
Barack Obama Publishes Defense of the ACA in the New England Journal of Medicine - cagrimmett
http://www.nejm.org/doi/full/10.1056/NEJMp1616577
======
thomasthomas
_Thanks to the ACA, a larger share of Americans have health insurance than
ever before_

because its compulsory. this shouldn't an argument for the ACAs effectiveness.
I have to buy car insurance if i choose to drive a car on public roads. i have
to pay income tax if i have income. now, by birth, i automatically owe the
state. i'd like my freedom and right to choose back please.

the fact this isn't the main argument from GOP shows their incompetence.

~~~
dlp211
You pay for private insurance or you pay for public insurance via taxes. Any
other solution is unworkable and you are a free rider.

~~~
thomasthomas
i'd like the choice to not have any insurance

~~~
nyxtom
That's not a sustainable choice for our economy, it leads to too many people
living like nothing could possibly go wrong until they need a doctor. The
point of insurance is to distribute risk, not participating in that
effectively negates the effectiveness of the industry.

~~~
lend000
The whole idea of health insurance is backwards and inconsistent with a free
market in my opinion (fraudulent). The problem is that the government has
enshrined it as the gateway to healthcare.

Insurance is a useful product for mitigating risk, so accident insurance could
be a very constructive concept (protecting against accidental injuries, broken
arms, falls, car crashes, etc.). However, health problems are not a risk; they
are a guarantee with probability approaching one as you age. The whole point
of insurance is that you mitigate risk by paying more than you take out on
average, but that doesn't make sense for healthcare, where almost everyone
ends up going over their limit near the end of their lives.

If we didn't have all of these subsidies everywhere and inflated demand from
Medicare/Medicaid/restrictive occupational licensing/FDA-granted
monopolies/ACA, then perhaps we could pay everything out of pocket, which
would make a lot more sense.

~~~
mikeash
The basic concept of health insurance works fine. Yes, your probability of
dying approaches 1 as you age, but the costs you incur along the way can vary
enormously. Somebody who's wonderfully healthy until they instantly die in bed
of a heart attack will cost the insurer basically nothing, while somebody with
a chronic condition can easily cost millions of dollars over decades. Costs
can vary enormously depending on your luck, which is just the sort of thing
insurance is good for.

There are big problems with running the whole system using insurance, of
course. It's fairly easy to predict future costs for a lot of people. Given
free reign, insurers will charge completely unaffordable premiums to those
people, effectively excluding them from the system. You see the same thing
with other types of insurance: if you have a horrible driving record, or if
your house is in an area that gets a devastating hurricane every ten years,
your premiums will be huge. The difference is that those are optional
activities, and if you can't afford the premiums then you can walk, bike,
hitch a ride, buy a different house, etc. A sick person can't switch to a
healthy body.

That's why the ACA has the mandate. If you require everyone to pay in, then
you can also require insurers to ignore certain predictors of future risk when
determining premiums.

Fundamentally, there are only two choices. One choice is to have lots of
people dying of easily treated conditions because they can't afford the
treatment, and the other choice is to have government step in and socialize
the system to some extent. The system was already socialized before the ACA
with the Emergency Medical Treatment and Labor Act, which requires hospital
emergency rooms to treat all patients regardless of ability to pay. This was
horribly inefficient, of course, but that's how it was.

So: choose your poison. If you think the advantages of going full free market
in health care outweigh having poor people die of easily treatable diseases,
then that's a valid opinion, but you should acknowledge the negative
consequences. If you want poor people to be able to obtain treatment, then
you'll need to accept some interference, the only question is how you'd like
to have it be structured.

Edit: rather than "poor people," I really should say "people whom the hospital
thinks are poor." If you get beaten up and mugged and left for dead, the ER
won't know if you have money, and might decide not to take the risk. There are
good reasons for even a selfish wealthy person to want some form of universal
treatment.

~~~
lend000
> If you think the advantages of going full free market in health care
> outweigh having poor people die of easily treatable diseases, then that's a
> valid opinion, but you should acknowledge the negative consequences.

How does one lead to the other? Social safety nets are not mutually exclusive
with removing a lot of other market barriers. See my prior comment on this
thread -- our healthcare market is the most distorted in the world (even when
compared to 'universal healthcare' countries). Freer market means 'easily
treatable' conditions are cheap, as opposed to our current system where they
are expensed behind oppressively occupationally licensed practitioners selling
monopolized medical products, where a 10 minute checkup with a dermatologist
out-of-pocket is nearly $500. But regardless, it is certainly an interesting,
quantifiable argument (albeit hypothetical) that a 20% speed increase medical
innovation in a free market could be measured against lives saved with today's
medicine in a socialized system, assuming that system makes services as
affordable/accessible as intended.

Here's the reason health insurance as an industry can be considered
fraudulent, especially when it's generally the gateway to all healthcare
access -- and why ACA fails to fix it. Pre-existing conditions and re-adjusted
contract rates.

If there was one company and one client, they could certainly craft a
perfectly sound insurance contract to pay a set rate with steady increases
over X years in exchange for coverage in the event of future, currently
unascertainable medical services. But if you are responsible and get insurance
BEFORE you get sick (by the way, not much sympathy for those who do not and
demand that insurers take them, since that's the whole point of insurance),
you are effectively tied to this contract and can never again negotiate
another of equal value after you have been diagnosed with a condition, even
though your initial/current contract already priced in the risk of getting
those conditions. In fact, the rates to cover your risk, which need to be
higher on average than the amount of healthcare you actually use, become
ridiculous quite quickly. This problem is amplified by the fact that the
government thought it was a good idea to tie healthcare to employers, so
people switch very frequently and therefore are forced to renegotiate
contracts frequently, robbing them of lost value that would be acquired if
they were able to ride out the original contract.

So to say health insurance is inherently fraudulent is hyperbole, but in the
current setup, it functionally is, because it is non-transferrable. ACA
attempts to address this problem by subsidizing those who do not make much
money and forces insurers to take everyone, but this just adds artificial
demand (due to the subsidies especially) up to the amount of the maximum
subsidy and raises everyone's rates (although those who are subsidized will
see somewhat lower rates), and does nothing to address risk renegotiation,
especially since it includes people who never had a contract. Similar economic
effect as student loans/student aid. Each dollar increase in student aid
raises tuition by over 40 cents... the rest is probably distributed across
student housing, amenities, textbook prices, concert prices in college towns,
etc.

A better way to eliminate the fraud, while still limiting ourselves to an
insurance-dominated system, would be to legally codify standards for contract
negotiations, which would allow contracts to be traded/transferred between
companies, effectively locking in your risk at the time you first get
uninterrupted insurance (and perhaps some protections for temporary uninsured
periods).

~~~
mikeash
"But if you are responsible and get insurance BEFORE you get sick (by the way,
not much sympathy for those who do not and demand that insurers take them,
since that's the whole point of insurance)"

So, screw people who are born with a chronic condition, or people who lose
coverage due to poverty and then want to get back on later?

~~~
lend000
> So, screw people who are born with a chronic condition, or people who lose
> coverage due to poverty and then want to get back on later?

I don't think insurance is necessary in the system I propose, but to the first
point, nature already screwed you, life isn't fair, etc. To the second, I
actually addressed that in my comment as something that could be eligible for
protection for some period.

But let me know if you take issue with the main points -- not trying to get
into a battle of details.

~~~
mikeash
How long is that period of protection? Anything less than infinity seems
deeply problematic.

I consider these questions to be among the main points. If you don't, that
would explain our difference of opinion. I really can't understand shrugging
off screwing over people born with chronic conditions on the basis that life
is unfair anyway. I mean, you can use that argument to justify nearly
anything. Why outlaw murder? Sure, it sucks to get murdered, but life is
unfair.

~~~
lend000
> How long is that period of protection? Anything less than infinity seems
> deeply problematic.

Our current system of infinity is clearly problematic. But I really don't want
to get into an argument of defending any implementation of health insurance
(even one which I think would be better than the current) because I don't
think there's a good way to do it period, as per my first comment.

> Why outlaw murder? Sure, it sucks to get murdered, but life is unfair.

Two completely separate things, not even on the same spectrum. Outlawing
murder is preventing a violation of a person's rights, i.e. aggression. You
maximize society's net freedom by outlawing it. Forcing society to try to make
life "equal" for someone who was born with some terrible condition inherently
violates freedoms through mandates, taxes, etc. And of course there's the
whole thing about it not being practical. Everyone dies, and almost everyone
would benefit from an extremely expensive heart transplant/frequent blood
transfusions late in their life. But unfortunately, we can't give it to them
(yet). However, there will always be some new and great medicine that is too
scarce for everyone to have. Fortunately, private individuals are very
charitable without the government and create institutions to treat and study
chronic diseases.

~~~
mikeash
A lot of people consider health care to be a basic human right. Taxing people
to provide health care is, from that perspective, not fundamentally different
from taxing people to prosecute murder.

I get that you probably don't think health care is a human right, but "not
even on the same spectrum" is not a simple statement of fact.

If your preferred outcome involves screwing these people and various others
because you think overall it's a worthwhile tradeoff, then so be it, but I
want to make sure we're clear on that consequence.

~~~
lend000
> I get that you probably don't think health care is a human right

Correct, I consider human rights to be more fundamental than a new
product/service -- health care didn't even exist a century ago. It is
expensive, scarce, and difficult to define, as it is constantly changing. The
only thing that is guaranteed is that there will be a point where a patient
cannot be given any more healthcare, because of the diminishing returns
(measured in hours of added lifespan per dollar).

> If your preferred outcome involves screwing these people and various others
> because you think overall it's a worthwhile tradeoff, then so be it, but I
> want to make sure we're clear on that consequence.

Yes you've mentioned that point before and I addressed it. To recapitulate:
there is definitely an interesting argument to be made for the tradeoffs
involved, and I think it would be worthwhile if measured in terms of average
lifespan. However, as I said, I am not as convinced as you are that people
with pre-existing conditions are going to be "screwed" in a more free-market,
insurance-free system. Their costs of treatment goes down, and by the nature
of insurance, they would typically be paying more than the cost of their
treatment anyway (over time) to the insurance company, so....

~~~
mikeash
Costs might come down in a free market system, but many chronic conditions
will remain unaffordable to treat even after, say, an order of magnitude
reduction in costs.

As for paying more in insurance premiums than you'd pay for treatment, that's
only if insurance companies are allowed to account for your chronic condition
when determining premiums. If you forbid insurance companies from charging
more for existing conditions (as the ACA does) then that doesn't apply, and
healthy people subsidize the costs.

------
JohnJamesRambo
I miss having a President that can write in complete sentences.

------
pcunite
_will likely be true with President-elect Donald Trump_

Is it still proper to refer to him that way?

~~~
grzm
Looks like the article was first published prior to the inauguration:

 _This article was published on January 6, 2017, at NEJM.org._

Admittedly it's a bit confusing, given the online article is dated January 26,
and includes "SOURCE INFORMATION: Mr. Obama is the former President of the
United States." Likely inconsistency when repurposing content.

------
maxerickson
Related discussion, JAMA paper published last summer:

[https://news.ycombinator.com/item?id=12081314](https://news.ycombinator.com/item?id=12081314)

------
jbigelow76
I doubt anyone in Congress or the White House working to repeal the ACA reads
the New England Journal of Medicine.

~~~
grzm
It's a pretty prestigious journal. It's likely that aides to senators and
representatives in key positions, as well as it being forwarded from
interested constituents will make sure that the article makes the rounds. And
it's generally good political practice to keep informed on the moves made by
major players. Likely people in the White House know about it as well.

~~~
dghughes
> It's a pretty prestigious journal...

It is but these days it can hard to know going by past reputation alone.

There seems to be a push by some sleazy publishers to buy prestigious medical
journals and then take money to publish questionable studies.

Even the watchdogs who have tried to warn everyone have given up (or were
forced to shut up).

[http://www.ctvnews.ca/health/website-tracking-so-called-
pred...](http://www.ctvnews.ca/health/website-tracking-so-called-predatory-
publishers-taken-offline-1.3251792)

~~~
grzm
While I appreciate the skepticism, and it is sad that there is an apparently
increasing number of questionable journals out there, do you have any evidence
that NEJM is one of them? They're currently run by the NEJM Group, which is
controlled by the Massachusetts Medical Society.

[http://www.massmed.org](http://www.massmed.org)

~~~
dghughes
No I'm not saying NEJM is I was trying to raise awareness of the situation.

That's good to know NEJM is run by a stable group.

------
ikeboy
No peer review?

~~~
grzm
It's a Perspective piece, similar to an editorial. It's not a paper.

------
uberuberuber
For 8 years, this man had the option to walk humanity back from the threat of
hair-trigger, launch-on-warning nuclear armageddon. An armageddon that would
either destroy humanity in a single day...or perhaps merely starve a few
billion in the resulting nuclear winter. From these facts alone, I know
everything I need to know about his, and all US presidents, commitment to the
health of their citizens, and humanity at large.

~~~
flukus
Or Armageddon simply isn't profitable.

------
spoiledtechie
It's a wonderful idea. Free healthcare for all. Sadly, it simply isn't
sustainable financially. I think in the next 10 years alone it was supposed to
cost tax payers 10 trillion and that money can't literally be printed fast
enough and the debt our country holds, extremely unsustainable. If they did it
cheaper or more cost effective, I would say yes, but financially, you can't.

~~~
toodlebunions
Do you mean the $10 trillion cost from repealing?

Here is republican senator Rand Paul on the huge budgetary expense of ACA
repeal

[https://m.youtube.com/watch?v=6AuIwR00T5g](https://m.youtube.com/watch?v=6AuIwR00T5g)

~~~
melling
At 1:20 he says he's in favor of repealing ACA He doesn't like how it's being
done.

