I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
> The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
The comparison you make between a bottle of wine vs a glass is not the right one. It's two different stores selling the same product. What's different about hospitals?
Audited financial statements of all kinds of hospitals, both non-profit and for-profit. Here’s data from Moodey’s a credit rating agency: https://www.chartis.com/insights/hospital-margins-trend-high... (“This month, Moody’s credit rating agency released its annual not-for-profit and public healthcare median financial report for 2024, showing that overall hospital performance continues to improve. The median operating margin increased from 0.5% in 2023 to 1.5% in 2024.”).
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
That's true, but obscuring the true costs through hidden cross-subsidies isn't helping anyone in the long run. We would probably be better off with state and local governments setting requirements for ER capacity in each region, and then running an annual reverse auction system where hospitals can bid on maintaining that capacity in exchange for cash payments.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
The US has top-tier cancer survival-after-diagnosis outcomes. We spend too much to get there, and other countries in our cohort would "argue" that we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar, but if you're going into these debates with "the US private health care system causes cancer deaths", that's a pretty rebuttable argument.
That overlooks the 27 million uninsured Americans. Uninsured cancer patients are more likely to be diagnosed at a late stage, less likely to receive treatment, and have substantially higher mortality than insured patients.[1] They also have worse survival, even after accounting for cancer stage.[2] So excellent U.S. outcomes among those who access care don't rule out preventable deaths caused by barriers to accessing it.
This is a cherry picked statistic. We still have lower life expectancy, high infant mortality rates, and one of the highest rate of preventable and treatable deaths among developed countries
The unfortunate truth is that if you break these numbers out by ethnicity, it tells a different story. Generally Asians, Latinos, and Whites are above while Blacks and Native Americans are below and pull down the average: https://pmc.ncbi.nlm.nih.gov/articles/PMC9256789/#S12 If you break the groups out and individually compare against countries of similiar ethnicity, the US is often ahead.
For infant mortality specifically, in the US we count every baby with a sign of life, regardless of the age. In many developed countries, they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics. It makes for an apples to oranges comparison.
You're right on "preventable and treatable deaths" with heart disease and diabetes being the biggest contributors. The question for that comes down to "is that a result of systemic issues or individual choices?" because we can do lots about one of those.
Life expectancy differences between the US and other countries are dominated by just a few factors:
* Car accidents, because we drive much more and are much more spread out than other countries.
* Drug overdoses, though other countries are starting to catch up to us there.
* Homicide, because of our gun policy and the universality of firearms (which also bears on our suicide stats).
* CVD.
That last item sounds like an indictment of the US health care system, but it isn't. If you break CVD out by state, northeastern states like Massachusetts have outcomes resembling the Nordics, and Mississippi has outcomes like a developing country. But the structure of the health care system is the same in both places.
Some good news is that ISH diagnostics manufacturing can go through 510(k) instead of PMA on Sep 16 onward, which should make those diagnostics 10x cheaper and twice as fast to get through.
>The US has top-tier cancer survival-after-diagnosis outcomes.
"Airplanes that get shot in the wing always survive" logic. People _do not get diagnosed and die_ because the US healthcare system is inaccessible to close to 50% of your population. A diagnosis easily reaches a few hundred dollars for the best cases (and several thousand if you need multiple tests/blood tests/operations like colonoscopies). And when you do get diagnosed, then you've just entered a world of having to pay hundreds of thousands of dollars.
>we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar
lmao no you simply don't diagnose people and they just "die of natural conditions" early because they couldn't afford the treatment even if they were diagnosed.
> US healthcare system is inaccessible to close to 50% of your population
So you have no idea what you're talking about. What is the point of making comments like this that are both verifiably false with about 2 seconds of online research and just sounds incorrect based on anecdotal data to anyone living in the US.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
Sure, it's possible in principle. But the US also has a much higher GDP per capita than the UK. The UK is a (relatively) poor country and is increasingly being left behind.
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
I'm saying if you think that administrative expenses (among others) can't be inflated for a profitable company, I would like to run your company and demonstrate what executive compensation can include:
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out that intense opposition chips away at it over time regardless of these studies).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
>Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
And this is precisely why nothing will ever change. I tell everyone who will listen to me on my soap box, we will never get universal healthcare until we divorce healthcare from employment (by that I mean, make it to where businesses cannot offer benefits at all).
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Part of the reason why there is no effort to fix this, to keep you a slave to a job that provides healthcare. Imagine the reduction in labor supply and increase in labor costs if healthcare did not require employment. On can, in many cases (facts intensive), bail to a developed country with healthcare if you want to realize this dream earlier than whenever the US will achieve the outcome (and your life situation supports doing so). It could potentially takes years, if not longer (~5-10 years), for the US to fix healthcare as the situation continues to degrade for those who need affordable healthcare today.
https://relocateme.substack.com (a product of andrewstetsenko here, no affiliation, I just like resources that can help humans achieve their success criteria)
https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)
(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)
That's not how this system came into being. It's a path-dependent quirk of the tax codes of the 1940s. We got into this predicament because of WW2-era wage controls (a dollar spent on health care by your employer was literally worth more than a dollar in wages).
This is one major reason why most of the world's universal systems make private insurance work, and it doesn't blow up the way ours does. But I don't think employers are any happier about it than you are!
You are of course correct on how we got here, I argue we are still here for many reasons, one of which is what I stated. I mean, there is no will to fix healthcare, but lots of will to spend $100B+ to go to war with Iran, right? I simply do not see anyone who cares enough to fix this exceptional mess, even taking into account the coordination problem of doing so. We could treat this as an emergency requiring a fix, but we don't. Why? We can certainly find this will for, "low ROI nation state actions".
Can we afford it? Doesn't stop trillions of dollars for DoD spending for middle east wars or tax cuts for the wealthy, so that isn't an argument, that's subjective cover for not fixing it, we do lots of things we cannot afford (current sovereign debt outstanding is ~$40T, as of this comment). Can't be done? Almost every other OECD country has solved this in some way. Therefore, as a scholar of systems, the root cause I am left with via Occam's razor is "This is an active choice to not fix this suboptimal system, where the fix would be both more economically efficient and humane, For Reasons while the electorate is lied to or paid lip service."
Employers, who supposedly are unhappy with their healthcare costs, could form a coalition and lobby for legislation and fund PACs to fund candidates who would fix this state by state with universal healthcare systems (Canda's universal healthcare system started in a single province as an experiment, for example). Why don't they? Are the costs not high enough yet? They can't argue they don't have enough power, they already, in many ways, bend the US government to their will. They have the power, they actively choose to not use it to fix this system failure.
The evidence shows we could spend less and deliver more within the scope of healthcare delivery (this piece). We actively choose not to. The Pentagon hasn't passed an audit eight years in a row, I hear little that "we cannot afford to keep funding the military at these levels and with such inefficiency."
Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
I think it's generally gotten better for insurance companies, at the expense of both end customers and providers (with the exception of providers that have vertically integrated into the ecosystem, e.g. Aetna/CVS, etc. to capitalize on the advantages that brings).
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
Without the ACA it would have been even worse. And by worse I mean that even if the premiums were lower, we would still have horrible limitations like maximum lifetime coverage amounts or exclusions for pre-existing conditions.
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.
So to answer:
>Who is it better for?
My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.
> ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
Then turn it into a tax and be done with it. I don't shop for my tax collector and I don't pay taxes to companies with the biggest buildings in the city. Companies that don't actually provide health care, but just collect their pound of flesh from patients and providers, driving up costs for everyone.
I'm glad your child has received care. I'm very much behind the idea that pre-existing conditions should not preclude anything from receiving _care_. I'm completely opposed to mandating a private 3ᴿᴰ party be between me and my provider.
Democrats tried, they did not get 60 votes in the Senate between Jan 2009 and Jun 2009. What we have is because at least 41 other legislators, including all Republicans, decided not to offer the US public this option, and since then Democrats have had nowhere near the numbers to enact any further reaching legislation, except the No Surprises Act in 2021.
No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
All the stories I've heard about that came from people with bad insurance (for instance: insurance programs that could rescind coverage if you were diagnosed with something serious, and that functioned mostly as billing processors for routine care, which is where ~none of the expense in the system is). The ACA did effectively regulate those plans out of existence, so if you had one, and relied on it, it raised your cost.
But when we talk about the ACA's impact on cost, we're always talking in a macro sense. Every program has individual winners and losers.
Insurance prices _dropped_ in NY after the ACA was enacted. Not "slowed down the growth" but actually dropped in absolute numbers.
That's because NY had enacted a coverage mandate even before the ACA, so insurance companies were forced to offer policies to everyone. This resulted in a runaway spiral where only sick people were getting insurance.
The ACA forced all large employers to buy insurance, greatly increasing the risk pool.
I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
I'm curious as to how your experience actually using the plan for more than preventive coverage? IIRC, plans before the ACA had a ton of customer unfriendly provisions which made the insurance far less usable in practice. E.g. denying coverage for preexisting conditions.
Keep in mind, I made no value judgement on ACA at all, just suggested that we learn about its opposition and, as you rightly point out, the difficulty of passing such legislation that can last over time.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
Your blame is misplaced. Costs are increasing in spite of the ACA, not because of it. Pre-ACA your family insurance policy was likely worse in some key ways: it probably excluded coverage pre-existing conditions and had a lifetime maximum coverage limit.
But then the blame might be correctly placed? If he had no pre-existing conditions and was on a no-existing conditions plan, that plan might have saved him a lot of money.
Imagine car insurance regulations changing in such a way to force underwriters to blanket-assume everyone has had a couple speeding tickets this year. I understand why we do it. We are ok with speeders paying more for insurance, and not ok with someone born with diabetes forced to pay more for health insurance. But it is the end result in any case.
Yeah, since the ACA my coverage has remained the same while my costs have risen 10x; I'm in my 30s and my medical insurance costs 3x what my mortgage costs, and I still have $$$$ sized bills after a round of strep throat.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
Let’s be honest, it was DOA. Even Gruber admitted to it later. The whole thing was basically a scam.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database.
Everyone's getting free shit no questions asked.
I don't know that "inclination to judge" is a necessary component of religious charity. Religious charities beyond healthcare give out a lot of "free shit no questions asked," and usually without any attempt at proselytization. Catholic hospitals are not known for turning down patients due to moral judgements.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
> "Findings suggest Medicaid expansion under the Affordable Care Act saved about 27,400 lives between 2010-22, including among younger adults."
> "Their findings show that Medicaid expansions led to a 12% increase in enrollment and significantly reduced mortality—not just among older adults, but also younger ones, who accounted for nearly half of the life-years saved."
Huh? Did you read it? My point was that we could have just expanded Medicaid to achieve this.
It was the Medicaid expansion that has been cited as saving lives [0].
Medicaid expansion saved lives. That is true and not in dispute. Other lives were saved too. It wasn’t just poor people who obtained life saving care from ACA. In an alternate world where only Medicaid expansion occurred fewer lives would have been saved than were saved with ACA as it exists now.
If we are going to be unbound by reality then we could "just" put a medbed to cure all diseases, reverse ageing, and regrow limbs using quantum space-age tech in everyone's home.
Too many people think snark is a substitute for insight.
The major GOP complaint about the entire thing was that it was the federal government forcing people to buy a product from companies. The Supreme Court ruled that it had that power.
The ACA was the Republican plan until championed by Obama. The Republican goal was to say anything to denigrate their own plan. Romney later became the nominee for President and it was his plan that the ACA was largely based off of.
Republicans fought hard to discredit their own plan. They just wanted to move to the right of whatever it was that the black man championed.
We could have a fully-libertarian system where the second your cost-of-care exceeds your economic output you are shot in the head and dumped in a pauper's grave, but society has opted not to do this. This means that one way or the other you will be paying for other people's medical care, and the question is what is the most cost-effective way to do this with the most aligned incentives.
> An expansion that has almost nothing to do with the rest of the ACA.
That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.
I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.
That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.
"Saved lives" or "Could Save Lives" is a ridiculous, un-falsifiable, and unprovable claim.
First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.
Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)
These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
The problem with models is that depending on your assumptions you can show just about anything. In general I think the foundation of a good argument, and good science, is assuming the minimum and seeing if your idea still works. They assume:
- hospital reimbursement drops to medicare rates ($296 billion)
- pharma prices decline 51% ($378 billion)
- administrative overhead way down ($286 billion)
- fraudulent billing way down ($286 billion)
- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion
Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.
(1) we don't know the claims of the study will be accurate if implemented and (2) we would need studies modelling cost savings of alternative approaches to actually compare anything.
Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.
There's a multitude of evidence that points to the success of the ACA from a cost perspective (among other things).
Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.
One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.
If the ACA was so successful at reducing coats we wouldn't still be having discussions like this about the excessive costs of both care and insurance in the US.
We will never know how costs would have changed if we didn't implement the ACA, and cost is not the only metric of success. But it clearly hasn't led us to a place where people feel okay with what the industry costs.
1. Do any of the cost savings recommendations you address come close to $1T/yr impact? This is the scale we should be aiming for.
2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."
That's a great question, and one that should receive similar funding and attention to properly compare.
My hunch is that (a) this study over estimates on the cost reduction side and would not pan out, and (b) improving health should always be a better cost savings than reducing corporate overhead (especially given how piss poor our average health is today).
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
The point of nationalisation is to address those underlying concerns. But it’s fair to say that in practice, nationalisation doesn’t always solve those problems.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
I don't think our problem is a lack of regulation though. If anything its a lack of market competition, and that is caused by over regulation and legal protections that make holding companies responsible difficult or impossible.
I think the high upfront capital required to start out in the industry is a much much bigger hurdle than the regulation.
You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.
Reducing regulation doesn’t solve that problem.
And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.
It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for entering into a contract!), but then the system makes up arbitrary bills after the fact - with fraudulent amounts that nobody actually pays! No other industry works like that, as it's not the foundation of a market in the first place. Imagine if going to the grocery store involved "paying" some token amount at the cashier for their time to put your items in bags, then for the food you received shakedown bills for years afterwards, that you had to spend time going through your old documentation to refute and bargain down. Absurd.
Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.
That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance.
The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves charge for anything. The problem I'm describing originates completely with them - no escaping blame here.
(And "might take years" lol. How about eliminate whatever regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
Sure, I'd be all for such reform. Those are the kinda of changes we can and should make before even considering nationalizing an entire industry. If nothing else we'd want that setup anyway under a centralized system, and we could change pricing regulations now with much less controversy unless you ask the lobbyists who would fight it tooth and nail).
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
Exactly. I'd at least want to see similarly funded studies comparing solves for underlying causes beyond just insurance companies not being nationalized.
Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.
We never attempted to solve the issue of distorted price signals that occur when customers aren't the ones paying for something. We're still charging $600 for a bag of saline.
That's not necessarily true; fewer limitations on who is allowed to provide health service and manufacture medicine and health technologies would also drop prices. Competition in healthcare is very, very difficult because it's often illegal to compete.
You're actually talking about the same problem. Competition in healthcare is heavily restricted by stuff like certificates of need because there is little cost-sharing with utilizers so you get overutilization & induced demand. This is Roemer's law [0]. A large part of the reason for competition restrictions is because of a hacky attempt to control overutilization without direct cost-sharing.
Something like 20% of healthcare services are "low value care" which aren't justified by evidence-based medicine criteria and may even harm the patient. Regardless of the financing system we could free up a lot of capacity and slash costs by eliminating that low value care. Of course in practice it's difficult to do that at scale.
In some cases they are provided healthcare services without a choice, so they're not really "consuming" those services. E.g. tests that don't change outcome but do cover a provider from a legal risk.
Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.
And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)
The wonders of American healthcare really mean that it's all more expensive, and at the same time, more is consumed, because so much of what is paid is done past deductible. If you look at so many standard of care situations vs, say, Spain, the American system will do a whole lot more. Even for preventive care: For instance America wants colonoscopies every 10 years from 45. Spain will give you a non invasive fecal test every 2 years, and only consider colonoscopies after the test is positive. Every time I send my american prescribed intervention list, given my symptoms, to my family members working in the Spanish public caresystem, they look at it with their hair on fire. Very different standards. You might think US insurance is restrictive regarding what needs to be done, but most public care system are significantly more restrictive than that. It'll be for better reasons, instead of defaulting to no on everything, but ultimately still far more cautious regarding their spending.
So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!
I think a citation is needed for "Americans regularly avoid care ... because they can’t afford it."
I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.
I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.
The people who avoid care they need because they can't afford it are a very small portion of the population that gets an outsized share of attention on the issue.
Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.
I'm not convinced that your assumption that they are a very small portion of the population holds up, but I only have the same anecdotal evidence you likely have.
I find it hard to believe that people who would like to seek care but are unable to do so because of limits on their existing coverage would say that they are satisfied with their medical insurance.
No, the problem socialists have is that most people are smart enough to realize they won't be better off under a socialist regime, to the chagrin of the self-selected vanguard.
I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
No one benefits when there's a single player in an industry. When that single player also owns your taxes and military, its a risk we should at least avoid if at all possible.
There’s multiple healthcare systems around the world, single payer results in vastly less administrative spending and equal or better outcomes overall.
Companies don't hesitate to lay people off when their jobs aren't needed. I don't see why these parasitic insurance companies need to stay in business.
It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
The disconnect between prices and end consumers is itself a huge problem. I should know what care costs before I get it, and I should know how much my instance company is paying on my behalf before I get care.
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
I think that’s a reasonable model to want, but it’s what we call “preauthorization”, and many patients along with most doctors absolutely hate it. In order to know with certainty what your care will cost and how much your insurance company will pay, the doctor has to contact them in between deciding what treatment you should have and giving you the treatment.
You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.
I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I understand that theres an argument for removing private insurance companies in favor of thr government can cut costs. It can also increase them.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
Social Security in its current form will be gone within two years. Instead you will be required to pay a contribution (just as you are now) but the money will be managed by a private company who will charge fees and provide no guarantees. Current retirees will get to keep the current arrangement, everyone else will be moved to the privately managed Social Security option.
We're talking about healthcare, so you're essentially claiming that the reason the GOP has failed to repeal the ACA despite numerous opportunities is because they actually like the policy, not because they're afraid of the political fallout. Can you elaborate more on when and why you think that happened?
We still have Medicare, Medicaid, and social security. Even though each program has been weakened, none of them have been abolished and they can all be restored.
Heck, we still have SNAP, even though it's almost universally hated by republicans.
It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty. For everyone else, political suicide is still very much a thing (see the various conservative republicans who've chosen to go against Trump over the years and have been cast out in favor of new loyalist challengers).
> It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty.
These are the same ones who currently would be able to repeal the ACA tomorrow if they felt like it. You're essentially asserting that the reason they aren't is that they like the policy, and I don't think it's crazy to expect more justification for a claim like that if you want people to find it compelling.
ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
FDR and "sensible" is always funny to me. The sensible politician that imprisoned Japanese Americans, destroying the lives of 120,000 of our fellow citizens.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
Sadly, this is a better comparison than you probably intended, because access to school lunch is still not universal in the US.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it. I still can’t believe they allowed payors such as UNH to buy up everything without ANY proper investigations during that period.
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
When I was a kid, my parents would say “with that attitude, you’re right.”
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
Nobody, including congress, gives a rat's ass about insurance companies and their profits. The truth is that someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision. After the CEO of United Healthcare was gunned down in the streets for doing that thankless job do you think congress is saying to themselves "hey, maybe we should get into that business"?
That's their point. Congress isn't going to get $10 million from providing universal healthcare (at least for any system that is any good), so they have no incentive to pass it. The year the ACA passed, Democrats suffered one of the worst legislative defeats in history. Nobody wants to be the person to tell millions of people that they can no longer see their chiropractor for free or that their healthcare is not longer paying thousands of dollars a month for weight loss medications.
Man I wish I could downvote a comment. This is what you’d see on Reddit.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
Most of the problems of the US system aren't really a matter of who pays, but the fact that so much is paid for services, at every level. Any really significant savings, cutting bureaucracy and pressuring providers to make costs resemble those of other developed countries, are taking money out of someone's pocket. Many hundreds of thousands of them, if not millions. This makes any significant reform very difficult, as those people vote, and will know exactly who made them worse off, even if the country in general was made much better off.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
It’s also geographically distributed. Substantially all congressional districts count a healthcare system as a top-5 employer. Those 70k/yr butts-in-seats admin jobs are occupied by voters, making them difficult to eliminate nationally. You’d have to go down to the state level at least to get anything done.
>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
Per the study we are discussing -- as well as the results from every single other developed country I believe? -- more efficient when it comes to healthcare, yes.
I can if I want to switch jobs too. Probably not a good idea given the current economic conditions. I'd be all for forcing a decoupling of these things, but I don't see that anywhere on the table, and it would probably run afoul of politics anyways.
The perverse incentive of the politician / general / bureaucrat to favor their personal interest over the public interest is identical to the perverse incentive of the CEO to favor his personal interest over the same.
I would argue the government case is actually much worse because at least the CEO has the feedback mechanism of revenue because the company <> customer relationship is entirely voluntary on both sides. The public vote is supposed to restrain the government in the same way, but in practice it seems to be much less effective in restraining politicians than the customer is at restraining companies.
And most of that income is salaries to existing healthcare administrators. Quickly ending the employment of the people working those jobs would be a significant shock.
Not really. Private health insurance would still exist alongside for the more wealthy (including nearly everyone on HN) that doesn’t want to wait a year for their public system MRI. Same thing that plays out in other countries. The U.S. already has a form of this in so-called concierge / premium providers too. Lots of profit to be made.
This isn’t true of the Medicare for All Act, for what it’s worth. That would ban private insurance altogether. Personally I think that’s a bug, not a feature, but if you’re very concerned with fairness then you probably think the opposite.
Having the machine capacity to get non-urgent MRIs in hours is part of why US healthcare is so expensive. Anyway, the average (again for non-urgent MRIs) where I live in canada is 9 weeks, which is i am sure skewed due to the rural population. In the city it’s like half that.
If private health insurance was allowed, UHC would be stillborn. It only works if providers don't have better options than medicare reimbursement rates.
> It only works if providers don't have better options than medicare reimbursement rates.
1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
2. Less importantly, in this world where everyone has medicare, but a smaller fraction have private coverage, your argument is that the existing healthcare providers would choose to give up most of their (medicare) patients? If so, why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
> 1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
Mainly, expectations. I understand that UHC in European countries doesn’t cover all the things Americans assume it does.
Japan apparently keeps costs down by not using cutting-edge drugs. That’s not going to happen in the US.
The US Congress just isn’t good at keeping costs down.
> 2. ... why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
They absolutely do. Many providers don’t accept Medicare. Very few providers accept Medicaid. The payments just aren’t high enough.
Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
In all seriousness, this would be a massive stimulus to the economy. Americans are consumers at heart. All the money saved on insurance and/or other healthcare related costs would then be spent elsewhere.
Cars, clothes, TVs, Labubu dolls. People will use the savings to buy things. In massive quantities.
There is also some indirect bonus: if people's healthcare is not tied to their employer then it's easier to look for a new one. Also if the system is done well, then many companies would lose the incentives they currently have for not giving full-time employment.
Are you implying you would decide to sacrifice citizens health for a few GDP points, a somewhat useful but oversimplified metric that doesn’t reflect anything tangible?
Presumably not; the same national income would just be redistributed from shareholders to insurees (or shareholders of companies that pay for employee health insurance).
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
The Republican party is not a Conservative party, its a Reactionist party of capital, so generally anything that threatens the interests of capital will be absolutely crushed.
When they make campaign promises, they go to small towns and talk about "Main St" businesses. Not sure why anyone believes them at this point (for the reasons you mention), but it is what they campaign on.
I think republicans could get behind some measure of portable health plans between employers. What they could not get behind is universal, in the sense of "everyone living in USA" health care footed by the US Government. The objection would be about centralization of health care funding and about, you know, who would get the benefits.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
The insurance companies had substantial input to the specific text of the ACA. I'm not sure how you can imply the ACA was not a BigCorp bill when BigCorp wrote it.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
Decoupling health insurance from your job and going single payer are separate things.
You can have one without the other.
You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
If you could say Universal Healthcare only for MAGA white people Republican Party will get behind it. Especially if there is some opportunity to commit large scale fraud.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
Interesting. In every European country I know of, the private option is still available. Just vastly cheaper and more beneficial due to having to compete with a public option which covers basic necessities, surgery etc.
Yes, this is what I find a little odd about the US proposals. I've lived in UK and Spain and in both they have great free public healthcare for everyone, and if you (or your employer) want to layer private insurance on top you can. Wouldn't that be a much more appealing proposal to Americans?
Is this quality improvements including or ignoring the 30-ish percent rejection rate of the most popular healthcare system, including such gems as insulin and pre-authorizations refusing surgery for necrotic tissue when “maybe they could PT it, have you tried?”
PT? Luxury! My daughter had PT referred by her pediatrician, then the insurance didn't pay all of it and when I asked the insurance company for the EOBs they said they were not allowed to give them to me because it would violate my daughter's privacy.
Our insurance paid for the bill from my wife's surgeon but spent 8 months refusing to pay for literally anything else, including the anesthesia. They said it was "medically unnecessary".
There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
This is frequently true in the USA as well. My provider's dermatology department is pretty backed up and couldn't make me an appointment for an excision until November. Fortunately it's not urgent.
Agreed, it was 2-3 months wait to get to see an ENT for me last year. My daughter's regular eye check identified a problem and it's 3 months to get her into an eye specialist to review it.
Somewhat related: a couple years ago my spouse had cancer, and the doctor could do surgery either 5 days after our insurance was changing companies, or 2 months after that, those were the next two openings. The insurance said that if we proceeded with the surgery, without the new insurance company giving us approval, but they couldn't start approving it until the insurance started, and the pre-approval from the other company didn't give us anything. We finally decided to go ahead with it and take on the risk of ~$70K if it was denied. Which we decided to do rather than my spouse spending a few months worrying. Turned out that was a really good call, because when they did the surgery it turned out that instead of the expected slow growth, it was actually growing extremely fast. That was probably the difference between it being fatal and it being treatable.
I agree with the main point. The thing is, in the US, wait times are a function of how much you're willing to spend. You can always pay for priority. But most people won't pay more, and the reality is that most healthcare systems have far less provider supply than demand, particularly in dense urban areas where most people live.
ZocDoc isn't reflective of availability as a whole. It has a lot of depth in certain areas, like dentistry, dermatology, and primary care, and less in other specialties. Many of the providers are not physicians, they're NPs and PAs. Perfectly qualified for certain kinds of issues but not others.
ZocDoc is also, obviously, working only with the providers who are willing to pay for new patients, such as newer practices trying to build a patient base. An established practice that is booked out for the next two months obviously isn't going to use such a service.
Finally, you're not considering insurance and continuity of care.
So yeah, in an urban area, you can probably find someone to see you sooner than later if they're in network or you can afford to pay, and you're okay with seeing someone you might never see again or with whom there might not be continuity of care.
Are all of those specialists "in-network"? Have you tried contacting them to see if they truly have availability? It's common for providers (or the insurance carrier), at least in my area, to claim they take new patients when in fact they do not.
(For those not in the know, out of network means costs to the patient are much higher).
That's not at all unusual in the US. My dad saw a neurologist for chronic severe headaches. It was very common for us to go to an appointment, have the doctor request a follow up appointment in 3 months, then be told during checkout that the earliest available time was in 5-6 months.
> If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
The US is not much different.
We don't have a wealth of specialists available to see people right away.
I've flat out been rejected from a specialist because they had no availability at all.
I actually tried again and got to be seen, but an appointment is months out, always.
Hah, even with "platinum" healthcare in the US, urology referral, 4 months. "You should start PT immediately" after a car accident, "we can see you in 5 months".
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
Does American private insurance pay for everything? And if you say "but they can pay out of pocket", well Canadians can come to America and pay out of pocket too.
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
What about them? The Canadian healthcare system has better outcomes than the American healthcare system in several areas. Most simply, Canadians live longer.
I'm 29 and when I was a kid, getting a family doctor used to be an easy task and if you needed to see your doctor you could get in that day. Now all the doctors are so overworked, they're fleeing to America where they can get paid a reasonable wage for a reasonable amount of work. If you can even get a family doctor, if you want to book an appointment, they'll ask you which day you'd like 4 months from now.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
I also feared this, until I read that some US citizens avoid going to the doctor until it is unbearable. Take this examples: here in Spain you go to the doctor because you think that mole is slightly bigger than past year. They point you to the dermatologist in january 2027, a terrible 6 months waiting. In the US a lot of people thinks "hey, doesn't look that bad, and it could cost me $5,000". Five years pass, and now the mole is five times bigger, it bleeds and... well, it is a full blown melanoma: you get to the dermatologist 1 day after consultation, yet is too late.
My understanding is that a clinic or hospital can’t legally charge you for a procedure that’s universally available through the provincial healthcare system.
So you’re free to pay for anything else if you want.
Universal Health Coverage has a lot of other benefits:
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
they're tryna convince the populace who don't like to read with useless studies.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
We hate it and are more and more powerless to change it every day. The parties are entrenched and swing districts are becoming increasingly rare. Those competitive districts that remain are flooded with unlimited campaign funds from big business and plutocrats, thanks to Citizens United.
Last time I joined a discussion about US health care on HN (years ago), the picture looked bleak: secret chargemasters in every hospital, no realistic way for patients to compare options because the options are too complicated, and lots of people still falling through the cracks.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
The mortality numbers in this paper appear to be extrapolated from an observational study of 9,000 cases from 1988-1994. That paper distinguished between "privately insured" and "not privately insured". This paper distinguishes "adequately insured", "underinsured", and "uninsured", and applies the original paper's hazard numbers to everybody but the "adequately insured", with a coefficient modifier for the "underinsured" that they came up with themselves.
Hard to believe, currently Medicare/Medicaid make up around 23% of the budget. If you opened that to all, there would have to be a huge tax increase to pay for it. I suppose if you are very poor then it would be good, but the middle class would be the ones having to foot the bill for this.
It looks like this does not even include the current disincentive for insurers to treat chronic issues effectively early on. Since people switch insurers so often the odds you will be their “customer” in 5 or 10 years is low, so investing if your long term health won’t generate a return for them.
That's a very weird framework and dichotomy you have there. Try untangling yourself out of it by considering some empirical facts, for example, hospitals acquired by private equity often have worse outcomes.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
What's the point of "state of the art healthcare" if it's only for rich people? If Jeff Bezos and I get the exact same health issue - say, some form of cancer, we're going to have radically different treatments and mostly likely outcomes. His will be "state of the art", mine will (hopefully) be good, but definitely not be like his.
The thing studies like this never take into account is the degree to which all of these administrative jobs are corporate welfare. The inefficiency means a lot of people get a regular paycheck for work that is ultimately nonproductive. If you kill off those jobs by eliminating waste there will be millions of people looking for a new job.
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
For the most part, any time one person in the economy saves money, another person loses money. So, what about all the insurance company, private equity, and hospital system profits that would be eroded by a system that better serves individual humans?
Come to a country with universal healthcare (England) and realise that if you work then you're paying 5x the market price for the worst healthcare imaginable. MRI scan - we don't know, one month wait, maybe two. Operation - are you going to die tomorrow with out it? No, ok then that could be years.
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
People talk about policies like they're something like can be picked up off the shelf at supermarket. If you could take the policies and Sweden copy-paste them to the US, then sure, we could save $1T and a hundred thousand lives. This would be a very difficult thing to replicate if you're a country without any existing healthcare system. It is impossible in a country with an extremely mature healthcare system, which accounts for nearly 20% of GDP.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
I wonder how many people would be on board for a program to make Medicare available for free for households making over $100,000 annually with 1-3 children.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
First class citizens? Wow, that is both disgusting and sad. What do you do that you think is so important and irreplacable that sets you above the average person?
Many people feel that winners should be rewarded and losers should be punished.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
There is already a healthcare program run by the US government and it's called Veteran Affairs. Veterans can't even access the care they need resulting in almost twice the risk of suicide.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
That's basically my concern, too. If we had a "Medicare for all" system, would it end up like Social Security, a system that started out with great intentions, but has since ballooned into an expensive, bureaucratic nightmare?
Bro nothing is free, if the goverment pays for all of us, then it is our own money being used for that, we have the most liberal tax code in the world, we spend the most in healthcare.
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
How on earth have administrative costs been soaring when there have been so many healthtech startups propped up in the past 10 years to bring down the cost of administration?
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
It will never not be funny that whenever universal health coverage comes up, Americans will act as if it's some impossible task that wouldn't solve any problems when the rest of world seems to have sorted it out just fine.
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
The last time we got similar results in the data (but not the text) was a Koch-backed study that a bunch of economists reviewed and went “so you’re saying we’d save 2 Trillion over 10 years relative the alternative?”
let's imagine an impossible country where somehow Democrats pull this off in 2029 and the 2030s start with actual healthcare for all and not just "insurance"
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Universal healthcare doesn’t happen in the US because a certain subset of the American population would rather have worse health outcomes than guarantee abortions, HIV prevention, and gender-affirming care.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
You can easily drop those from a universal healthcare system - look at the NHS and gender affirming care across the pond. So it can't only be that part - I think it's wanting the undeserving to not have healthcare.
It’s not that easy. You have to make it through the primaries to stand for election. Both parties are increasingly dominated by their outside wings. If you said “I’ll try to get universal healthcare done and I’ll build the coalition needed for it, even if it means accepting painful compromises like not covering gender affirming care” you won’t make it out of the democratic primaries. That’s why there’s so many common sense positions that have majority support yet never a majority in political bodies.
What I mean is that if the conservatives only objection to universal healthcare was these things, they could just leave them out. There's no requirement that a single payer system cover all procedures.
Ergo the reason they didn't support the ACA and won't do this is something other than it covering hormones and abortion.
There's also a racist element (I know that's a politically incorrect word here, but such things happen). People don't want to fund services to the lazy ______s - fill in one or more of many groups toward whom hate is promoted.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
Another way of looking at is that some people are concerned about what happens to limited "free" healthcare resources when you simultaneously oppose any controls on immigration.
There are many reasons Jeffries might change positions; why do you say the reason was that he was bought? Is there evidence?
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
One of two major political parties, and the one that currently holds all 3 branches of federal government, has labelled it un-American and communist. And yet you point the finger at...a Democrat.
> the one that currently holds all 3 branches of federal government
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
> Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass?
I don't. However, if I were a betting man, I'd bet on the Democratic leadership to come around well before the Republicans. Not least because a significant, non-zero fraction of their politicians are already in favor of it (compared to the other side, which has close to zero).
Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen. So ultimately Republicans are the bottleneck.
> I'd bet on the Democratic leadership to come around well before the Republicans.
Jeffries was already around. He supported single payer but now rejects it, so he's moving backward.
> Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen.
Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc. Anyway, the filibuster can be eliminated. In 2013 Democrats eliminated the filibuster for most nominations, and in 2017 Republicans eliminated the filibuster for Supreme Court nominations.
> So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
No, I propose calling out Democratic leaders for corruption, removing corrupt leaders from their leadership positions, and running primary challenges against them.
As you said, Republican leaders are calling single payer "Communist". When the Democratic response is, "I no longer support single payer", they're essentially allowing Republicans to win the argument. That's political malpractice.
I would note that the Republican House Majority Leader Eric Cantor lost a primary challenge in 2012, yet as you noted, this hasn't stopped Republicans from taking control of the House and the entire government. "Vote blue no matter who" is not necessarily a winning strategy.
Why even bother asking me what I propose then? What do you propose?
I can certainly understand pessimism, but if you're going to be a pessimist, asserting that there's nothing we can do, then at least be consistent in your pessimism. Don't pretend that you somehow have a better answer than I do. The only possible "plan" I've seen from you is "wait around for Republicans to support single payer", which IMO is vastly less feasible than challenging corrupt Democratic leaders, since the majority of Democratic voters already do support single payer, while the majority of Republican voters do not. And if the debate is one-sided, "Communist" vs. "I don't support single payer", then voters will never be persuaded to support it. Leaders need to lead, persuade, not just take a current poll. If you don't persuade, the other side certainly will.
> The only possible "plan" I've seen from you is "wait around for Republicans to support single payer"
That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged, nominally-independent voter hears that and assumes it means "don't vote D".
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Healthcare reform is hard.
[1] Reasonable breakdown on the economics of advanced primary care models: https://olearykm.medium.com/the-cost-equation-for-new-primar...
Very curious where this comes from and how accurate it is. For example the $37 a provider charges for an Aspirin seems like more than 2-5% margin.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Eg Kaufman: https://www.vizient.com/insights/reports/national-hospital-f...
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When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
The comparison you make between a bottle of wine vs a glass is not the right one. It's two different stores selling the same product. What's different about hospitals?
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
ER’s for example are money pits, but society really needs them.
https://www.definitivehc.com/resources/healthcare-insights/h...
[1] https://pubmed.ncbi.nlm.nih.gov/25092774/ [2] https://doi.org/10.3322/caac.21732
For infant mortality specifically, in the US we count every baby with a sign of life, regardless of the age. In many developed countries, they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics. It makes for an apples to oranges comparison.
You're right on "preventable and treatable deaths" with heart disease and diabetes being the biggest contributors. The question for that comes down to "is that a result of systemic issues or individual choices?" because we can do lots about one of those.
* Car accidents, because we drive much more and are much more spread out than other countries.
* Drug overdoses, though other countries are starting to catch up to us there.
* Homicide, because of our gun policy and the universality of firearms (which also bears on our suicide stats).
* CVD.
That last item sounds like an indictment of the US health care system, but it isn't. If you break CVD out by state, northeastern states like Massachusetts have outcomes resembling the Nordics, and Mississippi has outcomes like a developing country. But the structure of the health care system is the same in both places.
"Airplanes that get shot in the wing always survive" logic. People _do not get diagnosed and die_ because the US healthcare system is inaccessible to close to 50% of your population. A diagnosis easily reaches a few hundred dollars for the best cases (and several thousand if you need multiple tests/blood tests/operations like colonoscopies). And when you do get diagnosed, then you've just entered a world of having to pay hundreds of thousands of dollars.
>we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar
lmao no you simply don't diagnose people and they just "die of natural conditions" early because they couldn't afford the treatment even if they were diagnosed.
So you have no idea what you're talking about. What is the point of making comments like this that are both verifiably false with about 2 seconds of online research and just sounds incorrect based on anecdotal data to anyone living in the US.
People tackle hard things for nothing, never mind billions in savings.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
Shrinking US health expenditure by 3% of GDP while roughly maintaining health outcomes is eminently, obviously doable.
There's no way a Chairman/CEO would ever reduce the operating margin by just giving themselves and their buddies a raise is there?
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
The flipside to fraudulent billing is that people that need care are denied. The fraudulent billing was perpetrated by the insurer.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
https://worldpopulationreview.com/country-rankings/doctors-p...
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
I would quit my day job and completely focus on my side business if I didn't have to worry about healthcare.
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
The "well of course" moment took me a day longer than it should have.
https://news.ycombinator.com/item?id=47161587 (expat resources for those potentially interested)
https://relocateme.substack.com (a product of andrewstetsenko here, no affiliation, I just like resources that can help humans achieve their success criteria)
https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)
(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)
This is one major reason why most of the world's universal systems make private insurance work, and it doesn't blow up the way ours does. But I don't think employers are any happier about it than you are!
Can we afford it? Doesn't stop trillions of dollars for DoD spending for middle east wars or tax cuts for the wealthy, so that isn't an argument, that's subjective cover for not fixing it, we do lots of things we cannot afford (current sovereign debt outstanding is ~$40T, as of this comment). Can't be done? Almost every other OECD country has solved this in some way. Therefore, as a scholar of systems, the root cause I am left with via Occam's razor is "This is an active choice to not fix this suboptimal system, where the fix would be both more economically efficient and humane, For Reasons while the electorate is lied to or paid lip service."
Employers, who supposedly are unhappy with their healthcare costs, could form a coalition and lobby for legislation and fund PACs to fund candidates who would fix this state by state with universal healthcare systems (Canda's universal healthcare system started in a single province as an experiment, for example). Why don't they? Are the costs not high enough yet? They can't argue they don't have enough power, they already, in many ways, bend the US government to their will. They have the power, they actively choose to not use it to fix this system failure.
https://en.wikipedia.org/wiki/The_purpose_of_a_system_is_wha...
https://en.wikipedia.org/wiki/Five_whys
https://usafacts.org/government-spending/
https://usafacts.org/articles/how-much-of-the-federal-budget...
https://www.militarytimes.com/news/pentagon-congress/2025/12...
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Who is it better for?
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
People with pre-existing conditions. They were literally uninsurable before the ACA.
The insurance costs are also skyrocketing in the employer-sponsored insurance.
You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.
So to answer:
>Who is it better for?
My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.
Then turn it into a tax and be done with it. I don't shop for my tax collector and I don't pay taxes to companies with the biggest buildings in the city. Companies that don't actually provide health care, but just collect their pound of flesh from patients and providers, driving up costs for everyone.
I'm glad your child has received care. I'm very much behind the idea that pre-existing conditions should not preclude anything from receiving _care_. I'm completely opposed to mandating a private 3ᴿᴰ party be between me and my provider.
Democrats tried, they did not get 60 votes in the Senate between Jan 2009 and Jun 2009. What we have is because at least 41 other legislators, including all Republicans, decided not to offer the US public this option, and since then Democrats have had nowhere near the numbers to enact any further reaching legislation, except the No Surprises Act in 2021.
https://en.wikipedia.org/wiki/Public_health_insurance_option
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
But when we talk about the ACA's impact on cost, we're always talking in a macro sense. Every program has individual winners and losers.
That's because NY had enacted a coverage mandate even before the ACA, so insurance companies were forced to offer policies to everyone. This resulted in a runaway spiral where only sick people were getting insurance.
The ACA forced all large employers to buy insurance, greatly increasing the risk pool.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
My afib ER trip three years ago cost me $7k out of pocket even though I left the hospital still in afib.
Today in my 50s, my deductible is now $8,500. My partner doesn't have insurance because she's not poor enough or rich enough.
We had an insurance rep come to my work last year who said after ACA they had some people whose premiums went up 900%.
So yeah, ACA is better in your world, but not in mine.
Imagine car insurance regulations changing in such a way to force underwriters to blanket-assume everyone has had a couple speeding tickets this year. I understand why we do it. We are ok with speeders paying more for insurance, and not ok with someone born with diabetes forced to pay more for health insurance. But it is the end result in any case.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database. Everyone's getting free shit no questions asked.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
The ACA has killed a whole lot more lives than it has saved by causing healthcare costs to spiral up.
If you begin with something that is obviously incorrect and trivially debunkable, perhaps that's indication that you should review your priors.
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
[0] https://news.uchicago.edu/story/new-research-shows-medicaid-...
Medicaid expansion was a big part of the ACA.
Well see, first you narrowly define the ACA to be "everything that didn't help"...
> "Their findings show that Medicaid expansions led to a 12% increase in enrollment and significantly reduced mortality—not just among older adults, but also younger ones, who accounted for nearly half of the life-years saved."
Huh? Did you read it? My point was that we could have just expanded Medicaid to achieve this.
Medicaid expansion saved lives. That is true and not in dispute. Other lives were saved too. It wasn’t just poor people who obtained life saving care from ACA. In an alternate world where only Medicaid expansion occurred fewer lives would have been saved than were saved with ACA as it exists now.
Laws need votes.
If we are going to be unbound by reality then we could "just" put a medbed to cure all diseases, reverse ageing, and regrow limbs using quantum space-age tech in everyone's home.
The major GOP complaint about the entire thing was that it was the federal government forcing people to buy a product from companies. The Supreme Court ruled that it had that power.
Republicans fought hard to discredit their own plan. They just wanted to move to the right of whatever it was that the black man championed.
If they are down for it, I can make a call and it would be a near unanimous vote.
How are we paying for that? Debt.
On top of that, the ACA provides $100 billion a year to subsidize the healthcare markets.
That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.
I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.
That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.
First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.
Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
Saving $1,000,000,000,000/yr is directly addressing how damn expensive it is.
- hospital reimbursement drops to medicare rates ($296 billion)
- pharma prices decline 51% ($378 billion)
- administrative overhead way down ($286 billion)
- fraudulent billing way down ($286 billion)
- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion
Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.
Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.
Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.
One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.
https://www.statnews.com/2019/03/22/affordable-care-act-cont...
https://www.networkforphl.org/news-insights/the-affordable-c...
https://www.cbpp.org/research/health/chart-book-accomplishme...
We will never know how costs would have changed if we didn't implement the ACA, and cost is not the only metric of success. But it clearly hasn't led us to a place where people feel okay with what the industry costs.
2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."
My hunch is that (a) this study over estimates on the cost reduction side and would not pan out, and (b) improving health should always be a better cost savings than reducing corporate overhead (especially given how piss poor our average health is today).
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.
Reducing regulation doesn’t solve that problem.
And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.
Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.
https://www.cms.gov/priorities/key-initiatives/burden-reduct...
The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
(And "might take years" lol. How about eliminate whatever regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
https://nationalhealthspending.org/
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
And also how much is required. I bet a study investigating how much money and lives could be saved by reducing obesity would have 2x numbers
Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.
0: https://en.wikipedia.org/wiki/Roemer%27s_law
https://www.bloomsbury.com/us/price-we-pay-9781635575910/
Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.
And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)
So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!
I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.
I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.
> The survey showed that over nine in ten (92%) of insured respondents had delayed or avoided medical care because of concern about cost.
> In fact, 95% of those surveyed said a medical emergency would likely put them into serious debt even with insurance.
People get so hung up on the idea that they should have to pay for health care, when you have to pay for every other necessity in life.
Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.
I find it hard to believe that people who would like to seek care but are unable to do so because of limits on their existing coverage would say that they are satisfied with their medical insurance.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
You could have universal health with zero additional spending by the US government, but all that administrative overhead is someone’s income.
There’s multiple healthcare systems around the world, single payer results in vastly less administrative spending and equal or better outcomes overall.
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
I don't see why you'd need to do that. Just expand medicare to everyone and if people want to also buy private insurance they can.
They'd just need to be more competitive and add significant value, which they don't currently do.
I think once universal health coverage is established, it amounts to political suicide to try to take it away again.
Heck, we still have SNAP, even though it's almost universally hated by republicans.
These are the same ones who currently would be able to repeal the ACA tomorrow if they felt like it. You're essentially asserting that the reason they aren't is that they like the policy, and I don't think it's crazy to expect more justification for a claim like that if you want people to find it compelling.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
I suspect Social Security would have met that definition at one point in time. Perhaps even paid overtime, the 40-hour work-week, etc.
You mean like overturning Roe v. Wade? Can't ever happen, right?
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
most of the society doesnt operate in the way that you described.
Describes everything the GOP offers as “solutions.” Theirs tend to strip rights while Democrats tend to provide rights.
We’re still waiting on the GOP’s “concepts of a plan” for healthcare promised on the last campaign trail.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
Sounds nice, though.
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
His annual compensation was over $10 million.
https://en.wikipedia.org/wiki/2010_United_States_elections
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
I mean, you can do that here. The system just restricts what you can do until you've spent more time commenting.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
So well known you neglected to state or cite them? I'd invite you to do so now.
It was not for a lack of motivation or a lack of cut-throat pursuit, consequences be damned.
I would argue the government case is actually much worse because at least the CEO has the feedback mechanism of revenue because the company <> customer relationship is entirely voluntary on both sides. The public vote is supposed to restrain the government in the same way, but in practice it seems to be much less effective in restraining politicians than the customer is at restraining companies.
There's this idea that there are no upsides to the American system, only downsides.
1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
2. Less importantly, in this world where everyone has medicare, but a smaller fraction have private coverage, your argument is that the existing healthcare providers would choose to give up most of their (medicare) patients? If so, why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
Mainly, expectations. I understand that UHC in European countries doesn’t cover all the things Americans assume it does.
Japan apparently keeps costs down by not using cutting-edge drugs. That’s not going to happen in the US.
The US Congress just isn’t good at keeping costs down.
> 2. ... why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
They absolutely do. Many providers don’t accept Medicare. Very few providers accept Medicaid. The payments just aren’t high enough.
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
Cars, clothes, TVs, Labubu dolls. People will use the savings to buy things. In massive quantities.
But I suppose they are the party of big business, not the party of business in general.
https://kffhealthnews.org/news/nixon-proposal/
Oh hi. That is me.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
And nothing will come of it. Too many entrenched interests, regulatory capture, and lobbying + political donations.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
Somewhat related: a couple years ago my spouse had cancer, and the doctor could do surgery either 5 days after our insurance was changing companies, or 2 months after that, those were the next two openings. The insurance said that if we proceeded with the surgery, without the new insurance company giving us approval, but they couldn't start approving it until the insurance started, and the pre-approval from the other company didn't give us anything. We finally decided to go ahead with it and take on the risk of ~$70K if it was denied. Which we decided to do rather than my spouse spending a few months worrying. Turned out that was a really good call, because when they did the surgery it turned out that instead of the expected slow growth, it was actually growing extremely fast. That was probably the difference between it being fatal and it being treatable.
The US system is far from smooth.
https://benchmarkcanada.org/Governing_Healthcare-Wait-Times....
The US does far better than the UK and Canada.
https://www.chiefhealthcareexecutive.com/view/hoping-to-see-...
ZocDoc isn't reflective of availability as a whole. It has a lot of depth in certain areas, like dentistry, dermatology, and primary care, and less in other specialties. Many of the providers are not physicians, they're NPs and PAs. Perfectly qualified for certain kinds of issues but not others.
ZocDoc is also, obviously, working only with the providers who are willing to pay for new patients, such as newer practices trying to build a patient base. An established practice that is booked out for the next two months obviously isn't going to use such a service.
Finally, you're not considering insurance and continuity of care.
So yeah, in an urban area, you can probably find someone to see you sooner than later if they're in network or you can afford to pay, and you're okay with seeing someone you might never see again or with whom there might not be continuity of care.
You should see how long their surgery departments are backed up!
(For those not in the know, out of network means costs to the patient are much higher).
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
I've flat out been rejected from a specialist because they had no availability at all. I actually tried again and got to be seen, but an appointment is months out, always.
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
It was a rhetorical question. I'm aware it doesn't.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
https://commons.wikimedia.org/wiki/File:Life_expectancy_vs_h...
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
Gap between Canada and US life expectancy overall: ~3 years in favor of Canada
Gap between Canada and US life expectancy for top 10% economically: ~0
So you’re free to pay for anything else if you want.
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
In the UK it's about 20%.
Yet apparently the UK is mostly nationalised under the NHS, while in the US there is huge additional spending on private insurance.
Can somebody from the US explain to me how that's the case and why American's still put up with it?
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
The way that universal health coverage saves money is by rationing care. You do not save lives when you ration care.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
https://pmc.ncbi.nlm.nih.gov/articles/PMC10751598/
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
https://hms.harvard.edu/news/deaths-rose-emergency-rooms-aft...
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
/sarc
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
Quantify the impact on productivity
A lot of people do not want it, and you've thus far failed to make them want it.
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
https://pnhp.org/news/the-mercatus-analysis-of-bernie-sander...
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC8729831/
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
Ergo the reason they didn't support the ACA and won't do this is something other than it covering hormones and abortion.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
I don't think anyone perceives a flip-flopper as anything except unprincipled. There's nothing "moderate" about corruption.
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
Look at his health PAC contributions over time:
https://www.opensecrets.org/profiles/hakeem-jeffries/us_cong...
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
I don't. However, if I were a betting man, I'd bet on the Democratic leadership to come around well before the Republicans. Not least because a significant, non-zero fraction of their politicians are already in favor of it (compared to the other side, which has close to zero).
Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen. So ultimately Republicans are the bottleneck.
Jeffries was already around. He supported single payer but now rejects it, so he's moving backward.
> Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen.
Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc. Anyway, the filibuster can be eliminated. In 2013 Democrats eliminated the filibuster for most nominations, and in 2017 Republicans eliminated the filibuster for Supreme Court nominations.
So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
Maybe if you flip a few Republicans (to supporting UHC) it might go easier. It'll give their leadership something to think about at least.
No, I propose calling out Democratic leaders for corruption, removing corrupt leaders from their leadership positions, and running primary challenges against them.
As you said, Republican leaders are calling single payer "Communist". When the Democratic response is, "I no longer support single payer", they're essentially allowing Republicans to win the argument. That's political malpractice.
I would note that the Republican House Majority Leader Eric Cantor lost a primary challenge in 2012, yet as you noted, this hasn't stopped Republicans from taking control of the House and the entire government. "Vote blue no matter who" is not necessarily a winning strategy.
Godspeed.
Why even bother asking me what I propose then? What do you propose?
I can certainly understand pessimism, but if you're going to be a pessimist, asserting that there's nothing we can do, then at least be consistent in your pessimism. Don't pretend that you somehow have a better answer than I do. The only possible "plan" I've seen from you is "wait around for Republicans to support single payer", which IMO is vastly less feasible than challenging corrupt Democratic leaders, since the majority of Democratic voters already do support single payer, while the majority of Republican voters do not. And if the debate is one-sided, "Communist" vs. "I don't support single payer", then voters will never be persuaded to support it. Leaders need to lead, persuade, not just take a current poll. If you don't persuade, the other side certainly will.
> The only possible "plan" I've seen from you is "wait around for Republicans to support single payer"
That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged, nominally-independent voter hears that and assumes it means "don't vote D".
That's the only thing that matters in Amerika.