
Affordable Care - mattkrisiloff
http://blog.samaltman.com/affordable-care
======
virmundi
When my wife and I looked for insurance just before ACA, the private plan
without subsidies, because they didn't exist, was $250. It was a basic plan
with a high deductible and an HSA. It was pretty much what my employer
offered. After the ACA, same plan, by name, now cost $530. Sure it had more
bells and whistles, but I didn't want nor need them. This priced me out. This
same plan today is $780 a month without subsidies.

We are now on an ACA plan. $270 with subsidies. Think about that. The
government doubled the price of the plan or more, and is paying with our tax
dollars the difference between my $270 and $780.

The ACA helped many people. It helped people under 26. It helped people with
pre-existing conditions. It helped give free or low-cost health care to people
that couldn't afford it because now the government is picking up the lion's
share of the tab.

As much as people like to rag on the Republicans, and they deserve it, I don't
think they will throw out the good parts. I think they will look at the
industrial recommendations such as expanding risk pools across states
(Commerce Clause allows this regulation), and other rational plans. Will it be
perfect? No. Will it be better than the current ACA? Maybe.

~~~
vinhboy
> I don't think they will throw out the good parts

You are mistaken. The good parts, like covering pre-existing conditions is
exactly what causes your insurance to go up. It's basic economics. The
Republicans do not have a plan to fix that.

If there was a way to fix it, don't you think it would already be implemented?
You think they're purposefully keeping your rates high just to fuck with you?
Not to mention suffer all the political fallout of it?

Don't forget. Obamacare is the Republican plan. This repeal and objection to
Obamacare is all politics, not an attempt to fix a broken system.

~~~
smnrchrds
Seconded. ACA puts a cap on the profits of insurers. They are not just
increasing the premiums and pocketing the difference. Most, if not all of the
difference is going towards medical care by law.

"MLR measures the share of health care premium dollars spent on medical
benefits, as opposed to company expenses such as overhead or profits. For
example, if an insurer collects $100,000 in premiums and spends $85,000 on
medical care, the MLR is 85%. In general, the higher the MLR, the more value a
policyholder receives for his or her premium dollar. The ACA requires an
annual, minimum 80% MLR for individual and small group insurance plans, and an
annual, minimum 85% MLR for large group plans." [1]

Source:
[https://fas.org/sgp/crs/misc/R42735.pdf](https://fas.org/sgp/crs/misc/R42735.pdf)

~~~
jrs235
So insurance is bounded by cost plus pricing now. They have no problem if
actual health care costs go up, their bottom line profits go up too! The
insurance companies interests are now misaligned. Yeah they want to keep costs
down to increase their spread, but if the spread is limited and allowed now
they have no problem if hospitals charge $200 for what was a $100 procedure
last year because $30 is more than $15 and they'll just increase premiums!

~~~
phil21
I never understood why this is not glaringly obvious before anyone implements
such a plan. Or maybe it was and this was intended? Seems just as likely at
this point.

I mean, this is a constant joke in professional circles. If you are hourly
billing and you can use your shitty talent to create something in 8 hours that
your good talent would create in 1 - it's usually economically beneficial to
have the worse employees do the work as it's more profitable overall. Up until
the point where you lose the customer - but in this case that's not a concern.

~~~
will_pseudonym
It's right up there with excess taxes on gambling and tobacco. Governments
become dependent on those excesses and are disincentivized to decrease the
activities they're ostensibly trying to lower.

~~~
daveguy
> excess taxes on gambling and tobacco

You may be mishearing the term "excise tax". An excise tax is a tax on any
specific good, such as tobacco or gasoline. Those taxes are included in the
cost of the good (it just costs more at the pump or on the shelf). Yes, they
are typically used to reduce consumption, or to pay for costs associated with
consumption (eg roads).

~~~
will_pseudonym
I'm aware of what excise taxes are, but I see why it might seem like that's
what I meant, because I wasn't really explaining what I meant by that phrase.
By "excess tax", I mean taxes in excess of the cost of the behavior they're
trying to regulate. Both of these examples are both excise taxes, the rates of
which are in excess of the costs borne to society of those activities.

------
jakewins
If I start a fire insurance company, and I have a policy that you can sign up
_even if your house is currently on fire_ , I'm unlikely to stay in business.

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).

~~~
platz
With regards to pre-existing conditions, Ryan's plan talks about continuous
coverage policies. Under a "continuous coverage" policy, a person with a pre-
existing condition would need to avoid having any gap in insurance coverage in
order to avoid paying more for insurance or being denied outright.

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.

~~~
hackerboos
So turn the entire population into H1B visa employees. Leave and you lose your
health coverage forever?

------
brandon272
As a Canadian, I hit CTRL+F and searched for "Canada" in this thread with over
600 comments and didn't find a single result. (Edit: My mistake, missed one
other Canadian!) I searched for a few other nations with universal healthcare
and couldn't find any references to them, either.

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?

~~~
bduerst
In the early 20th century, both Canadians and U.S. citizens formed unions to
push for better living/working conditions in their country.

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.

~~~
rgbrenner
_while U.S. citizens convinced their employers._

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...](https://en.wikipedia.org/wiki/Health_insurance_in_the_United_States#The_rise_of_employer-
sponsored_coverage)

------
grandalf
The problem is that middle class Americans are charged outlandish rates for
the plans.

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.

~~~
zaroth
ACA has got to be the largest tax increase ever foisted on the middle class.

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.

~~~
timr
_" ACA has got to be the largest tax increase ever foisted on the middle
class."_

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.

~~~
zaroth
It's simple economic fact that a subsidy or other government benefit which
decreases as your income increases is exactly the same as an income tax.

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!

~~~
timr
Health insurance is not a government benefit, unless you're on Medicare or
Medicaid. Your health insurance premium is not a tax. It doesn't go to the
government.

Being required to pay for a service doesn't make that service a tax. The
_only_ thing about the ACA that has been characterized as a tax is the penalty
you pay if you don't buy insurance.

------
mr_spothawk
I quit my job and moved to Colorado ("Health First Colorado" === medicaid).
Over the winter holiday I broke my collarbone.

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

~~~
turar
I'm confused, is Colorado Care actually working in CO right now? Quick search
seems to indicate that Amendment 69 has failed:

[http://www.denverpost.com/2016/11/08/coloradocare-
amendment-...](http://www.denverpost.com/2016/11/08/coloradocare-
amendment-69-election-results/)

~~~
mr_spothawk
Sry... I'm new to CO. Your'e right... Amendment 69 failed (72% against or
something?!?! who knows... I voted in favor).

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](https://www.colorado.gov/hcpf/colorado-medicaid)

~~~
rgbrenner
I'm in colorado.. just to be clear, we definitely do not have any type of
universal coverage here, and Health First Colorado is not open to everyone.
It's just normal 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.

~~~
mr_spothawk
Hey CO! Thanks for the details.

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

------
kobeya
Here's a counter-point, Mr. Altman:

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?

~~~
vinhboy
Are you saying that if Obamacare did not exist you would be better off?

~~~
MrZongle2
I know I can say it.

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.

~~~
colemickens
How could you possibly just assert there are far more people in your position?
There are tens of millions of people who had no access to health care that now
have it. And can you explain exactly how the ACA has made healthcare
unaffordable for tens of millions, since you assert more are disaffected by it
than helped?

~~~
kobeya
And there are hundreds of millions of people who have seen their premiums and
health care costs go up.

~~~
ceejayoz
As they did every year, pre- and post-ACA.

~~~
kobeya
Excuse me, "go up by a larger factor year-over-year than had previously been
the norm."

~~~
ceejayoz
Because they started lower, apparently.

[https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyro...](https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyrocketing-
obamacare-premiums-still-lower-than-employer-sponsored-insurance/)

> 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.

------
RRRA
It's frustrating to see so much energy wasted in fragmenting health coverage
solutions in the US. This makes it so costly, that it _looks_ like it's too
expensive or inefficient, making right wing politicians justify the fact that
it should be everyone for themselves.

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.

------
nooron
The prevalence of employer-offered, private health insurance is – like many
facets of American life and institutions – an interesting path dependency of
WW2.

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.

~~~
beat
Labor unions as well, who picked up on negotiating health care benefits for
their workers. It's an interesting bit of history.

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

~~~
Apocryphon
Labor unions... we also know what it's like to be dependent on a crucial
services that are no longer being supported...

------
Spivak
Something just seems wrong about a lot of these stories citing the provision
that they're allowed to remain on their parents insurance until they're 26.
Because the story is really, "not having to worry about the high cost of
health insurance afforded me the luxury of taking more financial and career
risks." Surely we can do better for people who are older than 26 or who don't
have the option of getting insurance through their parents. If we wanted to
give everyone this kind of benefit we would just have universal healthcare
with the state acting as everyone's 'parent'.

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?

~~~
Domenic_S
> _What 's special about healthcare except that it's expensive?_

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).

~~~
dragonwriter
> Everyone needs food, everyone needs shelter, everyone needs medical care,
> but this deep passion only exists for the last item.

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.

------
tptacek
Chiming in to say that we wouldn't have been able to start our last company or
this most recent one without the ACA. One of these YC stories had a founder
who was rejected because they had a sleep study done. Most people have never
interacted with the individual insurance market, and so don't realize that
_virtually any interaction with the health care system beyond a strep throat
test_ would, prior to the ACA, get you declined automatically: you were
uninsurable _at any price_. That's what happened to us; for instance: my
daughter had an unexplained seizure when she was 4 (she's a healthy 15 year
old now), and was thus declined.

------
pavlov
I've always disliked how right-wing parties automatically get to enjoy the
assumption that they are "business-friendly". That's not the case -- their
policies tend to be friendly to existing big businesses, but may be deeply
hostile to new or merely potential businesses.

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.

~~~
phamilton
The ACA increases the opportunities for young people and people with chronic
illnesses. By distributing those costs, healthy individuals pay more in
premiums, which limit their opportunities. If we are optimizating for overall
economic productivity, far more people benefit from not having the ACA.

~~~
bduerst
Not when you factor in _more_ insured people means _less_ expensive medical
costs - i.e. more preventative care and less emergency room visits.

~~~
chimeracoder
> Not when you factor in more insured people means less expensive medical
> costs - i.e. more preventative care and less emergency room visits.

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...](https://prescriptions.blogs.nytimes.com/2009/09/03/when-preventive-
care-costs-more/)

[1] [https://www.nytimes.com/2015/08/06/upshot/no-giving-more-
peo...](https://www.nytimes.com/2015/08/06/upshot/no-giving-more-people-
health-insurance-doesnt-save-money.html)

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

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...](https://www.whitehouse.gov/sites/default/files/page/files/20161213_cea_record_healh_care_reform.pdf)

~~~
chimeracoder
> The ACA report last month shows the opposite of what you're saying, that
> oupatient costs have dropped more than inpatient costs have risen

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."

~~~
bduerst
The majority of outpatient treatments are preventative healthcare, e.g. check-
ups, x-rays, rehab, minor procedures, blood draws, etc.

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._

~~~
chimeracoder
> The majority of outpatient treatments are preventative healthcare, e.g.
> check-ups, x-rays, rehab, minor procedures, blood draws, etc

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

~~~
bduerst
[https://en.wikipedia.org/wiki/Ambulatory_care](https://en.wikipedia.org/wiki/Ambulatory_care)

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

~~~
chimeracoder
I'm well aware of what ambulatory care is. But not all ambulatory care is
preventive care; in fact, the majority is not, which is directly contrary to
your previous claim.

------
grellas
The ACA passed on a purely partisan vote and will be repealed on a purely
partisan vote.

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.

------
mas644
I comment rarely, but had to chime in as the ACA was very important to me in
terms of starting a company.

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.

------
danjoc
Affordable Care Act?

[https://ycharts.com/indicators/us_health_care_inflation_rate](https://ycharts.com/indicators/us_health_care_inflation_rate)

Health care is not becoming more affordable. The rate of inflation in health
care is significantly higher than the US inflation rate.

[https://fred.stlouisfed.org/series/T5YIFR](https://fred.stlouisfed.org/series/T5YIFR)

How is that affordable? How are $600 epi-pens affordable?[1] How is a 4000%
price hike on a 62 year old generic affordable?[2] Google for "snake bite
hospital bill." $153,000. That's not affordable. That sounds downright
fraudulent.

It seems they should have named it something more appropriate, like the
Universal Health Insurance Act. Insurance that is no more affordable than the
overpriced health care available in the country. But point this out, and
everyone starts their partisan bickering and nothing gets done at all.

[1][https://www.bloomberg.com/news/articles/2016-08-29/mylan-
to-...](https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-sell-
generic-epipen-to-quell-outcry-over-600-cost)

[2] [https://www.washingtonpost.com/news/to-your-
health/wp/2015/0...](https://www.washingtonpost.com/news/to-your-
health/wp/2015/09/22/turing-ceo-martin-shkreli-explains-that-4000-percent-
drug-price-hike-is-altruistic-not-greedy/)

~~~
nantes
Wrt to your first link[1], the very first sentence in the overview tab states,
"US Health Care Inflation Rate is at 3.98%, compared to 4.26% last month and
2.95% last year. This is lower than the long term average of 5.40%."

I don't intend any snarkiness, but am I somehow misreading those numbers? I'm
reading that statement as "an inflation rate of 2.95% for the last year
compared to the long term average of 5.40% could be equated with 'more
affordable'".

[1]
[https://ycharts.com/indicators/us_health_care_inflation_rate](https://ycharts.com/indicators/us_health_care_inflation_rate)

~~~
danjoc
The long term inflation rate of the US is much lower than that as a whole.
That's the point. Inflation in health care exceeds inflation in the US as a
whole.

That is the core issue. That was not solved by the ACA. How do we solve it?
Ideas? Oh yeah, you know what? Let's argue about Obama and Trump instead. That
will surely work. Look at the comments in this thread.

If I asked you how to solve a sorting problem, I'd have a dozen good solutions
presented. If I ask how to solve a healthcare cost problem that many other
countries don't seem to have, everyone's brain switches off and they go into
arguing about politics.

~~~
giaour
"Health care inflation" isn't directly comparable to the overall inflation
rate, as the quality and amount of health care has been rising alongside the
increasing percentage of GDP we spend on it. Compared to when the only
available remedies were bloodletting and leeches, I bet we spend a lot more on
the health care sector.

~~~
danjoc
Are you seriously making excuses for the overpriced health care in the US?
Every other country has the same procedures we have in the US at lower prices.

[http://ritholtz.com/2012/03/comparing-medical-procedure-
cost...](http://ritholtz.com/2012/03/comparing-medical-procedure-costs-in-us-
vs-overseas/)

------
marknutter
I recently quit my six figure salary job at a startup here in Minnesota to
start my own startup. Just before I quit I was looking at around $650/month
premiums for my family of four as the absolute cheapest plan with the highest
deductible. Right after I quit, the two largest health insurance providers in
MN pulled out of our MNSure health insurance exchange, causing premiums to
spike up across the board. Now I am faced with a $1200/month premium which is
more than I'd pay for my former employer's health plan through COBRA. Having
to cover such a high premium expense is significantly impacting my ability to
start my company.

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.

~~~
fencepost
Then if you're still on it, pay COBRA for the year. Based on what I can see
without making up fake info to look at the Minnesota exchange[1], a Silver
plan for a family of 4 went from $905 in 2016 to $1405 in 2017, but with
$68k/year in income there'd be a $725 tax credit so the monthly premium would
have gone from $622 to $680. I assume since your numbers were a bit lower that
you were looking at the Bronze plans instead.

Just take hope! If you can just make it through this year you won't have to
worry about the question of purchasing insurance as an individual, because as
a family with several preexisting conditions (fertile female, children/disease
and injury vectors) without the ACA you'll be effectively uninsurable unless
you can grow your startup fast enough to make a group plan feasible.

[1] [https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-
cov...](https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-coverage-
plan-rates.pdf)

~~~
marknutter
I was seeing premiums way lower than $905/mo back when I was first shopping
for plans. With my current income 2015 I do not qualify for any federal
subsidies. I have no idea what my income is going to be for 2016 but I can
keep a majority of my income in my business so that my personal income is well
below the level I need it to be to qualify for medical assistance. It doesn't
feel right to me to be going on medical assistance with my earning power, but
I guess this is the reality we live in.

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.

~~~
fencepost
If this is your first year looking at Exchange plans it's worth doing a
spreadsheet with some auto-calculating fields based on guesstimates of your
number of primary care and specialist visits per year.

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

------
nodamage
A lot of complaints about the ACA seem related to monthly premiums going up
compared to pre-ACA plans. It goes something like this: prior to the ACA I was
paying $X, now I'm paying more, therefore the ACA is bad.

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.

~~~
curun1r
Here's my complaint with the ACA, and it has nothing to do with insurance
premiums.

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.

~~~
nodamage
Interesting, I haven't heard of someone getting denied coverage for applying
to an ACA plan before. What was the reason for the denial?

~~~
curun1r
The denial letter looked like it was making two separate, independent
eligibility determinations. One, for CoveredCA insurance and one for MediCal.
I was denied by CoveredCA because my monthly income was $0, which would
normally push me towards MediCal. But I was denied by MediCal because I made
six figures in both months that I reported taxable income.

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.

------
jchrisa
""my only option was to work for a large employer with an established health
plan that would provide me with the appropriate benefits to support my
situation""

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

~~~
epistasis
I'm not entirely sure that's true. I think a lot of the anti-ACA lobby is
doing it for purely partisan reasons. If the ACA succeeds then its a counted
as a big win for your opponents, so you fight like the dickens to make sure it
doesn't work out.

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.

~~~
jchrisa
Tactically you are right, but the people who fund the think tanks that fuel
the fires you are describing, are playing a longer game. Same people and
motivations behind the de-education of Americans kicked off by Reagan.

------
WhatIsThisIm12
As a young, healthy male in my 20's pursuing entrepreneurship, the best health
insurance for me is the ability to declare bankruptcy. I have chosen to go
uninsured and pay the ACA penalty because it's so much cheaper than paying for
a catastrophic health insurance plan. Why would I pay $4000 per year for a
$6000 deductible? I do not see any benefit from that except in the case of
catastrophe. It's just flushing money (that I don't have) down the toilet.

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.

~~~
wonder_er
This was what I did, until I got married. Now we've got a potential baby in
the next ~ 1 year, so "uninsured" is not an option.

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.

~~~
kevinburke
> I hope more and more people decide they feel no social obligation to things.

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](https://en.wikipedia.org/wiki/Social_contract)

~~~
chatmasta
There is not one single social contract that we all must subscribe to. It's
much more nuanced than that, with lots of little obligations here and there.
Some are more valid than others, and the individual should have a right to
decide which to be a part of. Not paying taxes is a much different violation
of a social contract than not paying for health insurance, especially
considering the very legitimate argument that the ACA penalty is
unconstitutional in itself.

------
jMyles
This post, especially presented as it is through the voices of these founders,
makes an important point.

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.

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

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.

------
nradov
For those with a Wall Street Journal subscription, they had an excellent
unbiased article on the economics of providing healthcare for people with
serious medical conditions. Anyone trying to reform or repeal the ACA will
have to address this issue.

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

[http://www.wsj.com/articles/health-cares-bipartisan-
problem-...](http://www.wsj.com/articles/health-cares-bipartisan-problem-the-
sick-are-expensive-and-someone-has-to-pay-1484234963)

~~~
secabeen
Here's a non-paywalled version: [https://www.msn.com/en-
us/money/healthcare/health-cares-bipa...](https://www.msn.com/en-
us/money/healthcare/health-cares-bipartisan-problem-the-sick-are-expensive-
and-someone-has-to-pay/ar-AAlNV6S)

------
clbrook
Had ACA existed when I graduated from college, I would've been able to remain
on my parent's health insurance plan until 26 (5 extra years). This would have
allowed me to take a job with a startup company that could not offer health
insurance instead of joining a large multi-national corporation that offered
good health coverage. Wow...thinking how different my path could have been
with that opportunity. I heard about YC two years out of college (it started
the year I graduated), all I wanted to do was apply and talked myself out
every time as I am unable to go without health coverage and would not have
qualified for an individual plan due to past health history.

------
alphabettsy
I have no pre-existing conditions, but being able to sign-up using the
exchange was a big reason I was able to go full-time in a small business
rather than continuing to work part-time for a large company to keep health
benefits. The monthly premium is too high in my opinion, but one hospital
visit made it worth it.

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.

~~~
amyjess
The exchanges are terrible. In Texas, the only options available on the
exchanges are HMOs, and in large chunks of the state, only a single provider
is available.

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

~~~
alphabettsy
Texas. Need I say more? The state chose to make ACA as unworkable as possible.

------
lend000
People seem to think that without ACA, the US healthcare market is free, which
is why it has so many problems.

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.

~~~
nodamage
> 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?

~~~
lend000
Unfortunately not, but I'd love for our country to be the first.

~~~
nodamage
Why do you believe such an approach would work? Is there any evidence behind
this position?

~~~
lend000
Is this so radical? There's ample evidence that our healthcare bureaucracies
are NOT working. And there's ample evidence that free markets are more
efficient at providing value, when held to a legal framework that maximizes
freedom (for everyone, consumers and proprietors alike). I'm not even
suggesting a fully 'free' market -- just reducing the size and scope of our
bureaucracies which have gotten out of control, and see how much prices drop/
health-care improves before we commit ourselves to eternal government-quality
care with minimal innovation.

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.

~~~
nodamage
> And there's ample evidence that free markets are more efficient at providing
> value, when held to a legal framework that maximizes freedom (for everyone,
> consumers and proprietors alike).

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))?

~~~
lend000
> 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.

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.

~~~
nodamage
> Yes, that's crony capitalism, not a free market.

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?

~~~
lend000
> You're getting close to "no true scotsman" territory here.

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?

~~~
nodamage
I think we need to accept that much like communism is an ideal that might work
in small groups (literally communes) but quickly falls apart when dealing with
large groups (because people are terrible and will find ways to abuse the
system), pure capitalism is also an ideal that might work in small groups but
also quickly falls apart when dealing with large groups (because again, people
are terrible and will find ways to abuse the system).

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.

~~~
lend000
Communism is flawed in theory because it relies on people not acting in their
own personal interests, which is not a declared assumption (because it would
be so ridiculous). The free market you often hear about is sound in theory
when it makes clear assumptions about the government, but those assumptions
are idealistic because they require government officials to not be persuaded
by rent-seekers.

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.

~~~
nodamage
Yeah I did not mean to go so far off topic, just wanted to point out that I
think a free market approach to health care will lead to an abusive system due
to for-profit entities like insurance companies behaving in ways that are good
for itself, but ultimately bad for patients.

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.

------
DoodleBuggy
Nice post, the stories echo multiple people I know as well. Having health
insurance tied exclusively to a job is anti-entrepreneurial. That should be
fairly obvious.

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.

~~~
amitdeshwar
There is none: [http://krugman.blogs.nytimes.com/2017/01/10/there-will-be-
no...](http://krugman.blogs.nytimes.com/2017/01/10/there-will-be-no-obamacare-
replacement/)

------
patrickg_zill
Sorry, but Sam Altman (and many others) are missing the point.

Without actual PRICE DISCOVERY nothing(in terms of reform) works.

I got a tetanus shot (booster as an adult, Tdap) and called around to
different clinics. Prices ranged from $131 to $39. For what is _required by
law_ to be exactly the same thing.

That "well your insurance might mean you will pay a different amount" is
EXACTLY the problem. No one can easily determine the price of anything.

Is there a base-model Chevy that is sold at one dealership for $35K and at
another dealership in the same city, for $65K?

No, because people would very quickly do price discovery...

------
zmitri
Something of note - not a single woman on here. Pregnancy, birth control... so
many expensive, and common medical procedures that are very relevant to all
female founders have been overlooked or neglected.

------
zaroth
Faced with a similar decision pre-ACA, the fact is that CA already had
guaranteed issue small business health insurance. ACA roughly tripled the cost
of the same plan, but made it more accessible to people by putting a web
front-end on top of what was otherwise a fairly opaque process.

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.

------
ThomPete
I am unconvinced that healthcare affects the number of startups as this have
been going down also after Obama got on board and is going down also in Europe
(ex Denmark where healthcare is completely free)

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...](https://www.washingtonpost.com/opinions/why-is-the-number-of-us-start-
ups-
falling/2016/05/19/53fe8e04-1ded-11e6-9c81-4be1c14fb8c8_story.html?utm_term=.3786a4f853de)

------
gorbachev
If only Mr. Altman had a pre-existing relationship with someone very close to
Mr. Trump. He could then perhaps raise these arguments with that person.

------
losteverything
ACA works. But it seems to me that young people just starting out have it so
much worse when it comes to healthcare.

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.

------
hamilyon2
That's a pity american people have to think about healthcare that much and as
far as i can see not long time ago didn't even have a backup plan in case
their employment goes wrong. Post soviet countries all enjoy pretty affordable
health care, free in most cases. Govermment pays all the salaries so it is
pretty simple. Of course it is overused, as every public good is, but maybe
that is not actually the problem. Sick people with huge debts because ot their
sickness looks far worse in comparison.

------
spoiledtechie
I am a Republican. More in fact, Fiscal Constitutional conservative.

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.

~~~
stinkytaco
Your solutions rely on something that does not exist in health care:
information parity. A true free market requires information parity. Health
care is complicated, thus information parity does not exist. Regulation is the
answer to dealing with that lack of information parity.

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?

~~~
bzbarsky
> A hospital cannot "publish prices" because prices vary wildly based on many
> factors.

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](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.

~~~
fattire
So should they explain the pricing schedule while you're still unconcious from
the accident at the crash site or when your eyes are fluttering in the
ambulance? Then at the E.R., they can talk you through your various choices in
surgery, a menu of blood products, and let you peruse through a catalog of
doctor histories. If you decide this isn't the place you'd like to have the
steering wheel removed from your rectum, you can always go online and browse a
few local options from the dozens of hospitals in your area until you find a
price point and payment plan that's right for you and your intestinal needs.

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.

~~~
bzbarsky
> So should they explain the pricing schedule while you're still unconcious

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...](http://www.privatehealth.co.uk/conditions-and-
treatments/hip-replacement-total/costs/) 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.

------
waivej
As someone that has worked for myself for 16 years, I will sorely miss the the
ACA. Let me know if you have any recommendations because surely I'm missing
something.

\- Before the ACA we had Blue Cross and I inquired about maternity coverage.
My wife was looking at a shoulder surgery so we were locked in. Blue Cross
offered us a $1000/month rider that had to be in place for 21 months before
birth and then they would cover anything over our high deductible. It worked
out to about $25,000 on top of our regular premiums before they would pick up
the bill. We jokingly priced getting an apartment in another city instead.

\- Then the ACA came out. Maternity was included free and the premiums are
about the same. We had a baby and had to cover twice the deductible. The
marketplace gave us some trouble due to stupid bureaucracy so we priced out
getting a plan directly (non-ACA) but the price was so much higher and it
covered less. So, even with the marketplace, the coverage and affordability
made it an easy decision.

Anyway, I could live without the subsidies (we haven't qualified for them
every year) and I wish the marketplace was a little easier to work with.
Though I feel like our coverage is so much better now. Why take it all away?

------
justicezyx
Isn't the biggest part of health cost is from drug company and insurance
company?

If that's the case, addressing the cost is the foremost issue, instead of
forcing everyone to join a universal plan. That does not help addressing the
root problem above.

~~~
misnome
So basically, your argument is to do nothing to help anybody unless you have a
magical fix-everything-in-one-go plan?

Good luck trying to get political support for anything that hurts the
insurance companies.

~~~
justicezyx
Isn't there plenty of fixes demonstrated many places already?

------
petegrif
The health system in the US is a total mess. Single payer is the only sane way
to go. That too will be imperfect and ragged but it is provenly absurdly
cheaper - practically all advanced industrial countries are single payer and
all spend far less as a percentage of their GNP - as in half to a third -
whilst covering everybody. The admin savings are staggering, the drug costs
are lower etc etc.

~~~
saosebastiao
We've eliminated the possibility of Single Payer in the US, and the reason for
this is stupid: Nobody on the left can criticize the ACA anymore. Due to our
ridiculously partisan shitshow that we've got going on, any criticism by
Democratic Party politicians of the ACA will bring a shunning from the party
leaders. The only thing they are allowed to do anymore is gloss over the ACA's
failings with flowery language, and say they want to "improve" it.

But you can't "improve" the ACA into single payer. You can only get single
payer by starting over from scratch.

The pathetic thing is that a public option, the original plan, could quite
easily be improved into single payer. And despite the largest Democratic
majorities in both the house and senate for several decades, with a sparkly
new progressive Democratic president that campaigned primarly on health care
reform, they couldn't pass it. It seems the Democratic party has something to
learn from the Republican party on how to get shit done.

~~~
woofyman
Single payer is considered socialism by half the population due to decades of
Republican rhetoric.

~~~
GFischer
That's because single payer IS socialism. The problem is that not all
socialism is bad :) .

We have single-payer here in my country, and anecdotal evidence is that it
works incredibly better than healthcare in the U.S. for 99% of cases (the U.S.
is far better at treating complicated health problems, but at staggering
costs).

------
tmaly
I would like to see prices published and anti-trust exemptions for the
industry scrapped. There is absolutely no transparency in the pricing.

------
c-slice
Having health insurance be offered by employers/ tied to employment is one of
the biggest mistakes in American healthcare policy. It encourages a "consume
as much as possible" mindset for employees and disguises the true cost of
care. Creating clarity of price and cost in healthcare would be one of the
most beneficial shifts.

------
noobermin
Of course, it's better to have a nationwide health service, now that ACA is
toast, may be it is time for states to start considering health care systems
within their borders. Many states have populations multiple the size of many
countries which have universal health care. It could be very possible.

------
drawkbox
I went full-time in my business in 2010-2011. I got denied for months for
health insurance. I was in my early 30s, wife, and one child with no major
health issues and barely ever used insurance. I got denied from the same
companies I previously had insurance working full-time non-stop for years and
years from. Finally I did get some by putting me and my family on differing
plans across companies. It was insane, I was actually taken back at how messed
up that seemed. It caused more panic than it needed to.

The ACA (or similar basic rules: no pre-existing, must cover, supports small
business and self proprietors as the market goes more that way) is needed for
entrepreneurship and in cases where you can't get it through a job, it is a
must for starting business today. Other places have a competitive advantage to
starting a company in a country that has healthcare figured out and away from
the job.

We should be able to get insurance as a pool of individuals. The current
insurance companies are not setup for non employer based healthcare and need
to either change or go. They group based on company or individual not pools of
people across companies and individuals, which is a broken legacy system. We
need consumer facing companies to be in healthcare if private healthcare is
the main thing, companies in auto insurance and other insurance are more
consumer focused (Geico, Progressive, Nationwide etc). I wish for more
competition in this area that is consumer focused not employer focused.

Insurance needs to be remove from employment (probably through legislation or
market benefits) to ultimately solve this consumer facing insurance problem
for healthcare. We also probably need a separate health insurance plan for
catastrophic events and a healthcare plan that handles day to day healthcare
needs, bundling them is a bit wrong when compared with other insurance i.e.
car maintenance is not covered under auto insurance, home maintenance is not
covered under home insurance.

Ultimately, fixing healthcare is needed for business and quality of life
reasons. Our system is becoming a competitive disadvantage to businesses in
the US.

~~~
intellegacy
>Insurance needs to be remove from employment

ding ding we have a winner. This is a no brainer that anyone, Republican or
Democrat, should agree on.

------
em3rgent0rdr
Regarding the concern about health insurance being tied to an employer, it is
important to consider why employers have historically been the source of
health insurance in US. A primary reason is the higher marginal income tax
rates, which makes it hard for companies to effectively reward valuable
employees with heavily-taxed salaries. So the companies instead resort to
providing non-salary benefits such as health insurance. If mid-to-high
marginal tax rates weren't so high, then employees would be paid more in
salary and could purchase insurance themselves so they aren't "locked-in" to
their company for providing essential needs.

~~~
pcvarmint
Health insurance became tied to employment in WWII, when the government
imposed wage controls. To attract employees while getting around wage
controls, fringe benefits were added instead of increased pay. [1]

[1]
[http://www.nber.org/papers/w14839.pdf](http://www.nber.org/papers/w14839.pdf)

~~~
em3rgent0rdr
Sure that was one of many contributing factors. A couple sentences later that
study affirms the point I was making:

"Finally, in a landmark 1954 ruling, the Internal Revenue Service clarified an
earlier administrative court ruling regarding the income tax status of ESI by
exempting such benefits from income taxation and adding this provision to the
tax code."

------
tomohawk
There were many issues with health insurance prior to Obamacare. Obamacare did
not fix very many of these things, and broke a great deal of other things.

Sure, it's nice that pre-existing conditions are covered better and 26 and
under people can get insurance with their parents, but those kinds of benefits
could have been covered by a one or two page bill. What's in the rest of it?
Special deals for corporations such as AARP.

The law does nothing about making malpractice insurance more affordable, or
making the malpractice lawsuit environment more rational. Why is that?

Why is my employer still involved in my health insurance? Why not move the tax
benefits from my employer (it's a company, and cannot get sick) to me? My
employer doesn't need the insurance. I do.

Why can't I buy insurance across state lines like other insurances?

Why are there separate 'risk pools'? The US is a single market - there should
only be one risk pool. This would put maximal pressure on the insurance
companies in terms of cost as they would have to compete for my business
instead of negotiating cozy deals with companies (and companies don't get
sick).

Why does the gov't get to tell me what's in my plan? If I'm a single male, why
do I need to buy a plan that covers ObGyn? Why can't I buy a high deductable
plan anymore?

Why does Obamacare think its wrong for doctors to own medical facilities?

If controlling cost is so important, why is it practically impossible to find
out the cost of anything ahead of time? This makes making decisions based on
cost impossible. Why is the price one person pays radically different than
what another person pays? Why does cost have no relationship to quality? I can
get an MRI with a brand new machine or with a 15 year old machine that
produces crap images, and the crap will cost more. Why not require publication
of prices?

Why is it that my dad, a wounded combat veteran, cannot get decent health care
at the VA in a major metropolitan area? The VA is completely controlled by the
gov't. It is the gov't. And yet, if he goes to a private hospital to get
decent care, he gets penalized.

~~~
fattire
Let me just answer this one: Why can't I buy insurance across state lines like
other insurances?

Because then pretty much EVERY insurance company will pick up and move to the
one most desperate state that writes laws in their favor, doesn't tax them,
allows them to sell substandard insurance, gives them liability protection and
forced arbitration and in every way abuse the customer.

And the industry will become abusive, fraudulant, manipulative, and
untouchable. Every state will lower its standards and revenue streams to keep
insurers from leaving and taking jobs with them. And the customer will have
very few if any good choices and no recourse when screwed over. Over time, the
industry's power over the state will become even more entrenched. Exhibit one:
The credit card industry, and south dakota. Go watch the Frontline episode I
refer to in another thread.

I'd like to answer some of your other questions like "why do I have to buy a
plan that covers obgyn" but I'm too pissed over having to pay for rear
seatbelts I'll never wear, a space program I'll never use, fire hydrants I'll
probably never need, and taxes for schools I'll never attend. Living in a
society sucks. I mean, I have to pay for roads I'll never drive on. It's
bullshit. I mean even my freaking insurance-- I have to pay for all these
diseases that it'll cover! I'm NEVER gonna get ALL of them at once. And only
one of them can even possibly kill me, maybe two max. Why should I pay for
protection from a heart attack AND cancer treatment?!!! Bullshit, man. That's
how they get you. I mean, I saw tonsilectimy on the list and I don't even have
tonsils any more. Tyranny. I want an a la cart health insurance plan where I
can figure out what I'm likely to get and only get insurance against that
specific disease!!!

~~~
em3rgent0rdr
> "Because then pretty much EVERY insurance company will pick up and move to
> the one most desperate state that writes laws in their favor, doesn't tax
> them, allows them to sell substandard insurance, gives them liability
> protection and forced arbitration and in every way abuse the customer."

By that same logic, people would also move to the state most beneficial to
them or would vote for laws in their state that they think is best for the
people.

Competition benefits everyone.

------
ccrush
GWB upped the age of coverage to 25 and the ACA only moved it a bit but gets
all the credit. DJT wants to keep the preexisting conditions part and do away
with the fines for not having insurance and increased costs of forcing
insurers into the ACA by repealing it and replacing it with interstate
insurance competition without the bureaucracy of a government managed program.
Too bad everyone thinks Obama was a holy man for putting together the garbage
that is the ACA, and thinks of any improved solution as an assault on his
legacy.

~~~
mikeyouse
GWB most certainly did not up the age of coverage to 25.

Prior to the ACA, nearly every employer-based coverage plan stopped dependent
coverage at 19-years old or upon college graduation. Those that allowed older
children would refuse dependent coverage if the children's employer offered
health care, which meant that if you got a entry-level job out of high school
at a company that offered insurance _at any price_ , you couldn't use your
parents' insurance.

After the ACA, every plan, employer-sponsored or exchange-based, must offer
dependent care up until 26-years of age.

2.5 million <25-year olds gained health insurance in the first year after the
expansion, which was _before the mandate was in place_.

The ACA gets credit for the expansion since it caused the expansion.

------
phamilton
Many of these stories suggest that you'll have less overhead (and more runway)
as a 25 year old found than as a 27 year old founder.

I'm not convinced that's providing productive selection criteria.

~~~
mjolk
The anecdotes illustrate that there were two main benefactors: young people
without formal full-time employment and those with pre-existing conditions
that had allowed insurance coverage to lapse.

From someone too old to be on their parent's insurance, while I'm 100% behind
the reform that disallows previous conditions from affecting ability to get
coverage, the ACA was effectively a shake-down that made me delay taking the
risk to go full time on my startup -- the options for coverage in my state
were expensive and very low-quality, and the penalty for opting-out would have
been $4000 for my domestic partner and I (on top of the additional taxes we
paid to support ACA).

~~~
phamilton
Thanks for sharing. I alluded to this in another thread but got downvoted and
stirred controversy.

My claim is this: For the median entrepreneur, there is more financial drag
due to insurance now than there was before the ACA. For those who are sick or
young, there is less financial drag. Your story anecdotally supports that
claim.

~~~
mjolk
Yeah, I think that there's a political type that is just a zealot scared of
anything that will challenge his/her worldview and feels a need to
flag/downvote/hide.

The reform surrounding pre-existing conditions for people that let their
health coverage lapse is the only good thing that came out of the ACA, and it
was _very_ expensive for the taxpayers and continues to be. This should have
just been a piece of legislature and not a terrible government shakedown of
the American public; a simple reform was needed, not another way to subsidize
the non-working while compelling the public to give money to private
corporations.

------
elihu
A few years back, I quit my job and founded an (ultimately unsuccessful)
startup. A big factor in deciding to do it was that the ACA would go into
effect before my Cobra coverage expired.

------
baccredited
Damn. I saw the title and thought YC was starting a healthcare company. That
would have been awesome.

------
rdtsc
> One thing the ACA definitely did was help a lot of founders start their
> companies--without it, being a founder would make sense for less people

Hmm. I've heard many small companies could not afford to provide health
insurance for their employees after ACA passed ( I don't know the details of
exactly the causal chain there ). So they stop providing it and pushed people
to use ACA which had ridiculous price hikes and also in some states companies
withdrawing from the exchanges.

In other cases I've heard companies have pushed people part time status in
order to avoid having to provide health insurance and other benefits. I think
that is mostly lower wage employment.

My own rates working for a small company a few years before the ACA and after
went up much high even before ACA was about to pass in anticipation. There the
insurance representative who we talk to every year stated clearly why there is
an increase -- because of the volatility and unknown effects of ACA they
decided to increase prices. After it passed and was being phased in our rates
were going up much high.

Some things were nicer, like no pre-existing conditions, no lifetime maximum,
some free preventative checks overall it has been worse.

Now, no doubt it has helped many people, but I am not sure if small businesses
and their employees (especially in the tech sector) saw a benefit.

~~~
BryantD
> I don't know the details of exactly the causal chain there...

This is a really sincere recommendation: if I were you, I would research that
and figure out if it's true or not. There is plenty of propaganda going around
on this subject from all sides; it's dangerous to rely on things you've heard.

~~~
rdtsc
Have you? What do you think is the reason?

~~~
BryantD
The reason for what? I can't even seem to validate the original claims, so...

~~~
rdtsc
>>> . I've heard many small companies could not afford to provide health
insurance for their employees after ACA passed ( I don't know the details of
exactly the causal chain there )

>> if I were you, I would research that and figure out if it's true or not.

> I can't even seem to validate the original claims, so...

I was just asking if you knew the reason already or have looked into it.

~~~
BryantD
Right. I'm saying I don't know if "many small companies could not afford to
provide health insurance..." is accurate. I don't know how we're defining
small companies (if they're under 25 full time employees, the mandates don't
apply). I don't know how we're defining "couldn't afford to." What effects
count? Are we saying that the rate of businesses going out of business has
increased? Etc., etc.

Once there's some data, we can have the perhaps more interesting question of
whether or not it's worth it. No question but that increasing the number of
people with health insurance costs money and that has to have some effect.

~~~
rdtsc
Makes sense. Sorry, I think my question sounded snippy. I didn't mean it that
way. I ask for opinion here often because I trust users here more than any
other online forum.

------
thembones
One of the best experiences I had was actually going through a different site
which seemed to have even more options than Healthcare.gov,
[https://www.policygenius.com/health-
insurance](https://www.policygenius.com/health-insurance)

I'm sure there's more as well, but this definitely helped several friends of
mine. Seems like these kind of things would have been impossible without large
swaths of the ACA.

------
dmode
Perhaps I am being overly simplistic, and I do support ACA reform, but I don't
believe there is a silver bullet to reforming ACA. If there was Republicans
would already have come up with it and would have been publicizing it for the
last 8 years.

The fact remains - covering pre-existing conditions, kids till 26, and low
income households is expensive. You can pay it by increasing the insured pool
- which is what ACA tries to do via the individual mandate, or by introducing
a single payer system whose buying power would be so big that they will
substantial leverage over healthcare provider. As a society we have decided
that a single payer system is socialist, so it cannot be adopted here (and it
has its own problems - wait times, lack of R&D incentive etc.). So now we have
to choose between not providing healthcare to 40-50 million people or pay
increased premiums to cover for those.

Some reforms that may somewhat bring down the premiums: \- Offer subsidies to
even middle income people, not just poor. May be set the income limit by
geography \- Make the individual mandate more expensive to incentivize
healthier people join the pool \- Offer a public option

------
SmellTheGlove
We need something like the ACA. Shit, we need more than that, but the very
imperfect ACA is a good start.

I look at it this way: Right now, I'm with a large company - I have a wife who
left corporate life to raise our daughter. It's all riding on me. And on that,
I have some ideas, one has become a small side gig, but if they grow enough to
become my focus, that essentially opens the basic question of how I'd provide
health insurance to my family.

Thankfully, I have a backup plan to some degree, as I happen to be a citizen
of a European country as well as the US, but it's an imperfect backup plan as
my "other" nationality is a place with notoriously difficult small business
bureaucracy, and while I could live in another EU country, I'd need to
establish the ability to support myself before anyone's going to let me stay.

Ideally, we'd stay in the US, because let's face it, this is a pretty great
country to found a company, warts and all. But we have to not be having to
worry about something as basic as healthcare if we're to take the kinds of
risks that lead to innovation.

------
temp-dude-87844
Healthcare is a touchy subject because people's quality-of-life and their
actual lives (vs. death) are on the line. But food and shelter are similarly
crucial to existence, yet they aren't provided at no cost, but must be
acquired through their own labor, or reliance on family, charity, etc.

It's interesting to me that we as a society have long accepted that people
have to work for food and shelter, leaving a permanent underclass in the dust,
while we're uncomfortable to say the same about healthcare.

But of course, it doesn't matter. Those who oppose the ACA or the individual
mandate or employer requirements or the notion of healthcare subsidies are
dancing around their justifications and are reluctant to come out and say that
people with health complications should just be out of luck. Instead, they'll
dismantle, maybe introduce an alibi entitlement scheme to save some political
face, and leave a status quo with the exact same result.

~~~
brixon
There are a lot of social programs for food and shelter in the US. The food
one works fine, the shelter one is more hit or miss.

~~~
dragonwriter
The shelter one may be hit and miss, but it's a lot better than healthcare
support (even under, but much moreso prior to, the ACA.)

------
rdl
ACA doubled or quadrupled my monthly insurance costs, which actually put a
strain on my budget when doing a startup at the time.

------
pkulak
I love this idea that we can "save the best parts". What part would that be,
exactly? The part where insurance companies can't deny you coverage? And the
part to get rid of would be the part where you are required to carry
insurance? Are people really so dense that they can't see how one absolutely
requires the other?

------
gm-conspiracy
I disagree this is a "party" doing.

Mitt Romney had similarly reformed Massachusetts law in 2006 as Governor.

[https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...](https://en.wikipedia.org/wiki/Massachusetts_health_care_reform)

I see the article briefly touched upon the American notion of health insurance
being tied to employment.

Nobody seems to want to really solve this problem, just band-aids and lip-
service. Neither mainstream party would consider a single-payer system, nor
direct government negotiation with drug companies.

It's as though the drug and insurance companies are better represented (and
have more rights) than its citizens.

Heck, even Medicare is divided into at least four regions to "negotaiate"
regional prices.

How do other countries perceive this?

The US falls further and further behind in healthcare and affordable and
available high-speed internet. Let's see some real progress.

~~~
neonnoodle
> just band-aids

INSURANCE EXPLANATION OF BENEFIT

Adhesive bandage. . . . . . $300 | Covered: $.02 | You Owe: $299.98

------
drc37
I think the point most of the people that Sam referred to where basically
saying that they would like others to subsidize their health insurance. That's
what insurance is. We all put money into a bucket and some people will use it
and some not so much and others a lot. The people who use it a lot want to pay
the same amount as those who are healthy and have the healthy subsidize their
health issues. That is what is currently going on and why prices have gone
through the roof. All those "unisurables" are on the same insurances as
healthy but now the bucket of money needs to be much larger to cover the cost
of the "unisurables".

If this is how the government wants to do it, don't call it insurance. Just
call it socialized medicine, because I am definitely not getting what I paid
for.

------
jeffdavis
I am optimistic that we have a chance for real solutions here:

* Pricing: How about transparent pricing up front for all non-emergency services? That means the price you pay, and that your insurance pays. Not some mystery of "you are responsible for some unknowable amount if the insurance company doesn't pay" or "we might make you pay your entire deductible".

* More effective implementation of high deductible health plans that's simpler for people.

* Medical expenses and insurance tax-deductible, full stop. No messing with HSA, FSA.

* When you are diagnosed with a condition, your current insurance is responsible for the rest of your life for related expenses. No new insurance company would deny you because it wouldn't cost them anything for your preexisting condition.

* Subsidize normal health insurance for poor people.

------
codemusings
As a European watching from afar I feel like the US government should rather
come after the insane pricing schemes of hospitals and pharma companies that
make insurance so expensive in the first place.

Need your appendix removed? Better get a loan from the bank. Just because they
can.

------
ftrflyr
"I had heart surgery when I was 18. I was virtually uninsurable. I now have
health insurance. Why we need the ACA is no more complicated than that."

I am a bit confused by this story. Was Zach not covered under his families'
health coverage? He also went to: Westminster School - one of the most
expensive private high schools in the US.

Now, one could argue he had a pre-existing condition and thus, was not covered
under any health care providers plan, but he states: "I was virtually
uninsurable." This tells me there were options, but none that covered the
entire cost of the surgery. Honestly, this story alone makes me seriously
question the purpose of this post.

~~~
ashark
A serious heart condition in one's youth (infancy, even), regardless of
insurance coverage at the time, could exclude one from all future private
insurance (as in: there are zero options, they will not do business with you)
leaving only incredibly-expensive state-provided (but privately administered ,
of course—profit over all) insurance as an "option", _i.e._ leaving the only
actual options as being employed with a large company, going without insurance
at all, or being poor enough to qualify for medicaid (so, avoiding
employment).

Source: I know someone for whom this was the case pre-ACA.

------
MicroBerto
Altman acts like buying insurance was impossible when self employed pre-ACA.
Give me a break.

I shopped online and bought a sensible plan just like anything else. There
were tons of choices and plenty of competition.

This whole notion that we'll all be doomed without it is utter rubbish. The
entire Healthcare system is broken, starting from our agricultural subsidies
to our ridiculous prescription drug prices (which many pharma-lobbied
Democrats just voted to keep high) to the artificially low supply of doctors
(you don't need 12 years of school to prescribe penicillin).

ACA is just 2000 pages of nonsense on top of all of that. We can do better at
all facets.

~~~
nodamage
> Altman acts like buying insurance was impossible when self employed pre-ACA.
> Give me a break.

It was impossible if you had any pre-existing conditions, no matter how
trivial.

~~~
MicroBerto
So, is the argument here that more expensive healthcare shouldn't make for
more expensive insurance?

~~~
nodamage
I'm not making any argument except pointing out that for many people with pre-
existing conditions, buying health insurance pre-ACA was indeed actually
impossible.

------
gwbas1c
I tried running a startup in 2010 before the ACA took effect. What ultimately
made me give up? My only health care option was Cobra, and I ran out of time.

At the time, I had sleep apnea and had to pay almost $500 a month for health
insurance. That was more then I spent on food, almost as much as I paid for
rent. (It was more than my car payment, which I paid off two years prior.)

18 months is a very short time period when you're trying different things to
see what sticks.

If the ACA was an option, I'd probably had another 4-6 months to go. Would I
have found something that "stuck?" I'll never know.

------
amyjess
The flip side is that the ACA has enabled small businesses to screw over and
exploit their employees by exempting businesses under a certain size from
having to provide health insurance to their employees.

------
sergiotapia
It's a balancing act though, no? Health Insurance is stupid expensive in the
US. In Bolivia I used to pay $300/month for my entire family full coverage, no
copay. But they did screen for preexisting conditions when I signed up.

So what's the answer? How can health insurance providers help people with pre-
existing conditions, and also not gouge young healthy customers?

Is the healthcare industry just charging too much money?

~~~
nradov
Asking everyone to pay into a shared risk pool is not gouging. That's simply
the nature of insurance. We're going to have to pay for people with pre-
existing conditions one way or another, whether it's structured as a tax,
penalty, or insurance premium.

Certainly there is _some_ waste, fraud, and abuse in the healthcare system
which could be cut. But ultimately the only way to significantly cut costs
would be to ration care. It's a hard issue and no one likes to talk about it.

~~~
sampo
> _But ultimately the only way to significantly cut costs would be to ration
> care._

As far as I know, Western European countries spend about half (per capita) on
health care as what USA spends. I don't know if US health care is that much
better. And if it's not, then in theory there is a way to get the same results
cheaper.

~~~
jquery
My experience with the USA healthcare system has been utterly phenomenal.
Almost no waits for procedures of any kind, top-tier care. My last hospital
stay was 5 days with many lab tests and two ER visits and an ambulance ride
preceding it. Out of pocket I paid $100, $50 of which was later refunded to
me.

Parts of the ACA are necessary but I can't help but feeling, based on the
price increases, the Act itself is horribly inefficient. We didn't increase
the supply, we just increased the demand for a product which is very
inelastic, resulting in skyrocketing premiums. A reform must involve
increasing the supply of care.

------
notalaser
I twitch a little every time I read something like this:

> Precision CNC milled from aircraft grade aluminum to 1/1000ths of an inch
> tolerance

What you need aicraft-grade aluminum for? And a 1-mil tolerance? Are you
building a really tiny aircraft?

"Premium design" stops when the design choices are the best you could ever
need. Beyond that, it's no longer a matter of engineering, it's about far less
respectable traits.

------
k__
Why can't the national health be handled as infrastructure?

I mean, we pay taxes for streets, so people can get everywhere. We pay taxes
for schools, so people learn everything. Why not pay taxes, so people are kept
healthy?

The whole public healthcare stuff doesn't even work like a real insurance, so
why not throw this stuff away, make a health tax everyone pays, call it
exactly that, and be done with it?

------
noobermin
I posted a comment already, but I have another thing to say, or rather ask:
honest question to sama and the rest of the YC people, why don't you lobby
congress to keep parts of the ACA? Money in politics is the reason we are
here, and until we fix that, the only way it seems you can play is to pay. I'm
curious is people from SV have considered lobbying congress.

------
bruceb
If you have to read this thread then call your rep. It litterly is about a 30
second call.
[http://www.house.gov/representatives/find/](http://www.house.gov/representatives/find/)

Even if you have a rep that favors the ACA it gives them an idea how much
effort in to saving it.

------
trvlngsalesmn
Simple question:

Why is there little or no start up innovation in the insurance space? Why
aren't YC17 companies able to attack this?

------
altoz
the seen: people it helps the (mostly) unseen: the higher burden on everybody
else

Is the tradeoff worth it? That's the question.

------
dkresge
Trump aims to be a job creator. As a member of the uncountable funemployed,
and while I may be working on the Next Big Thing(tm), it doesn't count. But
take away my affordable, subsidized, health insurance policy and force me to
seek shelter under the corporate umbrella? Then I'm +1 job.

------
daodedickinson
My last four insurance companies have gone under since the ACA. I get fewer
worse choice every year. My plan is now 5 times the cost as it was before the
ACA. Entrepreneurs are clearly hurt worse than the largest companies who werr
hit by ACA later. The subsidies are unsustainable and will end soon.

------
sjg007
Easy fix is to require all insurers to provide ACA plans. Also cross state
plans sound nice in theory but then you need cross state normalization of
insurance regulators. That may only happen at a Fdderal level and will be an
interesting constitutional issue. Same with Medicare and Medicaid.

------
Joof
I'm still left wondering how our government manages to spend more money on
healthcare than the vast majority of countries, but we have the highest out of
pocket expenses of any country and our life expectancy and infant mortality
still look a bit worse than other developed countries.

------
thomasthomas
sam, i'd like the choice to buy or not buy health insurance. thats a little
thing called freedom

------
chatmasta
The healthcare and health insurance system in the United States is a complete
mess. There are multiple distinct problems, but politicians like to group them
all together into one single problem. The way I see it, all the problems fall
into one of two major categories: (1) Healthcare costs are out of control, and
(2) Health insurance costs are out of control.

1) Healthcare costs are out of control.

In the US, healthcare spending is 17% of GDP, the highest of any country in
the world; the next highest is France, at 11% GDP. [0] The reasons for this
are very complex and intertwined, but there are a few major issues:

(1a) Intellectual Property protections: When only one company can sell a drug
for the first 10 years of its existence, they effectively have a monopoly and
can set the price to whatever they want.

(1b) R&D costs: If it costs $10mm to develop a new drug to treat a deadly
disease that affects less than 1% of the population, then naturally the
company must set a high price for the drug to cover costs of R&D; this is
related to (1a).

(1c) Primary care providers and pharmaceutical companies are accountable to
nobody when setting their prices. Because the majority of people pay for
healthcare via insurance, they are price insensitive. After all, if insurance
is paying for your healthcare, what do you care if the cost is $100k or $1k?
(As an example: A family friend of mine ran a "compounding pharmacy," where he
compounded multiple drugs into a single pill, so people who are prescribed 15+
pills to only need to take one. The insurance companies considered the
resulting compound to be a "new drug" and therefore he was able to set its
price to literally _whatever he wanted._ )

2) Health insurance costs are out of control.

This is a complex issue but it comes down to a few major factors:

(2a) Risk pools cannot cross state lines. As far as I can see there is
literally no reason for this.

(2b) The requirement to cover pre-existing conditions increases insurance
costs for everyone. As many have mentioned in this thread, it makes no sense
to call coverage for pre-existing conditions "insurance." If you already have
a disease, you aren't insuring against it; you're just paying for it. I do
think that people have a right to healthcare, and even as a republican I think
that taxpayers have a duty to subsidize those with pre-existing conditions.
But I don't think we should be including this obligation in the cost of
insurance from private companies. It should be a separate budget item, like
social security or medicare or medicaid (or better yet, take it out of the
defense budget...). If private companies need to insure (read: pay for) pre-
existing conditions, then they effectively become the gatekeepers for this
tax, and they have every incentive to make it as high as possible.

[0] [http://www.commonwealthfund.org/publications/issue-
briefs/20...](http://www.commonwealthfund.org/publications/issue-
briefs/2015/oct/us-health-care-from-a-global-perspective)

------
dnautics
isn't there a bit of a broken-windows fallacy here? How many founders can't
afford to leave their normal 9-5 / and do a startup because their premiums
have gotten more expensive and they can't build up a runway?

------
senthilnayagam
Sam Altman should get a list of all YC startup employees insurance data made
public, maybe with a a small questionnaire form with objective questions.

That way analysis becomes easier and all perceived sample biases can be
alieviated.

------
swalsh
It seemed weird to me that ycombinator wasn't at Trump's Tech meeting
(considering they're at the center of silicon valley in a sense). This post
makes me wonder if that was not an accident...

------
feistypharit
Thanks for writing this. Whatever your view on the ACA, you can probably agree
that health is important. It's a tough problem, how we handle it will define
the US more than anything else in the future.

------
samfisher83
I don't understand why we don't have Universal Healthcare? Every other first
world country has it. They also spend a lot less money than us. We should
borrow what works best from around the world.

------
yarper
Can someone explain the benefits of a US-style healthcare system vs
nationalised tax funded healthcare?

All I see from threads like this is a lot of Americans bickering over their
own healthcare, and as an outsider I don't really know how how it works, and
why everyone is so invested in how it works now.

What happens if you don't have insurance? To me any system where you make sick
people pay more than rich people seems bonkers no? If most people's employers
already pay it on their behalf, isn't it a business tax already?

~~~
kmicklas
> Can someone explain the benefits of a US-style healthcare system vs
> nationalised tax funded healthcare?

None.

> I see from threads like this is a lot of Americans bickering over their own
> healthcare, and as an outsider I don't really know how how it works, and why
> everyone is so invested in how it works now.

Because actual change is near impossible these days. (Ultimately this is
largely a result of flaws in our electoral system. Most notably,
gerrymandering gives Republicans a near permanent lock on the House.)

> What happens if you don't have insurance?

You die.

> To me any system where you make sick people pay more than rich people seems
> bonkers no?

Republican congressmen are bonkers and/or evil.

> If most people's employers already pay it on their behalf, isn't it a
> business tax already?

That's a large part of the problem. It got tied to employment in during WWII
when the government mandated salary caps for some industries so firms competed
on benefits. I think almost everyone agrees this is bad but it's impossible to
change because of gridlock.

------
discodave
Id only people cared about the Affordable Care Act this much, before! The
election...

------
frandroid
These individual stories are nice. But when are you Americans going to fight
to save your healthcare?

~~~
kevinburke
Many, many people have been calling their elected representatives every day
and otherwise lobbying behind the scenes

------
kevinburke
I'm currently working as a consultant and I'd not be able to do it without the
ACA.

------
Jemaclus
Arguments against ACA:

\- It cost me money

\- It's not perfect

Arguments in favor of ACA:

\- It literally saved my life

Regarding increasing premiums, the complaints tend to be anecdotal. According
to the National Conference of State Legislatures, in 2016, the average monthly
net premium increased just $4 -- or 4% -- from 2015 to 2016 among the insured
that take advantage of subsidies.[1]

Furthermore, premiums have gone up year-over-year every year almost every year
since I've been paying for my own insurance -- and that's well before ACA.

There's an interesting chart on the Kaiser Foundation website, where it shows
the average plan prices and percent increase year-over-year broken down by
state. It also shows that, after tax credits and with very few exceptions,
plan prices have remained stable (0% change) between 2015 and 2016.

I understand and sympathize with the high premium prices, but I have serious
reservations about the assertion that the high premiums are due to the ACA and
not external factors.

[1] [http://www.ncsl.org/research/health/health-insurance-
premium...](http://www.ncsl.org/research/health/health-insurance-
premiums.aspx)

[2] [http://kff.org/health-reform/issue-brief/2017-premium-
change...](http://kff.org/health-reform/issue-brief/2017-premium-changes-and-
insurer-participation-in-the-affordable-care-acts-health-insurance-
marketplaces/)

~~~
vmarsy
As a non US Citizen, I have a question:

If Obamacare is repelled at the Federal level, could a state just implement
its local ACA? what prevents California for instance of giving health coverage
for its residents? California is a good example since it "the world's sixth-
largest economy" (If California was a country) I'm sure healthcare companies
wouldn't want to cut themselves out of this market?

This would give California and SV an even bigger advantage regarding what is
described in Sam's post.

~~~
dragonwriter
> If Obamacare is repelled at the Federal level, could a state just implement
> its local ACA?

Some parts of the ACA could be implemented in state law, some would be either
illegal or impractical at the state level. It's also likely that a repeal
would be accompanied or followed by federal policies which would make state-
specified versions of the ACA less practical than they are now.

> what prevents California for instance of giving health coverage for its
> residents?

California already provides state-run send healthcare beyond the requirements
of the federal programs it participates in.

~~~
vmarsy
> Some parts of the ACA could be implemented in state law, some would be
> either illegal or impractical at the state level.

That's my poor understanding of U.S. Federal vs State government that fails me
here: what exactly would be illegal, what would be impractical? If a state ACA
is challenged in court, couldn't they use the supreme courts rulings of
Obamacare as a strong defense?

Other comments here mentions that Massachusetts already had it (and I assume
would likely keep it even after Obamacare is repealed), Couldn't California
copy the Massachusetts implementation?

> California already provides state-run send healthcare beyond the
> requirements of the federal programs it participates in.

But I assume those state-run programs aren't providing as strong of a coverage
as Obamacare was? Now would seem a good time to update it to match Obamacare?

~~~
toomuchtodo
> That's my poor understanding of U.S. Federal vs State government that fails
> me here: what exactly would be illegal,

Mandating coverage, which is basically a requirement of affordable universal
healthcare.

"What happens if I don't pay the fee?

The IRS will hold back the amount of the fee from any future tax refunds.
There are no liens, levies, or criminal penalties for failing to pay the fee."

[https://www.healthcare.gov/fees/fee-for-not-being-
covered/](https://www.healthcare.gov/fees/fee-for-not-being-covered/)

~~~
amalcon
Massachusetts did this in the program that Obamacare was modeled after, so
clearly that's not (currently) illegal at the state level.

The fee structure is different (just a missed deduction on the state taxes,
not a separate monthly charge), but it still works.

~~~
toomuchtodo
I'm not saying it _can 't_ be done; I'm saying its a pain in the ass due to
the political climate in the US. Apologies that wasn't clear.

------
general_ai
A fine example of confirmation bias: ACA aligns with Sam's ideological
position, so he hand picks some examples to support it. Don't get me wrong, I
think it's great that people with preexisting conditions can't be denied
coverage. But is it OK that plans are three times more expensive now, with
three times the deductible? I don't think so. Seems like a trillion dollar
money trough for Big Pharma and Big Insurance to me.

~~~
lsiebert
Well strictly speaking, if Obama could have passed single payer, he would
have. He went with a compromise based on a republican idea and negotiated with
the insurers to get their support. The thing is, expensive as it is, you have
the ability to get health coverage. The ACA made health care affordable to
people who previously couldn't afford it at all, particularly the working poor
through medicaid expansions.

~~~
TillE
He had two years of full Democratic control of Congress. He didn't even _try_
to get single payer, didn't even try to get the "public option".

Obama's disastrous politics are a result of going into every debate _starting_
at the "compromise" position, and then getting dragged further right. Just go
back to his 2004 DNC speech, it lays out exactly how he's going to fail.

~~~
mikeash
He had just a couple of months of full Democratic control. Due to Al Franken
not being seated right away, Robert Byrd being ill, and Ted Kennedy dying, the
Democrats didn't have a supermajority until September of 2009. They then lost
that supermajority in February 2010 when Scott Brown was sworn in.

I do agree that Obama tended to negotiate badly by compromising before it was
even needed, but that "two years of full Democratic control" thing gets
repeated so often, and it's annoyingly wrong.

~~~
DrScump
As they proved later, they didn't _need_ a Supermajority in the Senate -- they
just changed Senate rules. It was passed with a simple majority.

~~~
mikeash
Are you talking about the use of reconciliation to get the final version
through?

------
davidf18
Countries that offer universal care such as Canada, The UK, France (also also
NY State/NY City where I live) have a tobacco tax in the $5 to $7 range or
more that helps to pay for the higher health care costs of smokers. NYC tax is
$6.85 for city+state+fed. The US Federal tax is about $1. If the tax were
increased by $5 for the 13 billion packed smoked each year it would yield
approx $30 to $35 billion which could be used to mitigate the high cost of
insurance for others.

Also, the medical ratio of youth to elderly is 1:6 and before the ACA, youth
would pay about 1/6 of elderly costs. Congress unfairly mandated that ratio to
be 1:3 meaning youth pay 75% more than they should. They already have to pay
for student loans, save for a house, and now they have additional burdens
paying for smokers and those who drink daily sugar Cokes and thus obese.

Tax tobacco like other countries and NYC/NYS and use that money to make
premiums for youth and middle class more fair.

~~~
chimeracoder
> Tax tobacco like other countries and NYC/NYS and use that money to make
> premiums for youth and middle class more fair.

Tobacco taxes are incredibly regressive (they very disproportionately tax the
poor). So you're essentially proposing taxing the poor in order to pay for the
middle class.

~~~
davidf18
> "Tobacco taxes are incredibly regressive (they very disproportionately tax
> the poor)."

They disproportionately tax smokers making smokers at least pay a portion of
the additional health care costs they incur by smoking.

Taxing tobacco contributes over half the effect of ensuring teens never start
and smokers quit smoking.

------
FrancoDiaz
The fact that Obamacare was mandatory meant it had to go. Obamacare was really
a fascist's wet dream and why the insurance companies ended up being pretty
giddy about it.

Good riddance!

------
edblarney
I have nothing to say for or against Republicans, Dems, Trump or any other
political entity.

BUT

If they start pulling away Healthcare for millions of Americans ... and
Americans start dying because of this - well, there will be a revolution of
sorts.

It's inhumane for the wealthiest country in the world to take away basic
healthcare for it's most vulnerable citizens.

If you are so 'smart' and so 'great' \- then figure out a way to introduce
efficiencies, pricing intelligence etc. to get people more and better coverage
- instead of just smashing some law because it's not perfect and it was
written by 'Obama'.

~~~
Gargoyle
>If they start pulling away Healthcare for millions of Americans ... and
Americans start dying because of this - well, there will be a revolution of
sorts.

Which should be a very strong indication that's not going to happen.

Despite the endless propaganda, Republican lawmakers are neither stupid nor
evil.

People are not going to be left uncared for, that's just political
fearmongering, and we don't have to fall for it.

~~~
edblarney
They can definitely be stupid, and they can sometimes be borderline evil -
making jail time for crack 80x greater than for cocaine because of the
offender demographics, that's pretty evil (and stupid).

1) They are voting to repeal ACA in real time.

2) They have not offered even a hint of an alternative.

This is not only going to be potentially damaging those who will lose their
coverage - but it's also incredibly difficult for business: there is no
roadmap. Insurers, and all other businesses small and large now are left in
the dark with respect to their future. Introducing such ambiguity is
definitely stupid, and it's 'anti businesses'.

They have at least two years of unlimited power, they should debate solutions,
narrow it down to an actionable plan, and then modify ACA in a well thought
out process.

As it stands, they're just rolling back laws and haven't discussed anything
else, which I think is irresponsible. They don't need to be in such a panic.

~~~
Gargoyle
Neither of your points 1 or 2 are accurate, instead they reflect the political
fearmongering I mentioned.

People lament that our politics are so divided. Mis-stating the situations
we're in and exaggerating for political gain are a root cause of that. Do not
be part of the problem. Stop spreading the fear.

~~~
edblarney
This is false.

1) They are repealing ACA as we speak - the legislative process has been
introduced. They are voting today. This is fact.

2) _There is no alternative_. Neither Republicans nor Trump have offered any
plan. There are no white papers, working groups, coordinated policy plans, and
certainly no legislation. This is also a fact.

So what you're dismissing as 'fear mongering' is reality.

I don't have a problem with a total re-factor of ACA - but it needs to be done
responsibly, thoughtfully, with diligence and transparency.

They're screwing it up on a day one: rolling back legislation that affects
100% of Americans and 100% of business - without a plan. It's totally
irresponsible. They are doing it quickly (and recklessly) for political
reasons, instead of an underlying impetus of 'good governance'.

Which is too bad, because it's a complex issue and there's work to be done.

~~~
Gargoyle
You can keep restating the same things, but they still aren't accurate.

The ACA is not being repealed today. This simply is not true. It's not what is
happening. Saying that it is is in fact fearmongering.

The ACA will still be in place tomorrow. It will be in place next week. It is
not being repealed as we speak.

~~~
edblarney
"The ACA is not being repealed today"

Yes, it is. The Congressional process was started today:

[http://www.businessinsider.com/obamacare-repeal-process-
sena...](http://www.businessinsider.com/obamacare-repeal-process-senate-
vote-2017-1)

This is a fact.

And it is also a fact that the GOP has no plans whatsoever in terms of what it
will be replaced with.

If you have access to any working groups, white-papers, or legislation
otherwise - provide a link.

You can't - because there is nothing.

Obviously it will take some time to clawback all of the legislation, but it is
being repealed as we speak.

"The ACA will still be in place tomorrow. It will be in place next week."

Obviously - but what are businesses around American doing now? They have no
way to make plans, they have no idea what the future holds.

This is 'anti business' and 'anti responsibility'.

The responsible thing to do would be to craft a _plan_ \- and then put the
gears in motion so that people know what is going to happen, and individuals
and businesses have insight as to what will invariably affect everyone in
America.

The Republicans have full control of Congress and they can expedite the repeal
at least parts of ACA fairly quickly - once that is done - there is no ACA.
Boom, it's gone. Insurers will have to make fluctuating, ambiguous ongoing
changes to their polices. With no alternative.

It's laughably irresponsible.

There should be a plan, not a scramble into the void.

~~~
Gargoyle
From your linked article- "...what is expected to be a long, winding process
of repealing the Affordable Care Act"

So, not being repealed in real time, as you claimed. Not being repealed today,
as you claimed. Instead, "the long, winding process" has begun.

From your linked article- "Though the repeal is on the top of the legislative
agenda, Trump is unlikely to put his pen into action on it anytime soon."

It will be quite some time before the actual repeal happens. Not anytime soon.
No need for panic. No need to sow fear.

From your linked article- GOP leaders' comments that they want to replace the
bill at the same time they repeal it suggest that a seamless transition may
take time. House Speaker Paul Ryan said replacement and repeal would happen
"concurrently," and Trump has pledged it will be "simultaneously."

So by the Republicans own words, there will not be a time when there is no
plan in place.

In fact, Republicans are going to vote to continue funding for the present
plan. [http://www.politico.com/story/2017/01/republicans-
obamacare-...](http://www.politico.com/story/2017/01/republicans-obamacare-
subsidies-233618)

Again, no need to spread fear.

------
dforrestwilson1
I don't like subsidizing poor lifestyle choices to _any_ degree. I hope
whatever comes next takes things like choosing to drink, smoke, and eat too
much into account.

