
I don’t understand American healthcare – doesn’t mean I shouldn’t provide it - pavel_lishin
http://pandodaily.com/2013/05/04/screw-you-papa-john-i-dont-understand-american-healthcare-but-thats-no-excuse/
======
mgkimsal
Employer-provided health insurance is one of the worst things to emerge from
the US in the past... what? 70 years? It gives far too much power in the
marketplace to employers and very little to the actual users of the insurance
- the insured.

Why don't employers provide auto insurance too? They'd get a much better deal
via group rates, and we'd be 'better off' because we'd all 'pay less' for auto
insurance, right?

The idea of 'benefits' in general being 'expected' from employers is, in
itself, a bit crazy - just pay people well, and let them make their own
decisions. I'd have thought 'free market' supporters would be all over that
concept. Company 401K plans? Generally limit you to high-fee and substandard
mutual fund options. Company health insurance plans? One or two options, not
something which always fit people very well.

Employer funds in to an employee-controlled HSA was/is a decent middle ground,
but HSAs in general seem like they're going to be going away or more limited
in availability in the next few years under the Affordable Care Act, which is
a real shame.

~~~
kenjackson
_Why don't employers provide auto insurance too? They'd get a much better deal
via group rates, and we'd be 'better off' because we'd all 'pay less' for auto
insurance, right?_

Would we pay lower rates? Auto insurance is mandatory if you want to drive.
Everyone has it (well a very high percentage of drivers). There's a relatively
competitive market for auto insurance. I'm not sure moving it to employers
would change things all that much.

I do think that employer provided health insurance is odd, but I don't think
the alternative is "free market". We have to incentivize healthy people to get
insurance too, just as we have good drivers that get auto insurance. It seems
like we need to make health insurance mandatory or move to universal health
care. Neither are very likely in my lifetime.

Also most employers give employees the option to opt out of health insurance,
and you get some amount of the money back as additional pay. Virtually no one
takes this option.

~~~
TruthElixirX
>Auto insurance is mandatory if you want to drive.

No, it isn't. Unlike almost every other state, New Hampshire does not
automatically require motorists to carry an auto liability insurance policy or
provide some of financial backing in order to drive a vehicle within its
boundaries.

<http://www.dmv.org/nh-new-hampshire/car-insurance.php>

Further more, you can avoid auto insurance by not driving in most places. You
cannot leave your body at home.

~~~
nijk
So it is mandatory for residents of 49 states.

------
jgrahamc
_Maybe it’s because I’m a Brit, and we have the national health service. Every
man, woman and child in the UK is entitled to free healthcare from cradle to
grave. [...] America is a bigger country so free healthcare is off the table.
I get that._

I don't understand this argument at all. The NHS in the UK doesn't appear
magically free from the sky because we've only got 60 million people. We pay
for it through general taxation. This year it will cost about £110B.

Is it really the case that there's an argument that this can't work in the US
because there are more people?

~~~
Vivtek
No. Of course not. We have one person here per capita, just like the UK. If
anything we'd get more economies of scale. But it would be socialism, and
therefore inherently antithetical to the desires of every right-thinking
American.

~~~
laumars
I really don't get this attitude some Americans have that any kind of public
service designed to make the lives of your less fortunate peers just that
little bit easier is some how a bad thing. It's as if 70 years of brainwashing
that all "commies" are evil has irreparably warped their brains and now any
piece of legislation that doesn't propose proverbially kicking struggling
families in the "nuts" is seen as socialism and, by extension, wrong.

Capitalism is all well and good so long as peoples lives are not put in
danger; and I'm not talking about luxuries here, I'm talking about whether
people live or die. But what we have happening instead is a closed market
dominated by a small number of monopolistic drug companies who abuse patent
systems and extort their customers just because they can. Surely at some
point, even the right-wings have to appreciate that neither closed markets nor
putting peoples lives put in danger because of the greed of the few is neither
in the spirit of capitalism nor the Christian thing to do (and I only
reference the last part because of the emphasis that many right-wings place on
religion).

~~~
sageikosa
> I really don't get this attitude some Americans have that any kind of public
> service designed to make the lives of your less fortunate peers just that
> little bit easier is some how a bad thing.

I think the problem is we like to have the freedom to select our charities
(and charitable giving amount) rather than have them forced upon us by
statute.

~~~
laumars
It's not a charity though. It's about providing a minimum service for people.
Even with "free" health care in the UK, it's not free (it's paid for via
National Insurance taxes and many facets still have additional costs
(prescriptions, regular dressings, dentistry, etc) albeit often highly
subsidised.

Surely it's better to have a subsidised minimum service than to rely on
charities?

And more over, if your objection is purely because you don't want to be told
that you should look after your fellow Americans, then that's either a really
sad representation of how little respect Americans have for their kin, or the
facet of a childish mentality where kids deliberately disobey their parents
because they like to test their boundaries. Either way, it's just a terrible
attitude to have.

~~~
cookiecaper
Government-sponsored monopolies produce economy-wrecking effects. National
health systems are that.

How to fix the American health system in several easy steps, from a
governmental perspective:

* Stop all current governmental subsidies

* Outlaw medical insurance

* Purchase expensive medical equipment, and most importantly the means of production of such equipment, and resell to new medical enterprises at a reasonable price (most likely resulting in a severe loss)

* Provide a matching program on qualifying doctors' medical school debt

* Radically reform and/or remove medical licensing programs to focus on apprenticeship more than academics

* Reform pharmaceutical patent protections to allow drugs to proliferate freely

This will get us to a ground-up, self-sustainable medical system that is based
on ordinary rules of supply and demand, without giving a blank check to the
administrators of the current system, which is already irrevocably corrupted
by paper-pushers. The whole thing just has to be torn down and started over.

~~~
laumars
In an ideal world I'd probably agree with you. But what you're proposing is
even less likely to happen (particularly the pharmaceutical patent reform)
that a national health system.

------
bmelton
Color me critical, but it seems like, basically, the point of this article was
to show off exactly how informed in her 'hard-nosed' critiques, and how that
is proffered as justification for the obvious bias present in the article.

I also find it interesting that despite the apparent mountains of reading, the
author cannot determine _any_ good reason why one might oppose the Affordable
Care Act, which tells me that either her bias refused to allow her to accept
posed oppositions as valid, or that she simply doesn't care that other people
do object.

I think there are plenty of valid reasons for opposing it, just as there are
plenty of reasons to support it, and frankly, I think all of major
justifications on either side of the argument fall into the category of fairly
obvious.

That said, kudos on choosing to provide health care immediately. It _is_ a
tough decision, and it _will_ affect the company's bottom line, but despite
that, if you're an employer who believes that everybody should have affordable
health care, it _is_ the obviously correct choice.

~~~
onli
That was one of his points: There are no good reasons to be against the Act. I
can't really judge if that is true, but basically, the idea that it is
absolutely right to try to get as many people as possible insured is pretty
powerful. And most of the opposition one noted was on the level of "that is
socialism!" (which it isnt, and socialism isn't bad).

~~~
dantheman
There are lot's of good reasons to be against the Act. How about it forcing
the young and relatively poor to subsidize the old and relatively rich -- it's
a giant intergenerational wealth transfer mechanism.

Young adults will pay higher premiums under Obamacare because of its age
rating system. The law stipulates that the maximum variation allowed in adult
premiums is a cost ratio of 3 to 1. But as Heritage research shows, “The
natural variation by age in medical costs is about 5 to 1—meaning that the
oldest group of (non-Medicare) adults normally consumes about five times as
much medical care as the youngest group.” Obamacare’s “rate compression”
causes insurers to charge artificially low premiums for older adults and
higher premiums for younger adults. Moreover, “Actuaries estimate that the
effect will be to increase premiums for those ages 18–24 by 45 percent and
those ages 25–29 by 35 percent while decreasing premiums for those ages 55–59
by 12 percent and those ages 60–64 by 13 percent.”

[http://blog.heritage.org/2012/03/21/obamacares-2nd-
anniversa...](http://blog.heritage.org/2012/03/21/obamacares-2nd-anniversary-
no-gift-for-young-americans/)

~~~
cecilpl
Remember the perfect is the enemy of the good.

Don't oppose the Act because it doesn't bring about the best possible world.
Oppose it only if it's worse than the currently existing situation.

~~~
dantheman
I oppose it because I think it will make the situation much worse. I prefer
working in the direction of freeing healthcare not regulating it further.

------
oellegaard
In Denmark we have completely free medical treatment - I used to live in
Switzerland where they have a system where you have to get a health insurance.
I had to visit the doctor once to remove some stitches I got from an accident
while travelling. The first thing they asked for when I arrived at my doctor
was for me to fill out an insurance form - before that they didn't even ask
what kind of medical treatment I would need.

I have never felt more offended. I consider it a human right to have access to
health care. Why would the state not provide this? Everyone needs it, you
can't live without it.

~~~
johnnyb9
If you are really interested in learning why some people think universal
health care is not a "right" I encourage you to read this article:

<http://www.aynrand.org/site/News2?id=13873>

~~~
summerdown2
Clearly this is nonsense:

> Your right to anything at others' expense means that they become rightless.

So let me understand this argument ... my right to anything at all removes all
other rights from others? Because the UK has universal healthcare, its people
have no rights?

I suggest that the truth is not that exercise of one right diminishes all
others 100%, but by some fractional percent. And that life, liberty and
happiness are best served by a mixture of rights and liberty, not an extreme
in one direction.

~~~
johnnyb9
In the context of the entire paragraph, the author is stating that your right
to something _at another's expense_ is to the detriment of the other person's
right to liberty. You may disagree but I believe there is certainly a
tradeoff.

~~~
summerdown2
I don't think so.

To be more exact, you seem to have restated my own position, which is that
your right to something at another's expense is to the detriment of the other
person's right to liberty, and that there's a tradeoff. I.e. that your right
to something reduces someone else's liberty, but by some fractional amount,
not 100%. Hence, the trade off is a calculation you can make: how much right
is worth exercising, given it costs a little liberty. Clearly here there is a
sweet spot you wouldn't want to go beyond.

Where I disagree with your reply is that this is what the article says. Let's
take a look at the paragraph in question:

> To take one more example: the right to the pursuit of happiness is precisely
> that: the right to the pursuit—to a certain type of action on your part and
> its result—not to any guarantee that other people will make you happy or
> even try to do so. Otherwise, there would be no liberty in the country: if
> your mere desire for something, anything, imposes a duty on other people to
> satisfy you, then they have no choice in their lives, no say in what they
> do, they have no liberty, they cannot pursue their happiness. Your "right"
> to happiness at their expense means that they become rightless serfs, i.e.,
> your slaves. Your right to anything at others' expense means that they
> become rightless.

My problem with this paragraph is the absolutist nature of it. There's no
tradeoff here. In this paragraph, my right to anything at all means the other
becomes rightless. It's all 100%, and in my opinion nonsense.

If you want to argue for a sliding scale of rights taken vs liberty given up,
then I'd agree with you, but would also suggest that the article says the
opposite.

------
jaibot
One important takeaway from this piece is that putting employers in charge of
providing health insurance is a terrible idea. Paul Carr shouldn't need to
_make an effort_ to make sure his employees have basic health protections -
that should be a solved problem.

~~~
walshemj
yes unfortunately back in the 50's the big auto companies did a deal to
include healthcare as part of wage negotiations. Which derailed the USA's
progression to a German style model of healthcare.

If you talk to Alan Mulally and any on the AFL-CIO off the record they would
agree - that in hind sight it was a bad deal both for the workers and the
employers.

~~~
claudius
> German style model of healthcare.

Which has the curious drawback that those most able to contribute to it (i.e.
those earning more than X €/month) are allowed to opt-out of it. I never quite
understood why this would have to be the case, and the various attempts to
introduce an actual public health insurance system failed so far.

------
guylhem
_"This level of diligence is why when I state something on the record, I’m
always — always — right."_

Warning sign #1

 _"If there’s anything I can do to protect the health of my employees and
their families, shouldn’t I just close the fucking spreadsheet and do it?"_

Asking to use emotion instead of reason - check

 _"And — fuck you, Papa John"_

Insult or ad-hominem - check

 _"I’m going to have to work even harder to raise more money"_

Call for self sacrifice. We're done there.

This is at best a populist opinion, and _NOT_ a reasonable analysis, as per
the author own suggestion to use emotions instead of reason.

Also, when someone tells you about 100% accuracy, think about Dunning–Kruger
cognitive biais.

 _"If I made the wrong business decision, I’m an idiot but fewer people will
get sick. If I made the right decision, I’m a genius and fewer people will get
sick"_

Hey genius - that's assuming the medical care paid for will have a significant
effect. Modern medicine treat all kind of things, but for some we've just not
found the right answer yet. And I sleep quite well.

~~~
hype7
Thank god someone else pointed that out. I stopped reading at your first
warning sign — any doubt I had about Nicholas Carr being a complete dick just
went up in a puff of smoke

------
jusben1369
Running a startup I've gone through this exact same thought process. My high
level bullet points are: 1) It's insane that any business should spend so many
cycles on managing this. I would have thought Republicans (pro business) might
be more open to a state role in healthcare precisely so business's don't have
to manage this burden. 2) Somebody who is 35 or 40 with children fully
burdened is around $1200 a month or $14,000 per year. Someone who is 25 and
single is $200. You think that differential never goes through our minds when
assessing candidate and how much we'll pay them? That totally sucks but is a
reality. 3) The wealthiest and most likely to vote Americans get their health
insurance via their company. So they're entirely immune to the dysfunctional
system. If ALL Americans were procuring health insurance in the private
marketplace there'd be a much better system. Much less abuse. If the
government (like EU/AUS) was the sole customer there would be a much better
system. It's this mixture of employers, too small in aggregate to manage the
demand side, + smaller individuals buying it on their own, that drives the
spiraling costs here. 4) Having a startup provide your health insurance is
really dumb. Startups have a much higher % chance of closing their doors. So
one day you get laid off because your startup doesn't make it. Guess what, now
you have to go and find a new job AND work out what you're COBRA options are.
In the broader context, most people who get laid off in the US lose their job
AND now have a $1000 or more (if they're family provider) costs layered on as
they now have to start paying for healthcare. Like losing a war you didn't
start then being forced to pay repatriation costs when your economy is at its
weakest.

Politically, I think we're more likely to get universal healthcare via the
state through than to ever get all employers to stop offering it and put
everyone into the marketplace. So I support these efforts because the current
blend is the worst.

(PS right now we're paying full costs because we lean toward hiring more
mature people (read families) who understand what it would cost them in the
marketplace to get it so they can balance it against their overall lowered
financial compensation.)

~~~
justin66
> It's insane that any business should spend so many cycles on managing this.
> I would have thought Republicans (pro business) might be more open to a
> state role in healthcare precisely so business's don't have to manage this
> burden.

Two things to keep in mind, with this and a lot of other issues: \- The cycles
spent handling it aren't a big deal to large corporations. \- The idea that
small-business interests and large corporate business interests are one and
the same is one of the Big Lies of the Republican party.

~~~
jusben1369
Hey Justin66. Not true at all! Large corporations have to grapple with this
and spend a fortune managing health care for employees. The interesting
question is what % more might they pay in payroll type tax to move this onto
the state.

~~~
justin66
Consider the comparative overhead of dealing with this as a percentage of
income (or percentage of attention demanded of management, or any number of
things) and you'll see what I mean.

The issue isn't whether large businesses spend a "fortune" on health care, the
point is that their political incentives are entirely different than those of
small businesses because the effect providing health care to employees has on
their business is so entirely different.

~~~
jusben1369
Hey Justin. All you're doing is pointing out that it scales better as they get
larger. Imagine how much time and effort a company with 100,000 employees
spends on optimizing and managing health care. Now compare that against their
non American competitor who doesn't have any of this
time/cost/concern/overhead. That's why I think irrespective of size businesses
would want this off their plate.

------
wsc981
I think an important consideration could be freedom of the employee to spend
the money he thinks is best. I think that point of view is part of US culture,
but not very much of culture in Western Europe. I understand the writer of the
article is from the UK and as such might not understand this point of view.

The so-called social healthcare as pushed by the government will inherently
waste a lot of money because government is always wasteful with it's
resources. Governments are wasteful because whenever they run out of money
they have the option to tax people more. On the other hand companies that
waste a lot of money will eventually be removed from the marketplace, as they
are unhealthy. This is one reason why healthcare as a government
responsibility might be a bad idea, because whenever money is badly used in
healthcare, instead of fixing the actual issue the government is more likely
to just tax people more.

I think many opponents of social healthcare feel it should be an employees
responsibility to spend the money as they think is best. If they want to spend
a bigger part of their earnings on healthcare, they should be able to and if
they want to spend nothing at all they should be able to as well.

Proponents of social healthcare will argue that some people don't know how to
spend their money wisely and as such they will find it's a task of the
government to make sure a part of the earnings will be forcibly spend on
healthcare. It should be understood that this will inherently remove some
(financial) freedom of the employees and perhaps from the employers as well.

Here in the Netherlands social healthcare is financially becoming more and
more expensive. One big issue is that people who are forced to spend part of
the earnings right now won't be sure they will actually see any of it back in
30+ years when they grow old enough to need healthcare themselves due to our
society having more and more ageing population and less young people to
support the healthcare for this ageing population. We've pretty much got the
same issue with our socialised pension plans.

If young people would be able to save some earnings for their own healthcare,
they could have a better guarantee being actually able to use it when they
grow older.

The book "The Road to Serfdom" by F.A. Hayek explains why many socialist
measures (even with the best of intentions) often risk pushing government into
the same dangerous direction that Russia and Germany went in the past:
<http://www.tiptopwebsite.com/custommusic2/mrsilber2.pdf>

~~~
rbehrends
> The so-called social healthcare as pushed by the government will inherently
> waste a lot of money because government is always wasteful with it's
> resources.

This just isn't the case. Healthcare/health insurance, for a number of
reasons, is one place where government-provided solutions have traditionally
been less wasteful than private market solutions.

One reason is that single-payer systems are monopsonies: The single payer
(which need not be the government, and in some countries actually isn't the
government) has much greater bargaining power than any individual or company
and can negotiate better prices.

Second, the big cost drivers for health insurances are things that happen
either way; the 80/20 rule applies, and most actual costs are caused by
chronic illnesses, surgery, etc. These costs will occur either way and will
have to be paid for. They will eventually come out of your paycheck (or
somebody's paycheck), no matter who's being charged and how. There's no taxing
people more or less, because most of the costs are fixed. Single-payer systems
allow us to structure payment for these costs to minimize inefficiencies,
medical debts, etc.; universal healthcare furthermore reduces the risk of
treatment for acute conditions being delayed, which drives costs up further.

Third, healthcare/health insurance markets are less efficient than other
markets. One reason is that people do not have a desire to shop around when
getting sick; evaluating healthcare options takes time, and that's the last
thing you have when you need treatment. Another reason is that healthcare and
health insurance is simply too complex and time-consuming for patients to
fully understand and to appreciate, especially with the arcane complexity of
health plans as they tend to develop in a free market. Finally, insurers in a
free market will do their darnedest to insure healthy people and avoid
insuring sick people. All of this breaks the normal demand and supply
constraints in a fairly fundamental fashion.

Health insurance in the Netherlands may be becoming more expensive, but that's
because health insurance is becoming more expensive _everywhere_ as a
consequence of population aging and advanced treatment options. In the end,
your per capita health care expenditures are still 2/3 of that of the United
States. Under the US system, you could expect to pay a couple thousand Euro
more annually.

~~~
mgkimsal
"Another reason is that healthcare and health insurance is simply too complex
and time-consuming for patients to fully understand and to appreciate,
especially with the arcane complexity of health plans as they tend to develop
in a free market. "

Yet another reason: it's not like most simple commerce transactions with
'satisfaction guaranteed or your money back". If I choose option A over option
B when looking at medical procedures, I may live or die. No going back for a
refund. Or I may be permanently scarred, brain-damaged, or otherwise harmed
for the rest of my life. Or... I might be cured. There's very little ability
to 'shop around' and 'compare' options when talking about life-critical
situations.

It's somewhat similar to housing, in that most people only buy a few houses
(at most) over several decades - trying to shop around and compare options
only goes so far - once you've made a decision, there's rarely ever a quick
'undo and start over' option.

------
michaelpinto
I think I've lost count of the number of time on Hacker News (and else where)
that I read about a founder that got sick and didn't have health insurance. So
on top of a life threatening illness one has to worry about paying for it all.
And as one who does pay for health insurance it now costs me the sum of a very
good used used car every year.

Given this situation I'm frankly amazed that every business leader in this
country isn't calling for socialized medicine at this point in time. At this
point I see the insurance companies and the surrounding ecosystem as something
that hurts us in a global economy.

------
mcculley
It's only a debate for organizations that are trying to minimize costs where
quality does not matter. See the concurrent discussions about full-time
employment becoming rarer for service industry jobs.

If your organization is trying to get and keep the best people and keep them
productive, there is no debate. Provide health care and health insurance. I
don't understand how a venture capital backed organization could be confused
about this, as they should be going after huge value adds with fewer employees
instead of grinding out low margin labor.

------
m0th87
I don't understand why he's playing himself up so much for providing
healthcare to employees. Of the 3 startups I've worked at, 2 provided
healthcare and 1 provided a healthy allowance toward private coverage. All of
them I suspect were smaller than NSFWCORP.

I thought this was the default, even for startups. If it's not, it should be.

~~~
kenjackson
I don't think he's playing himself up so much as he is presenting a struggle
of whether or not to provide it and the realization that he must (not from a
legal, but from a moral perspective).

And while it may be common in the tech industry (where VC money can make it
easier -- and frankly its hard to recruit w/o it), it's less common outside of
the tech industry.

I still think it is odd to tie health insurance to employment, but given that
this is the case today, I do think that I'd do the same as a small business
owner. If I couldn't afford it (at least by the medium-term), I think I'd have
to question the feasibility of my business.

------
mgkimsal
Given the US Constitution's "general welfare" clause, I'm not sure why nation
health care options are such a hard thing to get passed and put in to place.

[http://en.wikipedia.org/wiki/General_Welfare_clause#United_S...](http://en.wikipedia.org/wiki/General_Welfare_clause#United_States)

------
antidaily
Ive done a bit of research on the subject, and it seems like if you do want to
offer your employees insurance and you're a biz or startup of less than 25
people, it's going to be cheaper and better incentivized than it used to be.

------
cpdean
[http://www.reasonwell.com/:06d4d5/The_Patient_Protection_and...](http://www.reasonwell.com/:06d4d5/The_Patient_Protection_and_Affordable_Care_Act_is_good_for_the_people_of_the_USA)

I have no idea.

------
yoster
The problem with the states on health insurance is that unless you are part of
the 1%, you need it. Healthcare industries are huge corporations that are in
it for the almighty dollar. If you go to the emergency room and do not have
health insurance, you can bet you will have a bill that will run a couple
grand minimum. I wish we were like other countries where we can have a
national healthcare system. This is one of the most basic human needs that
should be available to everyone. I am very thankful that my company offers an
excellent healthcare plan, and I think everyone should have access to a
healthcare plan.

------
sultezdukes
_What I don’t get is why anyone would oppose a bill that makes affordable
healthcare accessible to more people._

Ignoring the philosophical debate for the time being (something as a non-
American, he at least tries to understand), his premise seems to be that
Obamacare makes affordable healthcare accessible to more people. That (along
with the philosophical debate) is the argument.

