Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact.

This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered.

Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand.

Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).

I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different?

If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.

If you want everyone to pay something, we (as you pointed out) have something for that, it's called taxes. And that's what pays for your other "insurance" examples. (And don't bring up auto insurance. I don't have to have it, I can choose to not own a car.)

But by involving private companies you have creates perverse incentives that I have no sway or visibility into.

If we want to socialize health care then lets do that, but lets not introduce a private party middle man that not only disconnects the payer from the consumer but has a government mandated client base of the whole US.

I am opposed to it because it is a horrible individual rights breaking precedent.

Don't get me wrong, I'm a strong believer in single payer health care (I'm from Sweden), but in the absence of that, whether you pay the money in taxes or directly to a private end party doesn't seem that different to me. (And the US Supreme Court apparently agrees, since the mandate was upheld as constitutional.)

If it is allowed it will not stop at health insurance. Business has too active a hand in the US government as it is. How much worse will it get when they start greasing the palms to make sure they too have a required audience?

Edit: (Forgot) Yes, the supreme court upheld it. That doesn't make it right, just constitutional. If an amendment to the constitution is required, then so be it.

Seriously, it has me considering moving to another country.

The torture, indefinite detention, universal surveillance, and permanent war were insufficient on their own? It took buying healthcare?

One can decide not to buy insurance, and instead pay a penalty. The Court ruled that this penalty is a permissible tax.

https://en.wikipedia.org/wiki/Dred_Scott

https://en.wikipedia.org/wiki/Plessy_v._Ferguson

Yeah, this is something I feel very strongly about in Australia. For context, we have a fairly good public healthcare system. I've been to the hospital many times (not for anything much serious) and never paid anything. It's free to have a baby in a hospital (well, apart from taxes). Private health cover, while it exits, is not a necessity.

Then, the 'Medicare Levy Surcharge' was introduced to encourage higher-income earners to take out private health cover (PHC) to supposedly reduce the strain on the public system. So now, unless I take out PHC I get hit with a $3000 fine at tax time. So I took out a $800/year junk policy which gets me basically nothing and is not something that I need.

I'm really annoyed that the government more or less forces (because regardless how I feel on the topic, it's not unreasonable for me to choose a $800 option over a $3000 option) me to hand money over to a private company for a product that I neither need or will use.

Yep, and that's the catch about politics.

The ACA could've been challenged earlier by the Republicans if it introduced a new tax to pay for itself. That would've been the natural thing to do, and the Democrats were well aware of it. Because of that Republican blockage, they had to hide that fee in the "mandate" instead. Of course the Republicans weren't dupes and sued against it, but the courts sided with the Democrats accepting that the mandate wasn't a "tax". I wish I could come up with a source (it was big news back then), but right now my google search is overloaded with another recent ACA-related budget fight :\

There were many better alternatives to the current ACA as it is, including a single-payer option. But we got the ACA (which started as a Heritage Foundation idea[1], they're a nicely conservative think tank) because that's the best the Democrats could get past the Republicans.

[1] http://www.forbes.com/sites/theapothecary/2011/10/20/how-a-c...

I agree. And what bothers me further is that I am vehemently opposed to patents, while I am forced to send a lot of my money to drug patent holders.

How does that differ, really, from an individual insurance mandate?

vs.

Mandating that I purchase a private company's services myself.

In the first case, the government uses its bargaining power (all that money) to negotiate a lower price by requesting bids and selecting a provider. In the second case, I'm a captive customer with little, if any, bargaining power. My bargaining power does indeed depend on how this second arrangement is legislated and how many providers are available to me.

This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.

Insurance with pre-existing condition is just health care. You are not insuring against anything.

My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.

It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children.

There is no need to require everybody to buy an overprized service bundle.

So if you lose your job and your health coverage, insurers would be able to deny you coverage.

But if you never have a gap, then you can't be discriminated against.

Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.

The gap solution, though, is not a great idea. If someone falls under a certain level of economic or other hard times and incurs a gap for even a very brief duration, it is in my opinion a very harsh penalty to use that as an excuse to deny them coverage. This is especially true when many families pay a large amount for existing coverage.

The only tenable solution is to force everyone to have coverage. If that's the answer, I see no better implementation than single-payer.

Hence: The actor paying for chronic care is the one incentivized to provide great preventative care, separating the two will create incentives with negative patient outcomes and cost for chronic illness.

Another less obvious issue is that by splitting healthcare payment between actors, they are weakened against an increasingly monopolistic healthcare provider market. One key reason US healthcare is expensive today is that insurers are weak vs. healthcare providers - splitting them up would further reduce their ability to negotiate better prices.

While there's some truth to the argument that US healthcare is expensive because it pays for much of the worlds medical research, there is plenty of truth to the argument that the rest of the west gets better prices because their single-payer insurance is a massively strong negotiating party fighting for good prices for patients.

There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time).

This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.

How can you possibly think that?

It's stupid to require the poor to pay for plans they don't need/want/afford, and for rich to pay for plans when they can pay their own way.

MANY people opt to pay the fine as substantially cheaper than compliance.

And it's a safe guess that the political "Left" would be screaming outrage if the "Right" were compelling people to buy private-sector products (health insurance) they didn't want or afford.

Poor people don't need health insurance? Doesn't everyone need it? If anyone didn't need it it'd be the rich.

> /want

Too bad. If we let people not have health insurance we might as well legalize suicide by the same argument.

> /afford

So people who can't afford it should just... die?

> and for rich to pay for plans when they can pay their own way.

You have to be pretty rich for health insurance to not make sense. Not just like upper middle class. If you're suddenly diagnosed with some rare disease you could easily see medical costs in the hundred thousands per year.

Likewise the rich. If you're earning millions per year, you don't need ACA-imposed "$50 co-pay" type coverage for common services totaling under $100,000/yr. (Listen to Rush Limbaugh rant about such issues: forcing him to buy ACA-approved health coverage is stupid; he could buy the hospital if need be.)

Comes down to marketplace & choice: it's my life, and my money, who are you to force me (under threat of violence from the state) to buy what you consider sufficient coverage? Let's discuss fixing systemic problems with narrowly targeted solutions, yes, but don't fine me $3000/yr for preferring to pay my own way out-of-pocket completely up to $10,000/yr.

There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance.

Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them.

Then there are the people who prefer paying for things out of their pocket as they go.

The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.

It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.

Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with.

I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?

We also have a large contingent of people who take immense pride in voting against their own self-interest. They'll look to Canada's system and say "yeah but they wait for days to get an x-ray for a broken arm" ignoring the fact that they themselves couldn't even afford to get an x-ray. But it's worth it because even though I can't get healthcare, the people I hate can't get it either.

As shown by the most recent election, it's political suicide to imply that America isn't the single greatest nation in the world. It's even worse to suggest that we should be asking some other country for help. Those other countries are communists, and the only communist we like is Russia.

Recent experience - my daughter sprained her ankle, so went to the hospital for x-rays. I live outside the city so the doctor we saw was coincidentally our local GP. The price $0, time waited - about half an hour, this was on a Sunday night.

One thing that may be a factor here is the medical practices are run by doctors - no professional manager people which, from what I understand, seem to be in the US health system. The doctors, in general, really are people who want to make people well and thats what they do. Sure they like to make a buck and they do but not at the expense of everyone else.

If you let non medical people into the system to manage it then, I'd look closely at their motives, I suspect you'll find sometimes their motives aren't pure.

The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers.

This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less.

Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.

During WWII the government imposed wage controls.. but fringe benefits did not count as wages. And with a shortage in labor because of the war, employers used health insurance and other fringe benefits to attract workers.

The unions jumped onboard later.

https://en.wikipedia.org/wiki/Health_insurance_in_the_United...

Employer provided healthcare is an artifact of ww2 where employee compensation was practically frozen. Employers looked for other ways to create competitive compensation, and turned to healthcare.

http://www.npr.org/templates/story/story.php?storyId=1140451...

Oh we definitely look abroad. In fact that's one of the major arguments for a single-payer system in the U.S. - such a system exists successfully in every other capitalist democracy. So why can't we make it work here?

And this looking abroad is not a tonic against bad thinking. Conservatives routinely look at health systems in other countries and decry them: long waiting lists for elective procedures, high marginal income tax rates, etc., etc. Any flaw in another system is magnified and considered a non-starter.

Obamacare was based on an older Republican plan which had been implemented by Mitt Romney in Massachusetts. But in the run-up to Obamacare conservatives hyperventilated about "death panels" and how the ACA was going to destroy the economy. None of which came to pass.

Every other OECD country ("capitalist democracy" is a problematic category) except Mexico has some form of universal coverage, but not all are single payer, several are hybrid public/private systems.

By "capitalist democracy" I simply wanted to point out that a country can have a healthy and thriving free market economy and universal coverage at the same time. (e.g., Germany, Japan, UK, and many more). It's a counterfactual to small-government conservative hyperbole, which holds that universal coverage necessarily destroys and disables a nation's economy.

https://www.hsph.harvard.edu/news/features/mexico-universal-...

A problematic category? What does that even mean?

https://mises.org/blog/how-us-states-compare-foreign-countri...

Everyone understands the healthcare systems in Canada and most of Europe. There is no point mentioning it because for most of Republicans it's a non-starter. It's incredibly niece of you to think a bunch of liberals have never thought to look elsewhere, at best. At worst you wanted to just blanket insult the US.

The plan for my family last year cost over $1200 per month, and this year rose to $1400/month.

Previously, with employer-provided plans I paid at most $400/month for my family.

Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.

A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month.

In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan.

The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what.

I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price.

I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment.

One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.

We already have a progressive tax, but let's add an individual mandate, tax credits that phase out at 400% FPL, and cost sharing subsidies which phase out after 250% of FPL.

The maximum value of the tax credits for your family would be nearly the full cost of the premiums at 133% FPL, let's say $12,000. Then on top of that the cost sharing reductions would reduce your out-of-pocket maximum -- which if you're truly unlucky could run your family another $14,300 -- to a maximum of $4,500, so that's worth potentially another $10k.

What this means is ACA is a $12,000 - $22,000 tax on your family depending on your health care utilization, as income rises from 133% - 400% FPL.

For a family of 4 the 133% FPL = $32,250 and 400% = $97,000. So as you make that extra $64,750, in addition to all the other taxes you are paying, you are also phasing in $12,000 - $22,000 of increased payments for the same exact health care. Now that is one hell of a tax.

So while you and your spouse are working your asses off to earn $150k, you can look back and appreciate how $10k went to the town, $10k to the state, $30k to the Fed and ~$15k to the SSA. So it's really just the cherry you're being charged an extra $15k for insurance, come on, you can afford it!

I won't mention all the other subsidies you lose out on for being a productive member of society. Because when you realize the real tax rate approaches 100% on the first $97,000 it's a bit of a buzz kill.

Why wouldn't they, customers are insulated from the sticker price but can't really complain because high priced health "insurance" is required.

It's just a coincidence that Mylan took any flak for its abuse of the system. Many other pharmaceuticals are increasing in price way out of proportion to inflation, and way out of step with reality since the R&D costs are all borne before product launch.

That's just Not Even Wrong.

Your health insurance premium is not a "tax". You're getting health insurance. Moreover, not getting a subsidy for your health insurance is also not a tax. You can only use that logic when the tax credit is offsetting another tax. Which it isn't. It's offsetting your health insurance bill.

If, instead, you're trying to claim that every bit of increase in health insurance costs since the ACA is a "tax", that's maybe a bit more defensible, but still Wrong. Health insurance costs have been skyrocketing for decades. The ACA has probably slowed down that trend.

Finally, if you're just complaining that you're healthy but you have to pay for health insurance now...take a walk, please. Eventually, we all get sick. Health insurance only works if healthy people foot the bill of the sick people. That's how insurance works.

It's called "Effective Marginal Tax Rate" if you want to Google it.

From the CBO; "The effective marginal tax rate (for brevity, hereafter referred to as the marginal tax rate) is the percentage of an additional dollar of earnings that is unavailable to an individual because it is paid in taxes or offset by reduced benefits from government programs."

I mean, it seems almost ridiculous to say that buying health insurance & health care is a tax, but when the government is paying over a trillion dollars a year to buy health care for everyone except those who are too young or earning too much money, that's exactly what it's become.

And I'm definitely not complaining that healthy people should not have to pay for health insurance. In fact the healthiest 50 percent of people who pay for health insurance use only 3.5 percent of services, it's what allows the entire system to work!

The difference between your risk-adjusted premiums (based on your lifetime expected payouts + margin and overhead) and the amount that you actually pay in premiums can best be described as a "tax", because if it is positive, that money is directly going towards subsidizing someone else's premiums, and it is mandated by the government.

You can make the argument that it's the right thing to do because it allows people to purchase insurance that they otherwise would be unable to afford, based on their expected risk level (ie, past health) and their current income, but it's important to understand that that's not the way insurance itself works. The insurance is simply being bundled together with that tax, so you only see the one price at the end, instead of having it broken down and itemized.

The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage.

If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.

Around $200 per month. The risk pool aspect would be true if the risk were the dominant factor in the price, which I think it isn't.

> The idea is self-insuring $15-20k is absurd for most people

People who can afford $1400/month even if no healthcare is used? I'd much rather save the money and if someone in my household has a catastrophic scenario put it on a credit card or spend the next <12 months on a payment plan of $1000/month.

> subsidize more of the cost of this care

The key word in that sentence is this. What care are we talking about? The ACA plans cost a minimum of $900/month even if I use no care at all (and that's for the plan with very high co-pays, etc.).

I've been on an ACA plan for the past two benefit years, and the plans keep getting much more expensive and offering worse coverage. The question is, why is this happening? And why is it that on the so-called "marketplace" there is not a high deductible plan that had been available via non-ACA plans via employers?

I think the answer is that it is far from an actual marketplace. There must be some incentive for providers not to offer high deductible plans or actual risk-based plans.

A risk pool is a way of packaging a lot of people into one financial model, but the larger and more heterogeneous the group, the more the prices should reflect actuarial reality. The exact opposite is the case.

Considering that so much money and research has gone into building the healthcare.gov website, why can't I simply adjust sliders to optimize the plan the same way I book a flight? I'd like to slide the monthly premium slider to the bottom, slide the maximum out-of-pocket to about 15x the mid-high premium price, adjust the "worst case event" slider to about $20K and (hopefully) find a plan for a few hundred dollars a month, which I know exists in the actual market because I had it a few years ago! If anything, a larger risk pool should have allowed insurers to offer plans that strongly discourage adverse selection (such as high deductible plans) and reflect the actual risk of cost incurred to the insurer.

The plans on healthcare.gov not only fail to offer this, but the wording, the pricing examples, and fine print is all out of some sort of bureaucratic nightmare scenario. I actually had a physician and a lawyer sit with me to try to understand the fine print and the likely cost of a few scenarios other than pregnancy and diabetes (which are shown), and we sat there confused for several hours.

I'd like to see our president sit before the nation sharing his desktop screen and watch him navigate through the site and explain the answers to the very simple things we were wondering about, as well as explain some of the more confusing terminology, as well as things like "why are there two separate plans that are so similar being offered by this company?" or "which of the priced items on this list are excluded from the individual deductible?" I'm quite sure that he'd need to do quite a bit of research and rehearsal before he'd be able to give such a demo with confidence.

When we put trust in our officials to handle things for us, there is a tremendous amount of responsibility that they take on in that capacity. Here we were, one highly computer-literate person, one doc, and one lawyer, utterly flummoxed for several hours. Imagine the average person after a long day trying to make this very important choice for his/her family. It's just wrong.

Maybe the idea is to make all the plans more and more similar until there is really just one choice that is priced based on income and nobody feels it's worth the time searching or reading any of the coverage descriptions because we all realize that the plans are all nearly the same by design, and that we're just meant to pay our "share" based on income and be grateful that such great care has been provided for us.

One thing is for certain. It's not a marketplace. There are simply not competitive plans. There is no way to sort the plans according to any differentiating factors. The "wizard" that the site offers tries to partition people into three groups based on expected usage, but does not offer any consideration to low users or users who are comfortable with the idea of getting a large bill and either taking on debt to pay it off or going on a payment plan with the provider.

And, far worse, all any of the plans I reviewed do to create an incentive for low use is subsidize non-emergent primary care visits. There is zero incentive beyond that to reduce one's use of care. Since the spread between the cheapest and most expensive plan is so small, anyone who expects to need any healthcare at all is better off choosing a silver or gold plan. If this incentive is different for people whose coverage is subsidized, I'd consider it discriminatory fwiw.

ACA caps the maximum out of pocket for "essential health benefits". For 2017, that means a max deductible of 7150 for an individual, 14300 for a family. It's adjusted for inflation each year.

It's to prevent people who can't pay the high deductible from signing up for these plans to avoid the penalty for not having coverage.

If it were fair it would be based on a percent of income like other tax-related laws.

The ACA instead helps the insurance companies optimize based on their interests.

The preexisting coverage mandate will need to be re-engineered because it's in direct tension with the fundamentals of insurance. Wide open and the system is just cost transfer.

Isn't this just because now insurance companies have to cover preexisting conditions and also not charge them exorbitant prices? Naturally, they would be taking a loss in order to do this so that burden is instead shifted onto the healthy people. To prevent healthy people from just not buying insurance, the mandate was made because it's economically unfeasible without them.

If you're the type of person who would normally use a high deductible plan, you're worse off, but that's the way it was supposed to be. Presumably if one day you get very sick though, you will still be able to get insurance.

We shifted the burden of healthcare from lower class and sick to middle class.

But the fundamental problem is high cost of healthcare. Capitalism is usually a ruthlessly effective tool, but it doesn't seem to work with healthcare due to lack of choice.

Maybe it doesn't make sense to invest so much money into health?

Is it a worthy trade-off getting 80% of our current healthcare quality for say 50% of the cost?

It's a tough call to make, but this country is in decline and we need to make tough choices.

I'm a 19-year old developer working my ass off last 4 years for silly startups. Currently I make $30/hour but paying around 30% of my income in taxes.

Baby boomers benefited from generation before them and borrowed money from gen x'ers/millenials and they run this country into ground.

Once my agegroup starts seriously voting I feel like we won't have a lot of pity for older age groups and their retirement plans.

I support raising minimum wage to livable standards, but I hope universal income comes soon.

Over the last year I've been getting burned out working 60 hour weeks trying to use latest languages and libraries, while my company is hiring $3/hour phillipino php/WordPress codemonkeys...While all I wish in life is to Haskell in peace for next 30 years and then die.

I'm still trying to work toeard American dream, but it's dead for all but the software industry.

It's disilousining to see rich stealing the fruits of my labour while I have to pay government to keep the lower class alive.

As kids we were told about wonders of globalization, democracy, and America.

In the real world we now have to deal with fucked up environment, economics and Putin flexing his geopolitical dick.

So you older folks got us into this mess, what the hell do we do now?

Where are you getting this from? I thought we shifted the burden from.. sick people to non sick people

> But the fundamental problem is high cost of healthcare. Capitalism is usually a ruthlessly effective tool, but it doesn't seem to work with healthcare due to lack of choice. Maybe it doesn't make sense to invest so much money into health?

I don't know if I agree on the ruthlessly effective part, but I'm also not sure what you mean by lack of choice. Lack of choice in what? Insurance? After all, there are plenty of hospitals you could go to.

I'm guessing treatments sometimes are expensive because.. well we don't have a good understanding of how to many things so we use the best thing we know how to use, which is often expensive no matter the industry. On the other hand, it seems like a bad choice to use something cheaper because.. well because we don't want people to die.

> It's a tough call to make, but this country is in decline and we need to make tough choices.

By what measure?

> I'm a 19-year old developer working my ass off last 4 years for silly startups. Currently I make $30/hour but paying around 30% of my income in taxes.

> Over the last year I've been getting burned out working 60 hour weeks trying to use latest languages and libraries, while my company is hiring $3/hour phillipino php/WordPress codemonkeys...While all I wish in life is to Haskell in peace for next 30 years and then die.

You certainly sound burned out. Why not try to find a better job? If they can hire that type of employee then perhaps you need to try to find a job where you aren't going to be replaceable? I don't really know that using the latest languages and libraries is a good thing..

> It's disilousining to see rich stealing the fruits of my labour while I have to pay government to keep the lower class alive.

Sorry you're going to have to elaborate. How exactly are the rich "stealing" your work?

> So you older folks got us into this mess, what the hell do we do now?

Sorry I'm completely lost now. If you have things you'd like to improve then you should vote on them and try to get the change you'd like to see enacted.

Would that still be true if you had to pay retail for all your care?

The grandparent's intuition that by being on a high deductible plan I would not be eligible for the "buying club" benefits of negotiated pricing doesn't pan out: The price is negotiated so that there is a captive "in-network" market which guarantees some level of utilization and helps with planning. Insurance companies want to offer a large population to care networks in order to negotiate a volume discount.

Also, if you consider a catastrophic plan that kicks in if something really bad happens and I use over $20K of care. Nearly any serious condition or accident would qualify. If it happened, I'd be able to switch to a lower deductible plan in the next open enrollment. Worst case, I'd end up paying my premium savings (and then some) toward that one event, but overall I would not be much worse off than if I'd just chosen the expensive plan to begin with.

When I had the high deductible plan through an employer I did the math on it compared to the most deluxe plan offered. Worst case, if I maxed out the individual and family deductibles on the high deductible plan, I'd end up paying about the same as the annual premiums of the deluxe plan. But if, as is likely, I didn't have a catastrophic incident, I'd save a lot of money (which I did).

You've got it backwards - Medicare (and Medicaid, to a lesser extent) are the ones who rip off providers, by reimbursing less than COGS[0]. The "retail" price is actually a way that providers make up for these losses by passing on the costs to private insurers (who then pay for those increased costs by accounting for them as claims, improving their MLR, and allowing them to raise premiums for it).

[0] Medicare's own financial statements attest to this; you don't have to take providers' words for it.

If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else.

Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes.

* - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about.

edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P

Having insurance tied to employment is utterly terrifying. You'll stick it out in a sub-standard job to maintain coverage. You'll be fearful of taking risks on self-employment. It's the exact opposite thing you'd do if you wanted to encourage entrepreneurship.

http://www.denverpost.com/2016/11/08/coloradocare-amendment-...

The correct name is "Health First Colorado". I signed up the day I was hurt, they backdated the signup to the month prior. It took less than 15 minutes to become covered.

I've been working for 20+ years, with spats of insured or not-insured throughout... mostly uninsured. After I left my SF gig, I gave up my insurance & didn't get any more since I'd already had 6 months for the year.

By the end of December, I needed it.

Edit - link: https://www.colorado.gov/hcpf/colorado-medicaid

They didn't care if you signed up when you were injured because you would have qualified for it anyway... you just didn't complete the paperwork. You definitely cannot do this when you exceed the income limit for medicaid and have to get normal health insurance.

The ACA increased the limits to qualify for medicaid. I know there were a few states balking at increased medicaid costs.. but you could have gotten this in most states, including CA.

Yeah... my income === 0. Hopefully, not for too much longer.

I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible.

I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off.

Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?

What I read, and I did read this online and haven't had the time to look for primary sources so please take with a grain of salt, but worth looking into is this:

pre-existing condition check was a major risk to the insurance industry since nobody knew how much it was going to cost them. So the ACA told insurance companies we'll subsidize some of your costs until things settle down (this is different than subsidizing people's payments). However when it came time for the gov to pay, Republicans blocked most of the subsidy payments to health insurance companies (I think they only received 12% of the expected amount).

And then because insurance companies didn't get that subsidy they obviously passed the cost onto consumers. And I'm sure whatever subsidy was further promised by the Gov they could no longer rely on so they priced that risk in as well.

The GP comment is just another example of how there's a ton of uninformed anger on this issue. People are spitting mad because they're realizing that health care is becoming really expensive, and they think the ACA is to blame because they heard about the ACA last. The amount of actual understanding approaches zero, because few people pay for their own healthcare in the USA.

I kind of want the GOP to just burn everything down and expose everyone to the full pain of this absurd system (in true, "free market" fashion). We'll have a political revolution overnight.

You can argue that cost increases are due to all of those previously uninsured sick people who are now insured and costing the rest of us money, but that's both wrong (costs have been going up faster than inflation for decades), and a pretty awful worldview.

And despite all of that, health care cost growth still dropped

"I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company."

Before the ACA, because you couldn't have gotten any health care coverage at all. Thus after the ACA, you had an opportunity that would not have been possible (safely) previously.

Married, two kids. Everybody reasonably healthy, have a decent job.

Healthcare costs have become expensive as shit because of the ACA. That's not a partisan talking-point: that's the bottom line in our household budget.

The happy-face anecdotes the ACA's advocates trot out are lovely, but there are far more people in my position.

You say this is like a bad thing. Shouldn't the healthier members of society be happy to contribute to the health of those less fortunate?

Gross to think otherwise.

It really depends on the people you have in your society and what the sick people are contributing.

Getting sick needs to have some kind of downside to it. Else people have no incentive to stay healthy. They can take as many risks as they want to their personal health because it's going to be paid for by other healthy people.

America in particular has a large obese population which is addicted to popping pills and overmedicating in general. If you give people free license to eat whatever they want or take as many drugs as they want without consequence our healthcare costs are going to be unaffordable very soon (they nearly already are)

Once you are in a system where everyone is forced to contribute, one person's actions affect others. If you don't take care of yourself and get sick, others are forced to pay for you. If you have too many people who don't take care of themselves, the healthy people are the ones who get screwed because it's effectively a wealth transfer: They're paying for sick people to have the license to do whatever they want.

The reality is that sick people are a drain on society's resources. Obviously we need a humane solution to treat them but the answer shouldn't just be a blank check. There are sick people who require hundreds of thousands of care YEARLY. They are not temporarily sick, they are permanently sick. I dont' think it's fair that they pay the same rate as healthy people. If you are permanently sick, that sucks but you should pay more of the burden.

Yeah it would suck if illness affected your ability to be physically active, gain and keep employment, be part of a happy relationship, enjoy hobbies, etc.

It's great that you've found a way to punish people financially so those ill freeriders don't get off Scott free.

If you remove any sense of personal responsibility from people's health, they will have no incentive to take care of of themselves. Everything they suffer will be covered by insurance (ie. other healthy people). That's how it is right now. Healthy people are not signing up for these shitty health insurance plans because they are being forced to pay for sick people who eat up 80% ( or some ridiculous number, i don't know what it is) of the actual costs.

It's not about "punishment". it's about people paying their own way. If other people were paying for your car insurance they why not speed, drive drunk, drive recklessly, etc. You are not personally liable for any of your driving consequences.

The reality is that people who are sick are a drain on resources. We have to decide , rationally, how much other people should be forced to pay for these sick people. If you are fine joining a health insurance plan with these people and paying more then fine, all the power to you. So are you doing that?

https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyro...

> A new analysis from the Urban Institute found that the average unsubsidized premiums in the Affordable Care Act exchanges, commonly known as Obamacare, are actually 10 percent lower than the full premiums in the average employer plan nationally in 2016.

What I don't believe is that healthcare costs have gotten more expensive FASTER THAN THEY ALREADY WERE because of the ACA, any more than I think that my cat died in 2012 because of the ACA ("Gee, Thanks Obama!") which I'm sure some people would also argue.

So in your comment, I absolutely believe

> Healthcare costs have become expensive as shit

But I think you're trying to assign blame where it's not due with

> because of the ACA.

The ACA introduced no cost controls and just shifted the costs around from 1 demographic to another (mostly to the lower-middle and middle class healthy people, who don't actually use much health care).

So obviously for every sob story of a saved life, there's at least 2-3 stories of relatively young (26-30) healthy people whose deductibles and premiums have gone through the roof.

That's why people on the internet can't ever agree whether the ACA was a good thing, because there's plenty of anecdata from both sides.

I think we, as a population have to accept that Americans, in general, are very unhealthy people. It's quite obvious with ~35% obesity and the #1 killer being heart disease. Naturally, mitigation health care is an order of magnitude more expensive than preventive care. Hence the rising costs of health care (for everyone, even though some people don't feel the pain of costs, whether by being subsidized or being rich)

In a lot of ways that's exactly what insurance is. It's pooling resources to cover expenses for the people who need it. In any given time period most people won't need it, or won't need it to an extent higher than their contributions, but it's there just in case. There's variation in premium amounts to account for the difference in likelihood of need (so those younger generally-healthier people pay lower premiums), but a very important part of making it work is having a large enough pool that only a limited percentage needs to use it each year.

There are also measures that were taken to try to reduce costs, but how effective they were may be up in the air. The only one I can name offhand was the requirement that insurance companies spend at least 80-85% of revenue on medical expenses. At least one person noted that might also lead to higher costs (via overpaying to let that overhead grow), though I think that that's the kind of problem that market factors would actually address - if you're overpaying, that money has to come from somewhere so you're also charging higher premiums and will shed customers as they seek cheaper insurance.

Other cost-cutting measures have been killed off through effective lobbying (e.g. Medicare being barred by law from negotiating drug prices, introduced back with Medicare Part D and the Donut Hole).

And yes, the general fitness level of Americans is pretty poor. Unfortunately, addressing that is more of a public health matter, and since the onset of modern medicine public health has been more and more relegated to a secondary role. Interestingly, some insurance companies seem to be trying to revive non-medical measures to improve the health of their customers through things like discounts for fitness assessments, fitness programs, etc. The assessments and advice resulting from them may make a difference, but even just the embarrassment factor of being unfit and going for one may help change behaviors.

I'll just note that in general, obesity is different from anorexia - fat people realize they're fat, are often concerned or embarrassed about it, and a large percentage of them would like to be be if not thin at least a lot less fat.

1. Rate Review & the 80:20 rule: http://obamacarefacts.com/obamacare-rate-review-80-20-rule/

2. IBAP or "death panels" if you're a halfwit politician from Alaska: https://en.wikipedia.org/wiki/Independent_Payment_Advisory_B...

3. Readmission Reductions Program where hospitals won't be reimbursed if patients come back with the same issues: https://www.cms.gov/medicare/medicare-fee-for-service-paymen...

4. The HCFAC was given an extra $350M to combat fraud and absuse: https://oig.hhs.gov/reports-and-publications/hcfac/index.asp

5. The ACA authorized CMS to run background checks and site visits (which were previously forbidden) on providers to ensure they're legitimate.

6. The ACA authorized CMS to withhold payments if fraud is suspected -- Previously they were required to pay, then try to get the money back.

7. The ACA greatly expanded the Recovery Audit Contractor program to Medicare C and D, mandating post-billing audits of Medicare providers.

8. The ACA gave the OIG the ability to levy large fines ($50,000/false statement) on providers who defraud health programs.

9. The ACA created a centralized databank to share claims information between Medicare/Medicaid/CHIP/VA/DOD/SSDI.

10. There are a litany of provisions about home health care, hospice, nursing homes, and other areas that were formerly high-risk fraud areas. New penalties, restrictions, enforcement mechanisms, etc.

11. The ACA reduces payments to hospitals that have high incidence of hospital-acquired infections in their patients.

12. The ACA greatly expanded competitive bidding for durable medical equipment ensuring that nearly all categories now will have a proper bidding process and regular price updates.

13. The ACA expanded the prescription drug rebate program: https://www.medicaid.gov/medicaid/prescription-drugs/medicai...

14. The ACA established the Center for Medicare/Medicaid Innovation which research and perform trials of new care delivery models with a focus on lower-cost, higher-quality service.

15. The Bundled Payments for Care Improvement changes the focus of hospitals by providing a target cost for an admission instead of paying for each service the patient receives. So if you go to the hospital with a kidney infection, instead of performing every test in the world on you to run up their reimbursement rate, the hospital is now focused on the lowest cost care that will prevent readmission: https://innovation.cms.gov/initiatives/bundled-payments/

I mean.. there are literally hundreds of cost-control provisions..

In addition while this is a contentious subject telling people to "reconsider your certainty [...] if you don't know basic facts" is needlessly confrontational.

Obviously, I don't think you're obligated to offer any details you don't want to.

I guess I assumed you had a point and weren't just firing off scary sounding exaggerated anecdotes.

As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly.

Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts.

In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.

The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.

Still, we all know what it's like to have a major design flaw in the legacy codebase.

The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?

Deaths due to homelessness (2010)[2]: 700

Deaths due to lack of medical care (2009)[3]: 45,000

What's different is the magnitude. Although the United State's patchwork of services for the homeless is ostensibly supposed to give everyone access to food and shelter, people do fall through the cracks. But it is not an endemic problem like lack of health care.

[1] Debatable, and I can't find a solid source. The only malnutrition related deaths I can find are in elderly populations and abused children.

[2] http://www.nationalhomeless.org/publications/winter_weather/...

[3] http://news.harvard.edu/gazette/story/2009/09/new-study-find... this is a higher end estimate from 2009, the lowest estimate I could find was 18,000 from a study done in 2002

(I'm the first story in the article)

Great question. Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item.

My opinion is because the system we have today is basically a wealth transfer from the taxpayers to large interest groups (nurses' unions, big pharma, etc).

Programs exist to make food and shelter universally available, as well, and while imperfect, the proportion of the population unable to afford food or shelter is lower than the pre (or even post) ACA rate of people being unable to afford healthcare.

The fact that the problem is less solved for healthcare is probably why there is more visible passion on the issue.

The healthcare system is totally a disaster, and it really should be fixed, but giving college-aged kids a free pass for a few more years isn't really a solution.

This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.

A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this:

http://www.patheos.com/blogs/dispatches/2017/01/11/republica...

Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.

Rand Paul dissented.

https://www.youtube.com/watch?v=SBWJ_LW_hBI

As a liberal-leaning person, I disagree with Rand Paul on many policy issues, but respect the fact that his actions are consistent with his stated ideals, which is becoming increasingly rare.

edit: what I said is 100% correct, so I will assume that the downvotes are simply political in nature.

I think it's pretty clear at this point that both parties love getting involved in the private affairs of individuals. Obama continued Bush-era spying policies, and in fact just this week (https://news.ycombinator.com/item?id=13390511) expanded the power of the intelligence community to snoop on Americans.

Blaming just one political party is demonstrable nonsense.

Growing the deficit from $580bn to $950bn over 7 years means it is growing at over 6.2% per year. To be fair, the median nominal GDP growth rate between 1933 and 2015 was 6.4% [1]. That said, forecasted near-term growth is expected to come in between 2.5 and 3.5% [2].

The difference between the 6.2% deficit growth rate and 2.5 to 3.5% nominal GDP growth rate will need to be made up with a mix of tax increases (austerity), inflation (redistribution) or, while unlikely, default.

[1] http://www.multpl.com/us-gdp-growth-rate

[2] http://www.tradingeconomics.com/united-states/gdp-growth

There is a big distinction between "pro free enterprise" and "pro business". The former supports capitalism, the latter crony capitalism.

> Under Republican policies, these businesses would not exist

I think the GOP has yet to figure out what their health care policy even is. They really need to figure out how to be for something again.

I'm not sure what the policy is, but I know they don't have a plan. I can't find the link, but I heard a spot on NPR (either Fresh Air or Here & Now) talking about the plan to repeal the ACA. The purported goal was to vote immediately to repeal it but delay the effective date. There's no plan. In the mean time, they're supposed to figure it all out.

Neither party is really in favor of free markets in any meaningful sense. The GOP happens to use that rhetoric more than the Democrats do in order to gain support for their policies, but knowing how to leverage the rhetoric doesn't mean that's what they actually support, if you look at their actions.

I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.

We should not have to have an insurance policy for a doctor check out that weird lump on our thigh or come in and spend 10 seconds pretending to talk to us before scribbling out a prescription for something that vaguely sounds appropriate and walking out.

Insurance is what distorts these markets. Patients need to pay doctors directly again. Real competition needs to be returned. Right now, the doctor inflates their bill 5x because they know the insurance is going to talk them down, the insurance talks them down because they know they're going to inflate the bill and not worry about it since it's an insurance company paying out, and round and round we go.

There's no reason the market for medical care needs to be different than the market for food, which is cheap and abundant. People often say that you can't can have an efficient medical marketplace because medical care is emergent, but that's usually not true; most medical care, like most meal times, can wait long enough to allow the patient to make a choice between competitors, and providers who charge more than the average demographic in their area can afford will go out of business.

The incentive to overcharge for emergent care is countered by the incentive to compete, which has already lead to many "urgent care centers" arising throughout the U.S. Good government regulations that prevent cartels from organizing and causing the markets to freeze up/fail can help. These regulations should include outlawing medical insurance.

Whatever the solution is, the current situation is an abject failure. ACA band-aids a couple of warts but it gave us new wounds in the process. Whole thing needs to be torn down and rebooted based on sound market principles.

It also provides for those who may never be able to earn enough working to pay for current health insurance, those who are retraining latter in life, and those starting a company.

The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment.

Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit.

There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\

Moreover, in the case of expensive or catastrophic coverage, society is picking up those costs anyway (or alternately, just letting people die). Your premiums then go to cover the costs of people who wound up declaring bankruptcy. And no insurance (or bad insurance) cuts into preventative care that can detect problems early, when they're much cheaper to treat.

I support the ACA (or better yet, much more socialized models) because I want to optimize for overall economic productivity.

I agree an employer based model does discriminate against startups, but my point is that the ACA also makes it harder for the median entrepreneur to succeed. The fact that the fringe cases can start companies does not to me justify the drain on all other entrepreneurs.

People pay into a pool and if one day they too become ill they'll need to draw on that. Prior to the ACA it was in the best interest of insurers to simply eject all the "sick" people from the pool. What use is insurance if when you really need it they cut you off?

This hurts everyone. It's not about paying more in premiums. It's about insurance that sticks around when the shit hits the fan.

The total cost of my health insurance premiums is about 20k/year; some of this is subsidized by my employer. I have a $4500 deductible. The insurance does not pay for anything, outside of preventative care, until I've paid $4500. After that, they contribute 80% up to some number, $7500 I think, and then they contribute 100% until the end of the calendar year.

Because I have such a high deductible, and due to the opacity of medical billing, I am not going to the doctor unless I'm pretty sure that not going to the doctor means I'm going to be put out of work or going to die. "Preventative" care is defined very strictly: you get a physical. For example, "preventing" the development of pneumonia by treating your respiratory illness early does not count as preventative care.

The best I can do is squirrel away what I can in my HSA...but that's one health catastrophe from being blown away. God forbid I come down with any kind of chronic illness that lasts longer than the calendar year.

That said, for the poor population, this is definitely true - Medicaid is a dream compared to private insurance. At least in my state, if you're on Medicaid, you don't even see medical bills. It's really lamentable the states were allowed to turn down the Medicaid expansion - the expansion of public health insurance was the best part of the ACA, in my opinion, and the most regrettable part of the bill is that the public option is not available to everyone.

That doesn't sound right - What is your maximum out of pocket?

Also, those numbers include only in-network providers. If I am given out-of-network care - which isn't always under my control - then I could potentially be on the hook for tens of thousands more dollars.

- An out-of-network providers gives you medical attention at an in-provider facility - maybe your ER doctor, surprise, is not in-network, even though the hospital is in-network. [1] [2] [3]

- Maybe you have a medical emergency and the closest facility at the time is out-of-network. (In some states and with some insurers under some circumstances, you can get them to pay the difference for emergency out-of-network care.)

The biggest risk factor is the "normal" <= $7500 medical bill from an in-network provider, but inadvertent out-of-network care is still something you have to be concerned about.

Also, I'm not sure if I'm reading you right, but "in-network" does not necessarily have anything to do with geography - sure, there exist in-network providers for my insurance throughout the country, but the second-closest hospital to me is still out-of-network.

[1] http://justcareusa.org/beware-of-out-of-network-er-bills/ [2] http://www.consumerreports.org/cro/news/2014/10/protect-your... [3] http://www.realclearhealth.com/articles/2017/01/09/in_throug...

EDIT: The HN backoff must be crazy high - 40 minutes later, and I still can't post, and I'll be offline the rest of the day.

Because the ACA didn't fix it. From my perspective, it was largely a giveaway to private insurance companies with some fortunate side effects.

The total cost for my health insurance premiums are 20k a year.

My in-network deductible is $4500.

My in-network out of pocket is $7500.

My out-of-network out of pocket is $20k.

Those are not hypotheticals, and because of those costs, I avoid medical care unless it is absolutely necessary. I'm afraid we're getting into the weeds - my main point is that the ACA's preventative care provisions are really quite weak and don't mean what we might think they'd mean; the preponderance of high deductibles and out-of-pocket maximums mean that people will continue to avoid getting prompt medical care until their condition becomes serious. The preventative benefit, mainly, is that everyone gets a yearly physical and a few other narrow types of preventative care.

You also said that your costs were 20k a year, but now you're talking about hypotheticals?

Well, you can make the argument for preventive care on medical grounds or even moral ones, but you can't say it actually saves money. When people have access to preventive care, they also tend to consume more, which means greater costs (although better overall care)[0].

This has borne out with the ACA[1], as the data shows that preventive costs increased faster than chronic and acute care costs dropped, by a very significant margin.

[0] https://prescriptions.blogs.nytimes.com/2009/09/03/when-prev...

[1] https://www.nytimes.com/2015/08/06/upshot/no-giving-more-peo...

The ACA report last month shows the opposite of what you're saying, that oupatient costs have dropped more than inpatient costs have risen, and that medical prices have not risen more than inflation.

Page 58+ here: https://www.whitehouse.gov/sites/default/files/page/files/20...

That's not actually the opposite of what I said. Outpatient vs. inpatient isn't the same comparison as preventive vs. responsive care. You're comparing apples and oranges.

> You should really read articles before you cite them

From the Hacker News guidelines:

> Avoid gratuitous negativity.... Please don't insinuate that someone hasn't read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that."

The majority of inpatient treatments are responsive healthcare, e.g. emergency, major surgeries, ICU/NICU, burn unit, etc.

Also, when you present an article as a source for something that it is not, then it is valid to question if you read it and present why, like I did. The full sentence of what I said is valid by HN rules, even if you attempt to quote it out of context:

>You should really read articles before you cite them, because neither use data after 2014, when the ACA provisions took effect.

This is absolutely not true, and in fact some of the things you list aren't even preventive care.

>Many Medical Investigations and treatments for acute and chronic illnesses and preventive health care can be performed on an ambulatory basis

Without ACA, a software engineer with a chronic illness wouldn't be able to start a business. Meanwhile, a healthy software engineer will start a business regardless of ACA because a minor difference in healthcare premiums is not material to that decision.

The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture.

What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk!

For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1.

I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it.

Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it.

Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.

So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses.

What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.

I've been on hold with MNSure for 2 hours so far today and I can't start an application until I talk to customer support because of some problem in their system. The whole thing has been a giant comedy of errors so far. I'm definitely not a fan of the ACA.

One thing that I discovered when I did that my first year was that the big difference between some of the Gold plans and the Silver plans was pretty much only in the minimum amount I'd be paying per month as premiums - the maximum out of pocket was pretty much the same and there wasn't that much variation in my "expected" out of pocket - I was just paying it as higher copays IF we did go to the doctor or as a higher premium regardless of whether we went to the doctor.

Something to watch out for is "coinsurance after deductible" aka "you get bupkis until you've used a lot of care." With school-age kids and probably a minimum of one checkup/physical per year per child plus vaccinations, etc. you might be better off looking for a plan with copays even if the premium is a bit higher. It's also worth looking at the emergency coverage, there can be some variation in there.

Oh, and check the provider network - BCBSIL at least has different provider network levels, so if you see seemingly-similar plans from the same carrier with a significant price difference it may mean that most providers or hospitals are going to be out-of-network which means you pay more.

Good luck

But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA.

Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place.

So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement.

It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations.

This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.

Yeah, the significance of rescission and the ACA's prohibition is often overlooked. Prior to the ACA, if you got sick enough and expensive enough, insurance companies could -- while you had outstanding claims, and this happened while people were in the hospital -- retroactively cancel your insurance, refund your premiums, and walk away leaving you fully liable not only for any future healthcare, but for anything they hadn't paid for yet from the time when you had coverage. Now, this could generally only be done based on an omission or inaccuracy in initial disclosures, usually related to a preexisting condition, but there was no requirement (federally, some states had controls) that the be intentional or significant, and insurance companies would hunt out errors once care got expensive.

The ACA elimination of exclusion for preexisting conditions itself elominated most of the basis for rescission and the onerous disclosure requirements that it was based on errors in, but the ACA also explicitly prohibited it except for fraud or intentional misrepresentation of material facts.

My job ended in January '16. I got a large severance and left the US for 7 months. I sold some stock in July, but other than that, my income was $0 each month. Looking forward, my income was likely to be just as erratic, with most months being $0. After spending way too much time talking with the folks at CoveredCA trying to figure out just how to fill out the forms for such an uncertain income level, I finally got all the information on my application and got denied. I couldn't even buy an unsubsidized plan. The exchange failed hard for my scenario and I ended up having to buy insurance directly from the health insurance company I was with when I was employed. It was quick and easy and cheaper than it would have been on the exchanges. And now, to add insult to injury, I'm probably going to have to pay a penalty for not having US health insurance for all those months that I wasn't living in the US, since I'm pretty sure I didn't pass the threshold for being a non-resident.

As a programmer, I'm all to familiar with code that handles the 90% case and just assumes those other edge cases don't exist. It's lazy and error prone and a sign of an amateur programmer. The ACA feels like the legislative equivalent of that sort of code. In their hurry to create a system where the majority of those without health coverage could get it, they created a system that's truly terrible for edge cases like me.

The MediCal denial makes sense. I don't see why I should have the state pay the entirety of my medical insurance costs when I'm making that much money. I also would like more choice when it comes to my doctor and treatment than MediCal allows and I'm willing to pay for it. The CoveredCA part is baffling to me. Why I'm not allowed to purchase health insurance with no premium assistance because I don't have a steady income leads me to believe that the ACA is poorly-written legislation.

I think the anti-ACA lobby sees this as a feature not a bug.

Similarly, a lot of people that support the ACA don't support the ideas behind it, as much as they support something being done from the previous, untenable situation. Obama took mostly Republican ideas and ran with them, now the Republicans have disavowed any involvement with them, and Democrats have adopted them as good (or at least better than what was there before, even ACA supporters acknowledge that it's a deep compromise from what anybody wanted.)

I think that the attitude of "it's going to help my side or nobody" is a much stronger driving force than the desire to prevent people from taking entrepreneurial risks.

The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster.

In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn.

There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome.

I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be.

Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece).

Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows.

Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.

If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years.

This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.

So, to pursue some things on my own time I had to negotiate a sabbatical with my company (which they generously allowed), so I could stay on employer health insurance.

If I wasn't able to do that, I'd be up shit creek, because there's no way in hell I'd risk my wife getting pregnant without health insurance.

I hope more and more people decide they feel no social obligation to things. Mass peaceful "law breaking" is really the best option, imo.

This is incredibly naive and ignores a lot of the political and theoretical underpinnings of our society and our country. https://en.wikipedia.org/wiki/Social_contract

FWIW, I used to be solidly in the "social contract" camp, and over the last few years have walked out of that camp, na'er to return.

Want to see how that argument feels when reversed?

"Your blind adherence to the maintenance of the state, despite vast evidence that it's a force of oppression shows an incredibly naïve view of the goodness and trustworthiness of man and institutions composed of members of the human race."

See? not much fun. Lets get a little more nuanced, and talk about, perhaps, at which point might a society by improved by ignoring the "social contract". Do you think that point CAN be reached? If so, when? What must we do when it IS reached?

Seven years is a long time, especially if you want to get married or have kids or get credit or not pay a ton in interest. Note also that bad outcomes in this case will compound; you've had a catastrophic injury and now you have higher interest rates and everything else.

However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores:

Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA.

The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA.

For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.

Absolutely agree. The ACA (or repealing the ACA) are both "solutions" to the wrong problem. So much potential innovation in the health care space is illegal. If it wasn't illegal, someone might (gasp!) find a way to provide a valuable service for less money than in the current system.

It will not, and cannot, be fixed by regulation, because of what you said - any regulation MUST be approved by the big companies. They'll never approve something that goes against their interests.

"Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay"

http://www.wsj.com/articles/health-cares-bipartisan-problem-...

Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.

If you don't have employer-provided health insurance, you're still basically screwed even under the ACA.

Have you been to a doctor before? Then you might have a pre-existing condition.

This could not be further from reality. We have more government distortions in our healthcare market than countries with completely socialized healthcare. For example:

Medicare: socialized medicare for the elderly, which alone creates more distortion than a universal program would cause by inflating demand/prices for non-qualifying citizens.

Medicaid: socialized healthcare for specially qualifying poor people, which creates the same distortion as Medicare.

An oppressive FDA: which, coupled with overly-powered IP laws, grants de-facto monopolies in the medical product industry. We have an incredibly expensive and subjective medical equipment pre-approval process (as compared to a less-terrible FDA that would just be in charge of labeling, preventing fraud, and maintaining accountability in the event of incidents). Then there's the length and flexibility of patent protections in our current system (maybe we could cut those protection times in half, and patent trolling would not be a lucrative industry).

Oppressive occupational licensing: It's way too hard to become a doctor of any kind, even the kinds that don't manually put things into your heart. This will be a major battle as AI comes to the point where it can better diagnose conditions and largely replace generic/non-specialized pediatrics. Of course, the government will not make this easy.

Plus a slew of more minor things like malpractice regulation, and now the ACA (which is not so minor).

If we cleaned up/removed all of the problems in the above and replaced it with single payer, it would be OK and we would have something similar to Canada/other countries with long wait times, not much access to specialists, and a system where the government gets to decide who gets the last liver transplant and who dies.

Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL.

Is there any country that has implemented this successfully?

Just ask any veterans relying on the VA how satisfied they are. On a tangent, universal health care is not 'great' anywhere, and the bigger the country, the less compelling the evidence (diseconomies of scale -- see Canada/England vs. Switzerland for example). And our country benefits from another order of magnitude of diseconomies of scale/bureaucratic bloat in trying to institute such a program.

So, moral of the story is that if it somehow did not end up making our healthcare system significantly better than universal healthcare countries, then we could still let states that lean a certain direction handle the bureaucracy of a universal healthcare system with slightly more efficiency.

I don't think there is. I think in many cases, what starts out as a "free market" is ultimately overtaken by a few large corporations (as others fold or get acquired) which then proceed to abuse their position of dominance to engage in monopolistic rent-seeking behavior to maximize their profits at the expense of everyone else. Think Microsoft abusing their dominance of Windows, or Intel abusing their position to prevent PC manufacturers from using AMD products. We're starting to get there with iOS and Android being the only two remaining choices for mobile, and Facebook for social.

My concern is even if you could hit a magic reset switch and turn the health care industry into a free market, it would trend the same way. Insurance companies would grow in size and squeeze the health care industry from both ends, charging patients more and more money, while paying doctors less and less, all so they can squeeze out a larger profit. Pharmaceutical companies would jack up the prices of their drugs because they have a captive audience, they know you're going to pay up because your life is at stake, all so they can squeeze out a larger profit.

It's questionable to me if the medical system could ever act like a free market:

1. In emergency situations you often don't have the opportunity to "shop around" for care.

2. If a pharmaceutical company is the sole manufacturer of a life-saving drug, what stops them from jacking up the price of said drug to maximize their profits, at the expense of patient lives?

3. If paying for someone's medical treatment is unprofitable, insurance companies have an incentive to drop that person's coverage instead of paying for treatment. (And often did pre-ACA.) How could a free market possibly address this situation?

Universal health care systems around the world are not perfect, but many countries have implemented them successfully and as a result spend less money on health care (as a percentage of GDP) than the US while simultaneously having better health outcomes. Why not move towards the known quantity which has already been tested and proven by every other modern country in the world, instead of this hypothetical free market system which we've never seen before, and frankly, sounds rather dubious in light of my questions above (especially (3))?

Yes, that's crony capitalism, not a free market. There is no such thing as a natural, malevolent monopoly (except for governments). They require special government privileges to maintain dominance for long, or they will fall to competition in a free market (or have to become benevolent enough so that they still maintain market share with consumers).

Corruption isn't something you just "solve" in any part of government. Except, maybe, in a government made up solely of AI/programs. But anyway, for now it's fair to assume that it's an eternal problem that plagues government, and in fact it is the problem with our current FDA. So do we just give in? No, let's continuously reset it, be vigilant, and avoid giving the government "privilege-granting" powers that allow it to enable rent-seeking in the first place, so that we don't need to do frequent resetting.

> It's questionable to me if the medical system could ever act like a free market:

Whether healthcare can be a free market is a different issue, and I've heard people even say it's inherently an immoral industry. I think healthcare is perhaps the MOST moral industry inherently, but the idea of medical insurance specifically is terrible to me, because for many people, healthcare is something they access frequently throughout their lives. I don't think health insurance is compatible with a free market, and probably constitutes fraud. The whole business plan of insurance is that people are hedging against risk/accidents, and will end up paying in more on average than they take out, but in reality health insurance is intended to cover WAY more than that as it currently stands. "Accident" insurance makes a lot more sense to me, and it's compatible with the idea of insurance (broken arms/trauma/etc.). But even serious illnesses are not really unexpected, because almost everyone gets them -- it's just a question of when. I think all medical expenses should be paid out of pocket. This is completely unreasonable in our current expensive, heavily and unfairly subsidized system, but if we refactor the system and take health insurance out of the equation, it's hard to imagine just how much costs would come down. Looking at the costs of raw materials and labor, there is absolutely no reason this should be so unattainable, and it's far more "fair." Yes, some poor people who got bad genes all around are going to have a more difficult time than a healthy or wealthy person and will have to pick and choose healthcare options that would be in their body's best interest, but such is life. Scarcity exists, and even the entire healthcare industry cannot keep one person alive forever. Side note: the majority of a person's lifelong medical expenses are incurred in the final two years of his or her life. There is finite medical care, and there is diminishing return (measured in hours/$) for how long you can keep a dying person alive another day. This is not a solvable problem with a socialist system -- there is INFINITE demand, so we need to let the market increase the supply as best it can (which is via competition, freedom, and profit motive).

So I think that answers number 3, where I very much agree with you. Number 1 as well, because you had the option to "shop around" for your accident insurance which should have you covered wherever your insurance is valid. Number 2 is solved by the free market and my additional post on reducing patent lengths. But what if the drug was just invented and they are still the only ones allowed to manufacture it?? Here is the real misunderstanding I think you share with many of my liberal friends. THIS COMPANY JUST INVENTED A LIFE SAVING DRUG -- WITHOUT ITS INNOVATION, EVERYONE WITH THE CONDITION WOULD DIE, AND NOW SOME ARE LIVING WHO CAN AFFORD TO HELP THE COMPANY RECOUP THE R&D COSTS + INCENTIVES OF MAKING A LIFE SAVING DRUG. And eventually, when its protections expire, the price will come down as others enter the market. In fact, it would probably not be in the company's long term interests to price gouge because people will remember that when competitors enter (who hasn't heard Shkreli's name?). Basically, well-intentioned people like yourself would benefit people who depend on this drug in the short term, through government intervention, at the expense of innovation in the long term as fewer corporations are attracted by the riches that await them for furthering the medical field and saving people's lives.

I apologize for the length of this post -- this topic is near and dear to my heart.

You're getting close to "no true scotsman" territory here. Microsoft abusing its position in the PC market: crony capitalism, not a free market? Intel bullying AMD in the processor market: crony capitalism, not a free market? Are there any examples anywhere in the world of a truly free market then?

> "Accident" insurance makes a lot more sense to me, and it's compatible with the idea of insurance (broken arms/trauma/etc.). But even serious illnesses are not really unexpected, because almost everyone gets them -- it's just a question of when. I think all medical expenses should be paid out of pocket.

The problem is serious illnesses tend to be the most expensive. Even if health care costs were magically cut in half, cancer treatment would still bankrupt the vast majority of the population. So, tough luck for them?

> Basically, well-intentioned people like yourself would benefit people who depend on this drug in the short term, through government intervention, at the expense of innovation in the long term as fewer corporations are attracted by the riches that await them for furthering the medical field and saving people's lives.

Yeah... I'm not necessarily convinced that medical research should be a for-profit enterprise either, for exactly the reasons you mention. ("Should we research a cure for this disease?" "Our projections indicate it won't be profitable" "Ok, moving on then...")

I get that you believe free markets will solve the problem of expensive health care, I just don't see the mechanism behind it. So far it seems very hand-wavy to me. 1) Free markets. 2) ... 3) Cheap health care. What exactly happens in step 2? How do you prevent it from turning into an abusive "crony capitalism" situation?

The free market is an ideal -- I do see where you're coming from. But the market is never free so long as there are corruptible people in government or the framework does not fairly protect freedoms, but does that mean we shouldn't strive to get as close to the 'ideal' of a free market?

For the Microsoft example in particular, they didn't benefit from government intervention until the government "punished" them, by forcing them to provide a more inclusive platform. Makes you wonder if 90% of the PC market would still belong to Microsoft if the government had not gotten involved... might have pushed us toward open source/Mac OS sooner. In the other case, Intel just plagued AMD with legal bills, which perhaps says something about the way our legal framework is set up (can't countersue to cover legal costs), but Intel always provided a superior product so it's a quite stretch to say it was a "malevolent" monopoly. So you're right, neither of those are really crony capitalist examples, but that doesn't mean they contradict my points on market freedom and ill-willed monopolies.

I challenge you to provide an example of a longstanding, malevolent monopoly that did not rely on government privilege.

As to the points on medical care, I assume you agree?

I think "free markets" will inevitably trend towards "crony capitalism" as long as 1) government exists and consists of, as you say, corruptible people, and 2) money exists, and therefore can be used to influence said corruptible people. Therefore, even if you managed to hit a reset switch and turn health care into a "free market" and ran the experiment over and over again, 100% of the time it will turn back into the same "crony capitalism" mess that we're in now. What can I say, I'm a cynic at heart.

And I've already mentioned this, but it also seems kind of silly to advocate for this theoretical experiment (which may not actually be possible to implement) when there are already many other countries around the world that have successfully implemented universal health care (either single-payer or two-tiered systems) with better health outcomes than the US.

But you've taken this way off topic to be honest, because I am not advocating the ultra-pure free market ideal. I am advocating scaling back and reducing the scope of our excessive USDA/FDA (which would cause the same problems in a universal healthcare system regardless), reducing IP protections (same problems regardless of universal healthcare system), making it easier to become a doctor (also a problem regardless of whether we have universal healthcare) and getting rid of our existing lop-sided "universal" healthcare systems which would be irrelevant in a universal health-care system.

To my original point, we have the most government distorted healthcare market in the world so it really should not be so surprising that our system is the worst per dollar. You can't just add another "universal healthcare program" and expect all of the problems to go away -- there's a lot of cleanup to do. And even after that cleanup, I think it would be silly to resign ourselves to the mediocrity of other systems instead of seeking progress.

I agree that reducing IP protections is a good idea. I'm not sure I would call other systems mediocre. They're not perfect but they're far, far ahead of what we have in the US. I don't think that our country is so different from others that implementing a similar system wouldn't lead to an improved outcome as well. Anyways, thanks for the discussion.

So, do you think everything's already been solved? There have been 100 billion people in Earth's history. Wouldn't you think one of them would have proved P vs NP by now?

If you have a legitimate argument against a cleaner, free(r), less corrupt health-care system, feel free to bring it forward.

But no, in modern medicine's one century of existence, the problem of finding the best health-care implementation has almost certainly not been solved. In fact, only a dozen or so countries have had the economic capability to sustain modern medical practice on a large scale for more than a couple decades. The others constitute the "second/third worlds."

The ACA has flaws but it also has some great features that need to persist: minimum care requirements, pre-existing condition exclusions banned (having a pulse is a pre-existing condition BTW), no lifetime caps on treatment.

What's the alternative? Still haven't heard anything.

But it's untrue to claim ACA provided benefits to any CA startup in terms of coverage, guaranteed issue or pre-existing conditions.

If you wanted to start a company in CA pre-ACA and you had prior credible coverage, you could get a great plan at a competitive price (the so-called "rating adjustment factor" was capped for the guarantee issue plans) with immediate coverage for pre-existing conditions.

But I am all for an alternative to what we have now or what we had.

The most important thing IMO is to make sure that people don't get hit by pre-existing conditions.

https://www.washingtonpost.com/opinions/why-is-the-number-of...

Example. Out of college. Got job. Had insurance and didn't think much of it. $2 all RX

Mid '80s had kid. 5 days in hospital (C section) and it cost $500. Insurance was 59 per month. (I making $36k)

Got thrown out of tech into federal job with federal insurance. Excellent coverage. Got $102k prostetic from New york hospital for< $5000 out of pocket.

My life with health insurance was been charmed. I am so glad I dont have to start like these young people.

Now that thats out of the way.

I hate the ACA. Its overreach by what the government should be doing. No where in the constitution does it say the government is allowed to force law abiding citizens to do something. ACA does exactly that. It forces people to do things against their will. Or they will be forced to pay a fine. Alright, don't down vote me just yet.

Lets repeal the ACA. But I certainly see things that should be quickly made into law.

* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.

* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.

* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.

* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.

* Lastly, I want hospital prices published. I want to shop around.

* I am business friendly, but these are common sense laws.

I think EVERY Republican can get behind these thoughts as every other Democrat, but forcing me to pay for it, when I just want to live off the land in some small town somewhere. Complete overreach and strictly unconstitutional.

A hospital cannot "publish prices" because prices vary wildly based on many factors. Even if they did, how am I supposed to know what I need for my healthcare? If I go to the doctor and they say "you need a surgery and it will cost 10,000" the posted prices do not tell me if I need that surgery at all, just what they cost. And, of course, the most expensive medical care is emergency, a time when price shopping is not possible.

> Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.

I'm not opposed to this, but it does remove state control over insurance regulation, which is an anathama to Republicans. I also have no idea how it will drive down costs? Are some states that much healthier than others?

> Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.

I don't even know where to start. If I can opt out of paying for some medically approved procedures, where does it end? Can I say that I want to opt out of ob/gyn care for unmarried women?

Here's a question: Dentists routinely publish prices. If you ask them how much some procedure will cost, they will tell you. If there is uncertainty, they will give you a range (e.g. to account for the possibility that complications will arise during an oral surgery). What is different in the hospital situation, apart from some rather extreme measures taken to obfuscate pricing?

> And, of course, the most expensive medical care is emergency

Is it? Or is it end-of-life? Genuinely curious to see numbers here!

> I also have no idea how it will drive down costs

Prices, not costs. The current situation is that in a lot of states there are somewhere on the order of 1-3 companies offering insurance of certain types at all. For example, for Maryland, I believe there is only one company offering an ACA-compatible PPO (everyone else has HMOs or even EPOs). See https://news.ycombinator.com/item?id=13393287 for where I got that data.

Of course in a monopoly situation there is absolutely no incentive for a monopolist to cut prices. Why would they? So to the extent that prices represent excessive profits (as opposed to the actual costs of health care), allowing cross-state insurance sales should drive them down. People who believe insurance companies are price-gouging should be _very_ in favor of removing restrictions on such sales.

Similarly, when your diagnosis comes in and surgery is required, you can take time off from your three jobs to carefully research the pros and cons of various procedures to determine which is most financially appropriate for you. I mean, it's not exactly heart surgery we're talking about here. Well, technically and literally it is, but it shouldn't be too hard for anyone to understand the pros and cons of different surgical equipment and procedures to evaluate the risks and cross-compare with the clear apples-to-apples data sets to arrive at a medically and economically responsible decision while blood is pouring out of your extremities and your body feels like it's on fire. Take the time and shop carefully. You are a model fiscal actor and will make the right call.

Free market forces will make this system work and work well. The invisible hand has been after all such a huge success in setting health care prices and has proven to be the model every modern industrial country has taken because it's so intuitive and has great proven results.

A lot of hospital care is non-emergency, but they don't explain pricing schedules for _that_ either, now do they? I think everyone understands the impossibility of comparison-shopping on emergency care.

> I mean, it's not exactly heart surgery we're talking about here

No, it's hip replacement surgery. And people _already_ do comparison shopping on things like that as much as they can, including comparing to and shopping in other countries. See medical tourism.

More to the point, people do comparison shop just like that for oral surgery. Yes, they may not have all the data they might like. Yes, they don't always make the right decisions. But by and large, dentistry works OK.

Again, the "stuff that must be done RIGHT NOW" thing is a strawman: there's plenty of hospital care that is not that sort.

> The invisible hand has been after all such a huge success in setting health care prices

The invisible hand has absolutely nothing to do with most health care prices today (at least in the US). There are some exceptions: plastic surgery, laser eye surgery, dentistry, some forms of occupational therapy, and maybe family medicine.

> and has proven to be the model every modern industrial country has taken because it's so intuitive

Various industrial countries have price transparency for their medical care. If want to know how much my hip replacement will cost in the UK not via the NHS, I go to http://www.privatehealth.co.uk/conditions-and-treatments/hip... and I get all the data I could want, including prices and the hospitals charging those prices. Importantly, those hospitals publish their prices. If I did go via the NHS, I suspect there is no real difference in the pricing, but would welcome data on how it really works.

Anyway, knowing how much medical procedures will cost you is not an uncommon situation. Except in the US, of course, where hospitals will never tell you ahead of time how much a procedure will cost.

Note that price transparency is necessary, but not sufficient, for some sort of sanity in the discretionary medical care market.

Pharmaceutical and medical equipment companies are raking in double digit profits. And they can sell wherever they want.

And you're right: by no means are insurance companies the only ones in this sector that engage in attempts at regulatory capture and creation of monopoly profits.

Though I should note that pharma companies have a lower return on capital than insurance companies last I checked, because pharma is so capital-intensive in practice. I haven't really looked into medical device manufacturers.

Does this exception generalize? From the start, I felt it was immoral to go into Iraq, topple the government, get 4000+ US soldiers killed and cause the deaths of hundreds of thousands of Iraqis. The pennies you pay for birth control a nothing compared to what I as compelled to pay for a war I didn't support from the get go. Can I get my money back for that one? I'm sure my objection to it is/was as sincere and deeply felt as your objection to birth control.