted/2014/ted_20140728.htm
> Meanwhile, every other piece of spare real estate in town is a new medical facility. Urgent cares, palatial orthopedic facilities… There's a crash coming.
Consolidation of hospitals/medical facilities/practices and the rapid spread of PE firms is absolutely destroying our already cracking healthcare industry. A crash is definitely coming. And just like with the financial crisis, we’re going to be the ones footing the bill and/or just dying on hospital steps.
Combined with so many doctors fleeing states with strict abortion/anti-LGBT laws, as well as the dismantling of programs encouraging doctors to work in under-served (often rural/low income/isolated) areas, it doesn’t take a genius to figure out who’s going to be hit the hardest.
Does “ACA health insurance” classification used here include everyone who buys insurance on their own who are not employed by a large-enough company or on Medicare/medicaid?
The job-based insurance system in USA is so bogus.
Yep the biggest problem with the ACA was that it doubled down on health insurance as a benefit of employment, when it should have taken steps to transition everyone off of employer provided plans.
It would be a political disaster to transition people off their employer plans.
The short term effect would be an increase in costs but no increase in pay for most people.
With a small tweak it would have the opposite effect. Just mandate that employers must add what they previously paid in health insurance to people's salary. So it would look like significant pay raises to a substantial portion of the populace. I bet that would be popular.
I don't know if you would even need to mandate it. Stop mandating it, and start taxing all benefits as income, and you remove the biggest incentive for employers for pay for them.
That would suck for employees. They just effectively got an effective decrease in pay.
A switch from employer-pay to government-pay should be a no-op for employees with employer health insurance. But in a naive scheme, it isn't. The burden for paying for health insurance moves from the employer to the employee (through increased taxes). The employer benefits because they stop paying for health insurance, the employee pays the costs.
Voters, who are mostly employees, would hate it.
OTOH, an on-paper pay raise for employees that doesn't cost the employer anything? That'll be much more politically palatable. "Both your taxes and your salary go up 10%" is a lot more palatable than "Your taxes go up 10%".
Health insurance contributions are pre-tax. Take home pay is post-tax.
It was a political disaster to keep people on the status quo of employer provided coverage, which the ACA did.
There's no safe path for any of this, with such effective propagandists ready to slander whatever move you make.
It's kinda hard to tell in the article but it seems specifically to apply to subsidized ACA purchases. There are market rate purchases on the ACA site too - I don't expect those will go up. They're already ruinously expensive.
Subsidies are going away but they're raising the unsubsidized rates because of that. This is the key paragraph:
> If healthy people opt out, the insurance pool is left with those who cost insurance companies more — people who can't go without health insurance because of chronic conditions or expensive medications. "That's why insurance companies are going ahead and charging a higher premium, with the expectation that the market is going to get sicker next year
Every plan is market rate. There is no distinction between subsidized plans and market rate plans. The individual subsidies simply reduce the cost of the marketplace plan for those who financially qualify for subsidies.
Premiums for all plans have been going up basically every year, even for those who don't qualify for any subsidies.
No, not everyone. For example, you can buy health insurance from Kaiser either through the ACA marketplace or directly. But the ACA has tax credits that you wouldn’t get if buying directly.
Only the plans you buy through the state marketplaces.
I've never dealt with it before personally, are there other places you can buy plans as an individual? How do the prices compare?
https://www.healthcare.gov/
Prices are rough these days, because Republicans later removed the individual mandate. The system was never gonna survive that; it changes the economics entirely.
Yep -- ACA health insurance refers to the individual market.
Man I thought we were getting raked with our 8% increase. 75% is unbelievable.
> “Pretty much every insurance company is talking about the expiration of enhanced premium tax credits in the ACA markets“
If I understand this correctly, enhanced premium tax credits were extended to 400% federal income poverty level during COVID. (e.g: federal income poverty line for a household of 1 is 15k), right?
Looks like it
https://www.medicaidplanningassistance.org/federal-poverty-g...
As with all things that are inhumane that the government is doing, the behavior will continue until a negative stimulus is introduced.
For someone like me who is considering quitting their job for an extended period of time, and whose financial situation will not qualify for any subsidy on the ACA, how much is the cost expected to increase? The article doesn't seem to say, since it talks about "average" (i.e. heavily subsidized I assume).
Last estimates from a few weeks ago were ~$500/mo premiums for a bronze plan (+ deductible of course).
From a more informative article[1] linked from TFA:
"The expiration of the enhanced [premium] tax credits is expected to cause ACA enrollees’ out-of-pocket premium payments to increase by over 75% on average, with people in some states seeing their payments more than double on average."
"The enhanced premium tax credits were originally passed by Congress in the American Rescue Plan Act (ARPA) and extended under the Inflation Reduction Act (IRA), but they are set to expire at the end of 2025."
[1] https://www.kff.org/policy-watch/how-will-the-2025-budget-re...
> Now that those subsidies are going away for next year, premiums are going to spike. For example, if someone paid $60 a month for their health insurance this year, they might be looking at $105 a month next year.
If you payed $60 a month you were mega subsidized. I'm at about $500 a month (50s, single, bronze). There's no way I'm suddenly going to be around $900. This is either clickbait or a NPR scare tactic.
(It's the OBBBA and knock-on effects.) The bill's Medicaid cuts will also impact the ACA market and health infrastructure broadly in the medium term.
In the renewal quote we just got, our small company premiums went up 12 percent while employee contributions went up 43 percent.
Don't know if that's just us or where the market is headed
I’m a little bit confused with how it will cost the average person 75% more?
Are the rates going up by the amount of the subsidy or are rates spiking significantly?
The ACA Bronze Plan is like $850/m and has a $10k deductible, absolute madness
You get what you vote for
Does anyone know if the medi share plans are any good?
https://www.propublica.org/article/liberty-healthshare-healt...
> For generations, members of the Beers family of Canton, Ohio, have used Christian faith to sell health coverage to more than a hundred thousand people like Martin. Instead they delivered pain, debt and financial ruin, according to an investigation by ProPublica based on leaked internal documents, land records, court files and interviews. They have done this not once but twice and have faced few consequences.
Even the legit ones don't have to cover stuff; they aren't health insurance. Even if they do, many facilities and docs won't take it, because they aren't required to cover things and they don't want the fight.
I’ve never understood why America doesn’t have a decent health care system. And then America voted for Trump, and everyone appears shocked at what he has done…
There is something very wrong with American attitudes.
America arguably offers the best healthcare in the world. If you can afford it.
The quality of care, technology, and expertise are top-tier for those with excellent insurance or deep pockets. But the system is neither free nor particularly efficient. For many, access is limited by cost, bureaucracy, and inequities. So yes, it is best care available, but not best care accessible.
In other words: so what?
working class USians continuously vote against their own interests
https://www.youtube.com/watch?v=I1BBBblrK44
I don't think we (Americans) have a solid understanding of political cause and effect. You see this in low turnout for local/state elections (vs federal), and just a lack of understanding of how the various political mechanics work.
My mother is an elementary school teacher in a conservative Michigan town. She generally doesn't talk politics at work, but a coworker mentioned that the school's "no questions asked" free breakfast and lunch policy was ending next year due to federal education cuts. My mom's co-teacher, who voted for Trump, expressed surprise, saying she didn't realize that was something likely to be cut, or that the states would make up the shortfall.
Anyone remotely following US politics wouldn't be surprised, and would know that most states are fairly strapped for cash. (Whether that's societally optimal is besides the point.) This is a pattern I see over and over again, on both sides of the line: you see Trump voters surprised that cuts to the FDA result in higher food recalls, and you see Democratic voters saying that nothing got done over the last four years.
It baffles me. I have more awareness of the local politics in our small Canadian town than I did when I lived in Chicago, and it all just comes from listening to my friends talk about current events. It's a wild feeling.
Most people vote based on pre-established party identity or single issues. The main problem is that a two party system ends up with the parties being opposed to each other, providing voters with only 2 real choices. If you don't agree with your party's stance on every issue, then you inevitably end up voting for someone who will do things you are opposed to.
There's a lot of media disinformation goes into keeping people that way.
It's a weird scenario. American politics is so loud and omnipresent that I, as a Brit on the Internet, end up following it involuntarily because it ends up in every discussion everywhere. But so much of it is just weird things made up by right wing talking heads.
The US oligarchy runs the biggest propaganda operation in history. From think tanks that sell neoliberal policy narratives, to captured journalists in the MSM, to Fox News and its imitators, to podcasts, megachurches, conventional media content, carefully curated addictive social media algorithms, paid SM influencers, troll and bot farms, normalised work ethics and workplace dynamics, adtech and the ad industry, and "edgy" sites like nChan - it's all managed messaging.
It's targeted across all US demographics. Sometimes covertly.
And increasingly it's fine-tuned towards individual interests and psychological triggers.
Hard to pay for a health care system when the population is incentivized to live absolute unhealthy lives.
Encourage not sleeping, advertise and manufacture processed garbage, encourage drinking poison, and most of all encourage working long hours over getting any physical activity.
Yeah, good luck with that. It’s an every man for themselves environment, the government and American society is fine with throwing your body into the meat grinder for more profit.
Ironically we’d be much more productive if we incentivized a healthier lifestyle for the population.
It is cool to be uneducated and to instead believe unchecked made up bs in the US, as long as said bs maintains the status quo. It is the saddest part of this country.
Depends where you look, but most of his voters don't know and/or don't care. I think the only thing he's done to rile them up so far this term is his recent comments on the Epstein case.
There has been an explosion of enrollments from red states in recent years, getting hit with a massive increase in monthly expenses will probably not go down so well: https://www.kff.org/policy-watch/where-aca-marketplace-enrol...
I don't think they'll enjoy a price increase, but I also don't have confidence that the average Trump voter will blame him for it. Most of them are already distrustful of government and this will just validate that. Of course Obamacare failed, Trump was right all along, it failed because too many illegals, etc.
The right wing media ecosystem they have created obscures the fact that Obamacare is the thing these people are using.
Then, once it fails, they will just lie and again blame Democrats for it instead of circling back to their talking points about how they wanted to kill Obamacare.
This is just some people. I have met a fair number of people who just think it is too bad, so sad if you are too poor or do not have a good enough job for good healthcare. I was visiting Canada once, and the folks at the company I was visiting recounted the last American who rolled through who espoused the "well, I guess they die" talking points - to their horror.
If rates go way up next year, I don't see how they're going to convince people the Democrats are at fault.
Stock market goes up: Trump economy! Stock market goes down: Biden left us a shitty economy!
Same will happen here.
Of course they'll say it. I just doubt that many people will believe it.
Spend a bit of time talking with tradesmen and you'll change your mind on that.
These people aren't stupid - far from it! I work with electricians all day and they're sharp as tacks. But most of 'em have been lied to so long they buy it all, hook, line, and sinker. Quite a few of them get drawn in by the social conservative outlook and then just go along with the rest of it.
Yes, but only about a third of voters are hard-core MAGA. There's a big group in the middle that pays less attention to politics, and swung for Trump mostly for economic reasons.
The last decade doesn't give me much doubt about that.
We're talking about folks who non-ironically walk around with signs saying "keep government out of my medicare". https://archive.nytimes.com/krugman.blogs.nytimes.com/2011/0...
> 44 percent of Social Security recipients, and 40 percent of Medicare recipients, believe that they don’t benefit from any government social program.
Why not? They're already primed to hate Obamacare. All you have to do is say that prices went up because of the law, not these changes, and they'll believe it.
Well their supporters are, quite frankly, unrepentant morons that have believed literally anything broadcast on their absolutely enormous propaganda machine for two decades.
I'm not exactly holding my breath that they'll suddenly grow a brain to connect cause and effect against the word of Dear Supreme God King.
Biden. Lol. Trump is still blaming Obama for stuff for some reason.
(Yes, we all know the reason)
America does have a decent healthcare system for the vast majority of its citizens (people with full time jobs and their dependents, plus the elderly).
That's a large reason why there is no major change in this area, even though one is sorely needed.
Personally, I'd just open Medicare up to anyone who wants it by paying some additional fee each month and see how that goes, but that's too simple for most politicians I think.
"Personally, I'd just open Medicare up to anyone who wants it by paying some additional fee each month"
The big question is how big the fee is. Even with Medicare you have plenty of costs, and that's after paying 5.6% of pay into the system for 30+ years. My guess would be that the cost will be similar to what we're seeing on the ACA market with $500-3000 premiums depending on your deductible.
The problem is it costs what it costs. To reduce individual cost you have to reduce the cost of service or pay for it from some other source.
54%
As of 2023, that seems to be the percentage of people that have healthcare through their employer.
Not sure where that number is from, but what I've seen it's around 60% usage and 75% availability for non-Medicare eligible Americans (https://www.kff.org/health-policy-101-employer-sponsored-hea...)
It's also worth noting that the percentages are substantially higher than the averages for the portion of the population who generally votes.
"Of the subtypes of health insurance coverage, employment-based insurance was the most common, covering 53.7 percent of the population for some or all of the calendar year, followed by Medicaid (18.9 percent), Medicare (18.9 percent), direct-purchase coverage (10.2 percent), TRICARE (2.6 percent), and VA and CHAMPVA coverage (1.0 percent). While the private coverage rate was statistically unchanged between 2022 and 2023, the employment-based coverage rate declined by 0.7 percentage points to 53.7 percent in 2023. At the same time, the rate of direct-purchase coverage increased by 0.3 percentage points to 10.2 percent in 2023."
https://www.census.gov/library/publications/2024/demo/p60-28...
More:
https://www.unionhealthcareinsight.com/post/why-employer-hea...
It's kind of amazing that majoritarian democracy is as good as it is at addressing problems experienced by small minorities. It is pretty bad, but it could be much worse.
It is incredibly good at addressing the problems experienced by the top 0.1 and 0.001%.
America's healthcare system is basically a house of cards. Yes for people with jobs and benefits, it works, for now.
But so so so much is wrong financially for hospitals, clinics and pharmacies.
This administration is poking the house of cards with a really large stick.
Pharmacies are so fucked by PBMs( that politicians only pay lip service to dealing with) that they _owe_ money to the PBM everytime they fill many prescriptions. Negative reimbursements. Many small time pharmacies now play games to refuse prescriptions because of how bad it is. PBMs have tried to counter by having distributors write contracts that bar refusals. Chain pharmacies aren't doing much better and are where the negative reimbursement customers end up.
"Mom & pop" doctor offices simply are going extinct. Due to both polticians lumping on requirements for digital records, infinite insurance games and cost of real estate going to the moon, every new doctor just joins a mega-hospital-network because they are already 2 million in debt after schooling. Old doctors just sell out their clinics to those hospital networks. Suddenly doctors that work there get put under strict quotas. This is something I've seen happen in real time in my suburban part of NY. My doctor's office that also fell under the growing blob of a mega-network, now has numerous signs saying "new concerns brought up during the appointment must be done under a new appointment for billing purposes".
"Decent" is a tricky word here.
Most Americans can get pretty good care. It also tends to be painful to get. You don't just go to the doctor. You visit some horrible web site clearly built by someone who doesn't have to use it, go through the list of in-network providers, pick one, call, find out that the list is out of date and they don't accept your insurance.... And then come the surprise bills. The office coded your lab work wrong so it doesn't count as preventive, pay up, or spend an hour on the phone correcting it. You offhandedly told the doctor you're feeling tired lately during your annual physical, and they give you some tips on getting better sleep. Then you get a bill because that counts as a consultation for a specific medical problem, so your free annual physical now requires you to pay a copay.
God forbid you have a major incident. Nobody can ever tell you how much things will cost. You'll be dealing with bills for months, and you won't be able to trust that any of them are legitimate.
The actual health providers are usually OK. The health insurance is godawful.
I think the system is a disaster and has actually gotten much worse over the last several years, but polls show that most people are satisfied with their care.
Maybe they're differentiating their care providers and insurer, but that's a level of critical thinking I wouldn't expect.
Because it’s a very profitable industry
Just like it is the case wrt Israel - it doesn’t matter who made it to office, the result was always going to be the same
Israel is a special case. Obama made some "maybe we should consider what the Palestinians have to say" noises and you see the political blowback he got over it.
The democrats obviously weren't going to destroy the ACA like this.
Yeah but if NPR is defunded then this isn’t a story. /s
The article sometimes throws in the term Obamacare — is it still popularly called that? And do most Americans know it’s the same thing?
Entirely anecdotal: most Americans don't really get it. When people sign up for health insurance through HealthCare.gov, they're just picking a plan and paying their monthly bill. The website doesn't really make it front and center that it's ACA.
People may think they're paying full price because they make some monthly premium payment... which isn't true, as either the government subsidizes a portion of the premium, or you're getting group rates that are way cheaper than if you tried to buy insurance on your own. So even "full price" is receiving a form of subsidization through the operation of the program.
The disconnect is that the media and politicians talk about Obamacare like it's this free healthcare giveaway, so people who pay anything assume they're not on it. They could literally be using the ACA marketplace with 0 understanding that it's "Obamacare". Most people just perceive ACA as government overreach into healthcare, not realizing they're benefiting.
I'm sure it's by design.
Most people don't talk about ACA / Obamacare on a regular basis (re: popularly). And I think empirically we can say many people don't know they're the same thing.
Came here to make the same joke.
Also it's technically Romneycare. The political right got everything it wanted with it, similarly to when Nixon passed HMO funding that tied insurance to work, basically forcing a work requirement in order to get healthcare:
https://en.wikipedia.org/wiki/Health_Maintenance_Organizatio...
This might be the biggest thing that caused US healthcare to double in cost vs the rest of the developed world, which provides universal or single payer healthcare to their citizens for free or nearly free.
Also the article got the numbers wrong. To be accurate, they should have said $400 or more, roughly $5000 per year for working adults pushing 40. More for families. That was 10 years ago when I was applying, I'm sure it's more now.
I'm surprised that a startup isn't providing transportation for medical tourism. A friend of mine lived in Costa Rica for a while decades ago, and care was covered even for noncitizens. So a round trip ticket and living abroad for weeks would still be cheaper than insurance plus deductible here.
It's to the point where half of you will block nationalized healthcare for the other half, even though we would continue paying double to cover you for free too. So much for objectivism.
Edit: I forgot my point, which is that I believe that healthcare may be a natural monopoly, which is when something that everyone needs must be regulated, or else it becomes a monopoly where the vendor charges as much as possible because people have no choice:
https://en.wikipedia.org/wiki/Natural_monopoly
Other examples include electricity, water, sewer, trash and probably education.
A great deal of people do not, in fact, recognize that Obamacare == ACA.
It even shows up in poll data. This poll from Oct 2024 shows a 15 point difference when the wording changes. +34 favorable when asked how people feel about the ACA, but only +19 favorable when asked how they feel about Obamacare.
https://navigatorresearch.org/the-affordable-care-act-remain...
Labeling the ACA as Obamacare was an incredibly effective tactic to leverage the American public's racist tendencies against the public's own interests.
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This is, quite simply, a lie.
https://www.kff.org/report-section/ehbs-2023-section-1-cost-...
Figure 1.12 shows average annual premiums from 1999 to 2023. The ACA was passed in the middle of that range. It's a sustained upwards march, before and after its passage.
For all that cost - 2-3x as much as the other OECD nations spend, inclusive of taxes - we get shitty outcomes.
https://assets.ourworldindata.org/uploads/2016/04/ftotHealth...
My rate and everyone I know had an increase of 60-100% after it was passed.
So not a 'lie' as you state. You are simply uninformed.
Rates have been going up since the 1970s, with a steady slope. Before and after ACA.
I don't doubt that your rates are going up. I doubt your attribution of the cause.
Prior to ACA all my colleagues in my peer group had employer provided health insurance that cost us very little, and it paid for virtually all medical bills except prescriptions. A HDHP was an option, but it only saved maybe a hundred or two a month, if that.
Today for most employees a HDHP is the ONLY option, and the cost is much higher than the old standard health plans were.
Your company is passing the ever-increasing costs (which, again, have been on a steady sloped increase both before and after the ACA, since the 1970s; https://ourworldindata.org/grapher/health-expenditure-and-fi...) along to you, yes. This is a significant problem with our system; people think they get healthcare for $50/month, but it's really coming out of a reduced salary.
You're getting fucked (as am I!), but the ACA isn't what's doing it.
Shouldn't that be obvious on the payslip?
That's part of the problem; it's only legally required to be shown post-ACA.
https://www.irs.gov/affordable-care-act/form-w-2-reporting-o...
> The Affordable Care Act requires employers to report the cost of coverage under an employer-sponsored group health plan. Reporting the cost of health care coverage on the Form W-2 does not mean that the coverage is taxable. The value of the employer’s excludable contribution to health coverage continues to be excludable from an employee's income, and it is not taxable. This reporting is for informational purposes only and will provide employees useful and comparable consumer information on the cost of their health care coverage.
So, it went from "I pay $50/month for healthcare" to "my paycheck says they're taking $2k/month! what the fuck?!" in folks' minds.
Your peer group consisted of working people who could generally wake up in the morning. Generally healthy people.
Your insured pool now includes people who don't take care of themselves and treat the emergency room like a private doctor's office.
Other countries with government-controlled healthcare introduced wait times to encourage people to consider whether eating that extra donut was worth the health risk. I suspect we'll follow that path, too.
> Other countries with government-controlled healthcare introduced wait times…
No, they have wait times. Just like the US does.
https://www.statista.com/chart/33079/average-waiting-times-f...
"According to a recent study by the Consumer Choice Center, the average wait for a GP appointment in the United States in 2023 was around three weeks, two to ten times longer than in Europe. For example, in that year, the average waiting time for a medical consultation was two days in Switzerland, six days in France and ten days in the United Kingdom and Italy."
Before it was passed, I as a young 25 year old was unable to get individual health insurance at any price due to "pre-existing conditions."
On the contrary, many plans were removed because they didn't cover enough, forcing many people into higher plans.
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We have essentially two options: Help people get medical care, or help much sicker people get medical care on an emergency basis.
Three.
Although only Republicans are in favour of the final option.
Don't forget the third option: let people die from treatable conditions if they can't pay, which includes you if you ever end up unconscious without proof of insurance on you.
Of course, this is so heinous that Ronald Reagan outlawed it and there's zero discussion of repealing that law. We've had universal health care in the US since 1986. All subsequent debate has merely been about how it should be done.
Not sure if serious... taxes (which we're now lowering for the wealthy, so even fewer benefits can be provided to the not-wealthy).
I always downvote green accounts that troll.
IMO participating on HN is a privilege earned through good faith discussion over time. If they want to make a point they can do it without being smart aleck and wasting peoples' time.
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I know your point. Don't make points with rhetorical questions. I'm daring you to have the courage to say it earnestly.
Five other comments that answered your question. Go on, engage honestly.
Welcome to Hacker News.
There are two options: you pay for health care for the poor through taxes, or you pay for health care for the poor through higher insurance rates.
Reagan was the one who brought socialized health care to America. He passed a law saying that hospitals couldn't refuse emergency treatment due to inability to pay. So uninsured people wait until their conditions are bad enough to be considered an emergency, and then show up at the ER. So hospitals have to jack up their rates for everybody to cover the cost of emergency treatment of the uninsured. Expensive treatment that would likely be much cheaper if treated before it became an emergency.
So this Trump move won't save you money, it just changes how you pay.
Your taxes. That’s the reason for them.
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A bit of context from the article.
The Biden administration started to heavily subsidized some health care plans with Covid as the backdrop, and now those temporary measures are ending.
In so far as I have found and I might be wrong, congress never voted to fund and subsidize those medical plans indefinitely.
Now health insurance companies are raising their rates on those specific plans since the government is no longer partially funding it, or perhaps not funding them as much.
Then I am convinced the insurance companies raised their rates more then strictly required as they nearly always to to make even more money.