Comment by jvanderbot

ACA is horrible for the middle class. The only reason it retains any type of popularity is because the media refuses to associated ballooning cost to cost redistribution that it enables. Preexisting conditions? Middle class family picking that up. Subsidy? Middle class family picking that up.

I think it's generally gotten better for insurance companies, at the expense of both end customers and providers (with the exception of providers that have vertically integrated into the ecosystem, e.g. Aetna/CVS, etc. to capitalize on the advantages that brings).

Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.

I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.

Out of curiosity what state are you in?

> Who is it better for?

People with pre-existing conditions. They were literally uninsurable before the ACA.

The insurance costs are also skyrocketing in the employer-sponsored insurance.

ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.

You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.

So to answer:

>Who is it better for?

My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.

Without the ACA it would have been even worse. And by worse I mean that even if the premiums were lower, we would still have horrible limitations like maximum lifetime coverage amounts or exclusions for pre-existing conditions.

There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.

And this is precisely why nothing will ever change. I tell everyone who will listen to me on my soap box, we will never get universal healthcare until we divorce healthcare from employment (by that I mean, make it to where businesses cannot offer benefits at all).

Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.

I also think about people stuck in bad relationships they'd otherwise leave.

Then you should consider emigrating to a country with universal healthcare such as Canada.

I was wondering one day why it seemed like so many YouTubers were Canadian.

The "well of course" moment took me a day longer than it should have.

Part of the reason why there is no effort to fix this, to keep you a slave to a job that provides healthcare. Imagine the reduction in labor supply and increase in labor costs if healthcare did not require employment. On can, in many cases (facts intensive), bail to a developed country with healthcare if you want to realize this dream earlier than whenever the US will achieve the outcome (and your life situation supports doing so). It could potentially takes years, if not longer (~5-10 years), for the US to fix healthcare as the situation continues to degrade for those who need affordable healthcare today.

https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)

(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)

No it didn't. The ACA slowed cost growth, which was already skyrocketing by the time it passed.

I don't believe you. It wasn't the "same plan". I guarantee that the plan you had before the ACA had a lifetime benefit limit, perhaps as low as $1M. Read the fine print. A single complex episode of care could easily blow past that limit and leave the plan member functionally uninsured.

Yeah, since the ACA my coverage has remained the same while my costs have risen 10x; I'm in my 30s and my medical insurance costs 3x what my mortgage costs, and I still have $$$$ sized bills after a round of strep throat.

I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.

Your blame is misplaced. Costs are increasing in spite of the ACA, not because of it. Pre-ACA your family insurance policy was likely worse in some key ways: it probably excluded coverage pre-existing conditions and had a lifetime maximum coverage limit.

So you support single payer where none of that exists?

Yep. We were promised it would save us money. Instead, healthcare care costs skyrocketed thanks to Obamacare.

Would you have been able to keep your plan under the system before ACA? There’s a lot of context missing in your comment.

I'm curious as to how your experience actually using the plan for more than preventive coverage? IIRC, plans before the ACA had a ton of customer unfriendly provisions which made the insurance far less usable in practice. E.g. denying coverage for preexisting conditions.

There was never a guarantee that you were going to keep your plan anyway, was there? Insurance companies are changing plans from year to year.

> I will never understand why people think ACA was so great.

I would never have healthcare without it due to pre existing conditions from childhood. I literally was going to be locked out of healthcare barring becoming wealthy enough to afford everything out of pocket until it passed. And that’s really wealthy not just software engineer money. I know a lot of doctors are offering routine services for cash at a discount in increasing amounts but if you need anything with a hospital or a specialist it’s a nightmare to even find out the price before agreeing to the service.

I don't know that "inclination to judge" is a necessary component of religious charity. Religious charities beyond healthcare give out a lot of "free shit no questions asked," and usually without any attempt at proselytization. Catholic hospitals are not known for turning down patients due to moral judgements.

If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.

Where is the problem here? Religious charity exists in places with universal healthcare.

Your linked to article does not demonstrate what you claim it does. Your reasoning is wrong.

Medicaid expansion was a big part of the ACA.

> An expansion that has almost nothing to do with the rest of the ACA.

That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.

I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.

That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.

"Saved lives" or "Could Save Lives" is a ridiculous, un-falsifiable, and unprovable claim.

First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.

Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)

The problem with models is that depending on your assumptions you can show just about anything. In general I think the foundation of a good argument, and good science, is assuming the minimum and seeing if your idea still works. They assume:

- hospital reimbursement drops to medicare rates ($296 billion)

- pharma prices decline 51% ($378 billion)

- administrative overhead way down ($286 billion)

- fraudulent billing way down ($286 billion)

- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion

Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.

(1) we don't know the claims of the study will be accurate if implemented and (2) we would need studies modelling cost savings of alternative approaches to actually compare anything.

Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.

I don't think our problem is a lack of regulation though. If anything its a lack of market competition, and that is caused by over regulation and legal protections that make holding companies responsible difficult or impossible.

Universal healthcare would cut down on the paperwork needed and provide opportunities to simplify it

medicare is basically the biggest culprit for the "too much paperwork" stuff. A m4a plan that doesnt involve capitation would have even more paperwork than the current system does.

Exactly. I'd at least want to see similarly funded studies comparing solves for underlying causes beyond just insurance companies not being nationalized.

Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.

That's not necessarily true; fewer limitations on who is allowed to provide health service and manufacture medicine and health technologies would also drop prices. Competition in healthcare is very, very difficult because it's often illegal to compete.

Something like 20% of healthcare services are "low value care" which aren't justified by evidence-based medicine criteria and may even harm the patient. Regardless of the financing system we could free up a lot of capacity and slash costs by eliminating that low value care. Of course in practice it's difficult to do that at scale.

https://www.bloomsbury.com/us/price-we-pay-9781635575910/

In some cases they are provided healthcare services without a choice, so they're not really "consuming" those services. E.g. tests that don't change outcome but do cover a provider from a legal risk.

Citation needed (per capita please).

Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.

And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)

No one benefits when there's a single player in an industry. When that single player also owns your taxes and military, its a risk we should at least avoid if at all possible.

Companies don't hesitate to lay people off when their jobs aren't needed. I don't see why these parasitic insurance companies need to stay in business.

Especially when the buyer and seller are the same huge monopoly entity, but the payer is “somebody else,” the incentives are completely perverse.

The disconnect between prices and end consumers is itself a huge problem. I should know what care costs before I get it, and I should know how much my instance company is paying on my behalf before I get care.

For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.

I understand that theres an argument for removing private insurance companies in favor of thr government can cut costs. It can also increase them.

I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.

Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.

Social Security is another great example.

We still have Social Security for now. Entitlements are sticky for better or for worse.

We're talking about healthcare, so you're essentially claiming that the reason the GOP has failed to repeal the ACA despite numerous opportunities is because they actually like the policy, not because they're afraid of the political fallout. Can you elaborate more on when and why you think that happened?

We still have Medicare, Medicaid, and social security. Even though each program has been weakened, none of them have been abolished and they can all be restored.

Heck, we still have SNAP, even though it's almost universally hated by republicans.

The Republicans have gone through two Trump terms now promising to repeal Obamacare and can't do it

It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty. For everyone else, political suicide is still very much a thing (see the various conservative republicans who've chosen to go against Trump over the years and have been cast out in favor of new loyalist challengers).

I agree it would be very difficult, but still a lot easier than 'perpetual'.

Would that Obama, Jeffries, Schumer, and others felt the same way!

Whoops, good correction, I did misremember public option versus single-payer, and I guess technically Liberman was not a Democrat at that point, but he had been for a while up until shortly before then and still had committee chair positions from the Democrat leadership, so it mostly feels like a distinction without a difference.

I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!

Sadly, this is a better comparison than you probably intended, because access to school lunch is still not universal in the US.

If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.

right. my point is last line of my comment.

most of the society doesnt operate in the way that you described.