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1. Deregulate the health insurance market so you can sell across state lines. 2. Employers start giving their employees the money they pay on their behalf. 3. People shop for the health insurance they want/need.

In a year, every other advertisement on TV would be for health insurance, like it is with car insurance now.




> 1. Deregulate the health insurance market so you can sell across state lines.

I've always found this suggestion a bit disingenuous.

First, there is no federal law that bans insurance from being sold across state lines. What they really mean (but can't say because it is not politically appealing) is "Don't allow states to regulate insurance sold in their state."

State boards regulate insurance. They seem to do it well. No insurance companies failed during the 2009 financial crisis and the ones that came close (looking at you AIG) did so because of their activities and investments that fell outside of the state regulations.

Not allowing states to regulate insurance would reduce costs, but not for the reason you think. The cost of getting a product approved in a given market is predictable and a very small part of the cost of doing business.

By taking this right away from the individual states, we could see a race to the bottom where all insurance companies would incorporate in whatever state offered the lowest reserve requirements and loosest oversight. This would decrease the cost of policies and increase the profitability of the insurance companies.

It would be great until there was a hard year and the insurance companies would have the be bailed out by the taxpayers.

State regulation of insurance companies is a great thing. The states keep each other in line and they keep the industry solvent.

Edit: BTW, auto insurance is also regulated on the state-level.


I don't live in America, but having strong opinions is fun so I'll wade in anyway :D

The things you are talking about are regulatory standards. I've not seen anyone really suggesting that regulatory standards are a problem in the Americas (on the contrary, everything I've read suggests if you have in insurance the whole process can be pretty comfortable).

gp's post is, in my eyes, clearly going towards the point that people should be choosing their own insurers, rather than their employers choosing insurers (on employees behalf). It seems like common sense to me that an individual will be better at choosing a healthcare provider than their employer.

The idea that healthcare benefits are a factor to consider when choosing an employer is bizarre. The only reason to link the two is because Americans enjoy being different. And strangely anti-individual-choice in this instance. That dynamic is an obvious perversion of the market to deregulate.


> It seems like common sense to me that an individual will be better at choosing a healthcare provider than their employer.

I have picked insurance as an individual and as an employer, and that is 100% wrong.

Any kind of insurance is difficult to shop for, because it's for something you'll only really need if you're unlucky; that means it's hard to tell whether the choice you make is a good one. Health insurance is worse, because it's an extremely complicated product.

A company, on the other hand, gets to amortize the cost of figuring out the right options across all of the employees, meaning they can do a better job. They will often have a professional doing it, which helps more. They also get to gather statistical data on how well the insurance performs. And they have have much more negotiating power than individuals.

One way to think of it is that markets work best when you have actors a) of approximately equal power, b) making frequent choices, c) where the products can be easily evaluated, and d) where experience with the product happens quickly, so that the feedback loops are short. Health insurance is exactly none of those things. Markets are tools, not magic wands.

> but having strong opinions is fun so I'll wade in anyway :D

Note that this is literally a life or death question for people in the US. You might think it's fun/funny. Having watched both my parents deal with cancer, that comes across poorly to me.

> The only reason to link the two is because Americans enjoy being different.

No. The American system grew up as it did for particular local reasons, not just a random desire to be contrary on some imagined global stage. It was in retrospect an obviously bad choice given that we spend way more than others while getting worse results. But it made sense at the time.


You might like to read up on the Dutch system. Everyone is compelled to have private insurance, but insurance is tightly regulated so that the basic level is more or less comprehensive. Insurers compete on the perks...specific hospital compatibility, vision, physical therapy, etc; you can buy nicer perks, but the basics are always covered.

Sometimes employers reimburse employees for health coverage, and sometimes they negotiate a nicer rate package that any employee is free to use; but it’s not tied to employment like it is in the US.

If you’re under 18 it doesn’t cost anything. If you can’t afford it you receive a government subsidy. GP visits are part of the basic insurance, and the system functions with the GP as a gatekeeper.

It’s certainly not a perfect system...for example, a non-urgent surgery might take months to be scheduled if demand is high.

But, overall, I’m convinced this is a vastly better system for society than what exists in America.

Edit: it’s funded through taxes, insurance premiums that are about €110-130 per month, and deductibles which are at least €385 per year


> I have picked insurance as an individual and as an employer, and that is 100% wrong.

Wha..? So, are you in favor of your employer picking out your car insurance or your home owners insurance? Sure, health insurance is complicated, but have you read your car insurance policy? I don't see the two as being FUNDAMENTALLY more or less complicated. Further, I will probably blame any irreducible complications you may quote as vestiges of a product that is primarily sold to... corporate specialists. I think these things would change if we got our employers out of the loop.


Life-long medical care is vastly more complicated than dealing with a car accident. It's true that the American system piles additional complexity on top of that. But the worst case in car repair is buying a new car. Medical care is so complex we can't even pick a worst case, but the many, many terrible cases can last years, cost millions of dollars, and have no clear answers from beginning to end.


> Health insurance is worse, because it's an extremely complicated product.

Get sick, go to hospital, insurer covers. There is a shortlist of things the insurer won't cover. You pay the insurer each month.

Insurance isn't complicated. It is a complicated by bad regulation that mean insurers aren't trying to sell to individuals.

> A company, on the other hand, gets to amortize the cost of figuring out the right options...

That sounds like a pretty decent argument until the implications are examined. An identical argument could be made for:

* Food

* Housing

* Schooling

* Entertainment

The truth is that the amortization of figuring out what people want is best done by the insurer, and then people just buy whatever their friends have. Like everything else.

> You might think it's fun/funny.

I think it is funny that I'm commenting on a system more than an ocean away, I'm not laughing at sick people. That would be a bit weird.

> No. The American system grew up as it did for particular local reasons...

The reasons are, in hindsight, stupid. They should switch to using a system that makes sense. Either the capitalist way or the socialist way. The crazy hybrid that is used in practice is crazy.

Just because there is a stupid system in place today is not a reason to stick to it, and everyone agrees with that idea.


> Get sick, go to hospital, insurer covers. There is a shortlist of things the insurer won't cover. You pay the insurer each month.

It is extraordinarily clear that you've never had to do this. And apparently never had to deal with a serious illness in your family. Which is great for you, but please understand that's not the case for others.

> An identical argument could be made for [...]

No, not at all. The only one of those that might meet the four factors I describe is schooling, which is also a highly fraught choice, but it's still not as bad on dimensions B, C, and D. Individual educational needs are also less varied and more predictable than medical care needs. And for choosing education, society puts extensive effort into helping people make those choices well: school rankings, guidance counselors, oceans of books and articles, school accreditation, etc, etc. Until the ACA, there was basically no assistance for picking an individual care plan. ACA marketplaces help a bit, but it's still an extremely difficult choice.


> Get sick, go to hospital, insurer covers. There is a shortlist of things the insurer won't cover. You pay the insurer each month.

> Insurance isn't complicated. It is a complicated by bad regulation that mean insurers aren't trying to sell to individuals.

It's complicated in America because the right wing in America's position is not "if everyone buys private insurance it'll be good," but rather is "I have good cheap-to-me insurance through my job that I like, and I'll be damned if i contribute a penny to those who don't, and you shouldn't force them to buy it, even if that means that only the unhealthy people will be in the private market."

When Republicans complain about the ACA's health insurance regulations they're talking about regulations that mean "people should be required to have coverage to keep the market healthy" and "that coverage shouldn't be practically-useless bullshit"


> Get sick, go to hospital, insurer covers. There is a shortlist of things the insurer won't cover. You pay the insurer each month. > Insurance isn't complicated.

But for things they do cover, what price do they pay? That seems to be the crux here.

Something like travel insurance is simpler, because when they buy you a hotel room / a new suitcase, most of the other buyers are not insurance, and so there's a market price they can refer to. But healthcare isn't like that, and it seems the the prices of many procedures vary wildly, like 100x between different hospitals. Nobody can afford a 100x increase in premiums.

From what I understand about better-functioning health insurance systems, there's usually also a pricelist written up by the government. That seems like the crucial foundation for a useful health insurance market. Much as I wish there was a nice market mechanism for this, I have yet to see one.


> Get sick, go to hospital, insurer covers. There is a shortlist of things the insurer won't cover. You pay the insurer each month.

> Insurance isn't complicated. It is a complicated by bad regulation that mean insurers aren't trying to sell to individuals.

I live in a country with public healthcare and even there, private medical insurance is ridiculously complicated. I'd wager insurance in general is in top 3 of the most complicated products available for regular people. Nowhere else I had to read and sign a TOS the size of a long novel. I imagine that for Americans, it's only worse.

And as for the book-length TOS, almost nothing in there seemed to me like regulatory requirements - it all read like the usual "try to exploit the customer as much as possible while making sure the customer can't exploit us" terms.


> I've not seen anyone really suggesting that regulatory standards are a problem in the Americas

This was a major component of Trump's platform, and where the "selling insurance across state lines" thing comes from.


Excuse me, but I've been saying this for a lot longer than Trump has been President. Not everything is about him, you know. Perhaps it is, in fact, a problem that needs to be addressed, regardless of who is in office.


This is a great comment - I'll just make one minor but important correction. Reserve requirements are fairly uniform across states (see [0] for a list of differences), so they likely wouldn't be a major driver of health insurers' decisions about where to incorporate.

The reality would be worse than you describe - rather than being driven by reserve requirements, the race to the bottom would be based on differences in the level of coverage that insurers are required to provide. Healthy people would buy coverage from states with lax requirements to reduce their premiums, while less healthy people would buy coverage from states with more stringent requirements to ensure their treatment would be covered. Premiums in states with stringent coverage requirements would increase, pushing more and more healthy people to cheaper alternatives, and eventually making coverage in those states unaffordable for the people who need it.

[0] (PDF) https://www.naic.org/prod_serv/SPD-OPS-19.pdf


>It would be great until there was a hard year and the insurance companies would have the be bailed out by the taxpayers.

Surely that wouldn't be the case? They wouldn't have to be bailed out; If a company hadn't planned ahead well enough to survive a bad year then they deserve to go under. In an unregulated economy, bailing out failed companies shouldn't be an option.


except all those people who's supposed to have been insured will now no longer be (but would've paid their premium, at least partially). So what happens then? Either those people lose their money, or the state bails them out.

If the gov't forces an insurer to keep a reserve (for such an occasion), then it becomes regulation!


Those people lose their money. I can't think of a good reason why they'd expect to get that money back, they were paying for a service that was being provided up until the company could no longer provide it.

Losing your money to a failed company is a cost of doing business sometimes, it's a risk everybody takes when they purchase things in advance. The company/owner would owe a refund for the service not provided due to company collapse, whether or not they can pay that is another matter and should be accepted as part of the risk. There's no such thing as risk free business and attempts to remove the risk inevitably remove part of the value too.


> Those people lose their money. I can't think of a good reason why they'd expect to get that money back, they were paying for a service that was being provided up until the company could no longer provide it.

> Losing your money to a failed company is a cost of doing business sometimes, it's a risk everybody takes when they purchase things in advance. The company/owner would owe a refund for the service not provided due to company collapse, whether or not they can pay that is another matter and should be accepted as part of the risk. There's no such thing as risk free business and attempts to remove the risk inevitably remove part of the value too.

I think we as a society have deemed it unacceptable to hold consumers accountable for company selection in some specific industries. Banking and healthcare come to mind. We certainly don't think it's okay for depositors to lose their shirts over a banker's risk taking and we hold that value to such a degree that in America at least it has been codified into law.

I know at least NJ mandates a separate fund that insurers must pay into to protect against this instance.


I don't agree that that is unacceptable, regardless of what "we as a society" have deemed. The consumers being held to account for their own business dealing is the reality of the situation, they're giving their money over to the business and in doing so accept the risk. Taking that risk and putting it on everyone who didn't take that risk through bailouts using tax money is unacceptable. Analogizing to a more personal scenario to highlight the moral wrong: It's as unacceptable to me as it would be if I had an accident in my car and forced everybody in the nearby vicinity who wasn't involved to pay for the repairs.

Businesses having separate funds to protect against it is a good idea but it shouldn't be mandatory to have one, only to tell the consumer whether there is one. I imagine most consumers would happily pay a little more and choose the company with one than the one without.


For businesses that provide somewhat of an essential service, the 'buyer beware' mantra does not result in societally good outcomes.

For example, healthcare services should be considered essential, and therefore, should not be left up to the market forces, as these forces would mean that some part of the population who is not profitable to serve will not get served.

in such cases, the best option is a socialized mechanism (such as universal healthcare, paid for by taxation). For some reason, the US of A is very much against this idea. It's as if these ideas have been tainted with the smear campaign of communism and red-scare.


This is likely the core of our disagreement; Healthcare is not essential, it's a luxury that has been afforded to us by those who were willing to study and learn how to do it in an advanced manner. No one has a 'right' to a healthcare professionals time and effort, same as no one has a right to my programming ability or an uber drivers driving capabilities. To phrase that in the positive light, everyone has the right to the product of their own labour, including healthcare professionals, regardless of the social cost that brings.

Leaving healthcare to 'market forces' is nothing more than leaving doctors alone to do healthcare as they please and for a profit that they earn, rather than using government to force prices down and make them work for less than they're worth.

I'm not opposed to a health care option provided by government, but it has to be optional both to pay in and use in order to be a morally sound imo.


While I agree in part, somehow society has deemed it so that I have a right to have electricity provided to my house and a number of other services (to the point that it is illegal to cut off heat in the winter, etc). Arguably, healthcare has existed longer than electricity, so how do you reconcile the seemingly arbitrary distinction? In truth, I have a right to the power company supplying me power, and the government seems to have indifference to the how of that execution (which means I have a "right" to the electrical lineman's work, in a sense).

On the other hand, I would concede that one would ask, "But where do you draw the line?" And I would answer, "Society collectively draws the line." Which is evidenced by our collective evolution of social programs provided by the government (which tend to be more expansive rather than less so).

Fwiw I am not in disagreement about market forces being particularly maladapted in dictating the pay of specialists (especially considering that many laypeople can't even accurately price nonspecialist time let alone a specialist's time or actual value)


I don't reconcile that distinction, it's based on the false premise that you do have the right to the provision of electricity. I don't agree with that on the same premise as healthcare, even if 'society' has agreed.

I think we may have a different conception of what is determined as a right: I tend to conceptualise rights as inherent, things required to allow a human to live to the best of their ability. When we think of rights in this way, they aren't things that can be given; they can only be taken away or protected. If I build a hut when I'm stranded on a desert island, that's my hut and I shouldn't be forced out of it and no one else stranded on the island has a "right" to the product of my labour. If I spend time and effort gathering food, the other people on the island who haven't put that effort in don't deserve some of that food just because they're hungry. Now if I give them some out of pity or for the benefits of keeping a group around me, that's a different story than if they take it by force. If they take it by force, they've committed a moral wrong and violated the right required to live for me.

My approach is unforgiving but its from the perspective of individuals and their property rights. It doesnt exclude empathy and willing charity, just excludes forced empathy and charity.


> If a company hadn't planned ahead well enough to survive a bad year then they deserve to go under.

Maybe, but we don't deserve to have them take the rest of the economy with them.

It's hard to overstate how much of the economy depends on insurance. If an insurance company becomes insolvent and can no longer cover it's long term liabilities, elderly people who were counting on life insurance or annuities will starve and the newly uninsured in need of operations will die.

If the human toll does not impress you, consider that the entire economy would freeze up without insurance. Residential and commercial building, freight shipment, construction, and most sizable loans all require insurance coverage.

The insurance industry is not like a banana stand. We need to (and do) strictly regulate and audit these companies.


The idea that all the insurance companies would go bust at the same time is laughable, it's a hypothetical with no basis. Even taking your hypothetical though, my opinion remains unchanged, people reaping the rewards, or in this case punishments, of their reliance on others is just. Granted, I'm not saying you shouldn't be relying on others, just that you understand exactly who you're relying on and the consequences of that should they let you down.

The pragmatic argument you're making saying the economy would freeze up isn't really relevant. You can only be pragmatic within a moral framework, with a value that you're aiming at and I'm speaking to that underlying moral framework. I would rather live in a moral, failing world than an immoral and thriving one.

That's all accepting your premise that regulation helps the economy though, I think the reality is that an unregulated (and therefore more moral by my estimation) economy would come back and be stronger having learnt not to rely on insurance so much.


>> Surely that wouldn't be the case?

That literally was the case in 2008 with AIG


Parent mentioned it would have to be the case, it doesn't have to. If it makes you feel any better replace it with "shouldn't" in your head.


The McCarran-Ferguson Act which is a law at the Federal Level enacted in 1945 is what gives states the the authority to regulate insurance offerings within their borders and what helped create the mess and inability to shop across borders. So yeah, its a Federal Law that screwed this up.

Just because it does not prohibit cross state sales is just mincing words. It gave states the ability to make it near impossible to do so. Without consistent requirements how would one expect to have a viable product?

There was an attempt to repeal it but that apparently did not get past the Senate, it was again pushed in 2017 through another act. There are attempts in the Senate as of 2019 to do it.


Give me a better way to express this idea, then: How do we create a REAL market for health insurance, so we can buy it like EVERY OTHER KIND OF INSURANCE?


It's not like every other kind of insurance, though. Health "insurance" covers many expected and predictable costs, which isn't what insurance is about in any industry.

What we call health "insurance" is really just access to health care with expenses adequately covered, with only the portion of that covering unexpected or unlikely risks properly falling under the heading of insurance.

Additionally, even the true insurance piece is one of the only kinds of insurance where it's a societal imperative (in most people's opinions) for everyone to get the insured benefits they need, regardless of ability to pay. Even car insurance isn't required for people who rely on mass transit.

Health insurance policymaking needs to differ from most other kinds of insurance policymaking for these reasons.


That is an awesome answer, but pedantic. The real question is, again: how do we express the idea to create a REAL market for health "insurance"? It's not about the difference between health "insurance" and other kinds of "insurance." The question is how to express how to create a market for it.


Yeah, I am disagreeing with the choice of a market solution for something which we want to make available to people who can't afford it.

That's not what markets are meant for or good at, especially not the deregulated free market that is often meant by questions like yours. As for a tightly regulated market with lots of requirements about coverage and price, some states already have that, and it's exactly those tightly regulated markets which the "let insurance sell across state lines" proposals want to disrupt.


You're #1 states two things as if they are the same. Your final statement seems to imply that the affordability of auto insurance derives from the above conditions. Except you make one glaring mistake: auto insurance is not regulated. Rather, the rates that insurers can charge is highly regulated.

#3 also doesn't make sense because people don't buy the auto insurance that they want. They buy the insurance that the state requires them to pay, and maybe a little more if they want something better. But the government mandates a minimum level of coverage which the insurance companies need to avoid either going insolvent or charging much higher rates than they do.


That's false. California, for example, has regulations on auto insurance rating factors and discounts (banning, for example, discrimination on sexual orientation or discounts not offered to the general public), among other regulations.


It's already legal in several states, but no insurance companies took them up on it.

Trump additionally signed an executive order to setup a national way to do it, but it died off as a policy proposal because the insurance companies aren't interested

http://www.ncsl.org/research/health/out-of-state-health-insu...


The problem with insurance across state lines is that insurance companies would create a policy in a state with lax regulation and rules and sell that policy everywhere else. It's the same sort of crap that allows credit card companies to set up in South Dakota because that state has lax laws over usury rates.


Regulations should apply where the product is sold, or used, not where it’s manufactured.


That's exactly what's meant by insurance not being able to be sold across state lines.

The issue isn't whether Kaiser can sell a Californian a Californian health plan and a Texan a Texan health plan, Kaiser can already do that. The issue is whether Kaiser is allowed to sell a Californian a Texan health plan.


I agree. And that's exactly the status quo for insurance in the US: every policy is subject to the regulatory requirements of the state in which it's sold. "Allowing" policies to be sold across state lines - which, as others have pointed out, is equivalent to preventing states from regulating policies sold within their borders - would reverse this.


Of course they aren’t interested—the default model is working for them right now.

Take away the default model, and open pure competition, and the insurance companies will have to compete on that level, and things will relatively quickly get better.


You're acting like every insurance company isn't already a massive multi-state corporation.

State Farm Texas competing with State Farm Kansas is surely going to solve all our problems.


There is probably a serious amount of overhead for those companies caused by making divisions in 50 separate states.


The providers still hold the key to pricing. When your choice of hospitals or specialists is limited, you’re going to go with whatever insurance company they accept, or pay some exorbitant price.

The problem is that most people don't pre-shop for insurance that way, and only find out that their local provider is out of network when it's urgent that they get help.


Even if you plan it all out ahead of time, you end up in emergency surgery in an in-network hospital, with an in-network surgeon, only to find out the anesthesiologist was out-of-network. And you still owe tens of thousands of dollars out of pocket. It's a bad system all around.


Insurance only gets cheaper the larger the company gets, because the risk pool can absorb more risk. Competition doesn't improve it.

A giant problem with getting healthcare through insurance companies is that it's not actually insurance. Insurance should only be used to pay out in catastrophic cases; it's always cheaper to pay for something predictable yourself than to make an insurance claim.

Of course, most people can't afford any healthcare at all. There's no way to insure that.


Don’t seem to have the problem in the UK. Everyone has healthcare. Those that can afford to (or their companies) top up with swanky perks, but it’s not needed for most.

Total cost is $2800 per person per year.

In the US it would cost $950b to provide that for everyone.

The US currently spends $1077b on Medicare/Medicaid.


Just imagine what the US could have if it fixed its pricing issues and regulations and kept spending the insane amounts they do today...


It is quiet shocking to see #1 getting posted over and over again. How is that supposed to solve the pricing problem? How do you like pricing of say Comcast, Apple or any other company with pricing power? They offer services accross all states. I think it is way past time that we stop offering cute free market solutions to our disasterous healthcare industry. Medicare for All or gtfo.


> It is quiet shocking to see #1 getting posted over and over again.

Yup. If anything, it'd make things substantially worse.

There's a reason all the credit card companies moved to Delaware - they found the most favorable jurisdiction (and work to ensure it stays that way).

Health insurers would love to all move to the most insurer-friendly jurisdiction.


Wrong. Everyone incorporates in Delaware because the Court of Chancery[1] has some of the most professional and consistent judges in the country. Both parties know what the judge is going to decide before it ever gets to trial, which makes reaching settlements and thus saving money far easier. A good businessman can work within the constraints of virtually any consistently applied set of rules. It's when court cases become roulette games that massive inefficiencies arise.

[1] https://courts.delaware.gov/chancery/


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

> The decision attracted little notice at the time. Two years later, the possibilities it opened up became clearer when Citibank, squeezed by interest rate caps, decided to move its credit-card operations out of New York City. The company persuaded Bill Janklow, then governor of South Dakota, whose agricultural economy was struggling at the time due to high fuel prices, to persuade that state's legislature to formally invite the bank there, as required by federal law before a national bank can do business from a state. He then successfully lobbied the legislators to pass a bill drafted by the bank that repealed the state's cap on interest rates, something a small group of legislators were already trying to do. Citibank quickly moved the 300 white-collar jobs in its credit-card division to Sioux Falls, where it has been ever since.

> South Dakota lured a few more large credit operators, such as Wells Fargo, before corporation-friendly Delaware repealed its anti-usury laws as well. Several other states also repealed their interest-rate caps, more lenders entered the credit-card field and introduced newer products and by 1990 the amount of credit cards in use in the U.S. had more than doubled. Credit cards, once a loss leader for the banks that issued them, became a major profit center as banks aggressively marketed them to "revolvers", customers who carried large balances but rarely paid more than the monthly minimum, resulting in large interest payments to the bank.


While that may be why some companies incorporate there, credit card companies specifically are headquartered in certain states (not just Delware IIRC) because, roughly speaking, the supreme court ruled that usury laws where they are headquartered is the only thing that matters. A while back several states tried to make high interest rates (20% or so) illegal and the supremes smacked them down.


Listen: If you know of a better way to encapsulate the idea of really creating a competitive market for health insurance, I'm all ears. That's just been the easiest way I've ever seen of expressing: "Hey, let's have a REAL market for the stuff, like EVERY OTHER KIND OF INSURANCE!"


Health insurance largely isn't like other forms of insurance, though. You can opt out of owning a house or driving a car. You can't really opt out of having health issues, and the potential costs involved make it impossible for most folks to effectively self-insure.

Most of the rest of the developed world has long since acknowledged this - that certain things are better disconnected from profit.


> In a year, every other advertisement on TV would be for health insurance, like it is with car insurance now.

It's strange to see someone say this like it's a good thing. Almost no one wants to "shop for the health insurance they need". They want to show up when they need care and receive it, and not have to think about it.


> It's strange to see someone say this like it's a good thing.

I'm saying that, because the situation would imply a price war for health insurance, which -- crazy me! -- I think would be good for everyone.


dunno, since the car insurance market was deregulated in italy (or better: regulated for transparent competition, which is different in some ways) my premium went from 1200/yr to 250/yr and I'm not receiving a worse service for it.

it's all about in how the regulation is carried out. paperless data transfer between company, ban on exit and transfer fees, standardized risk assessment that's binding for all companies allowed a healthy competition.


id take a look at the small print if I where you based on what happens in the UK


of course, most insurers are basically running a scam operation. that was happening before irregardless of changes that were introduced to protect customers.


> 1. Deregulate the health insurance market so you can sell across state lines.

Why can't health insurance companies sell across state lines right now?


> Why can't health insurance companies sell across state lines right now?

Every state has unique requirements and Congress has never superseded them with a national health law.


1) Every state also has unique requirements for car insurance.

2) Federal law has in fact controlled many aspects of health insurance plans, particularly employer-sponsored health plans, for decades. The elephant in the room is ERISA, passed 1974, but of course there's also Obamacare.


Federal law has set a minimum for car insurance, I think, might be per state (I think you have to have a minimum of liability). Many states have requirements that exceed the Federal min. They don't contradict it, but require extra, which so far has been held to be fine.

I don't know the full history about why you cant buy health insurance across state lines, but I think it's a blend of different state's regulations and not wanting to be beholden to interstate commerce clause regulations (ironically, the provision that was used to justify the ACA mandatory insured or penalty as a tax ruling.)

I never have nor will understood how the interstate commerce clause was used to justify the ACA "tax". The mandate is effectively compelling intrastate commerce (I know of know interstate medical insurance available) under the guise of regulation interstate commerce. This seems to fly against the letter and intent of the constitution in regards to interstate commerce.


It was not justified via the commerce clause, but rather via congress's taxing powers:

The Affordable Care Act's requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.

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


If the Congress supersede every state law with national law, what’s the point of having states?


No one said anything about superseding every state law, just those regarding health care.


Friendly reminder that our 10th Amendment rights exist specifically to limit federal power, and to give states superceding power over the federal government. The opposite doesn't actually exist.


Except for Article 1 section 8. If it can be used to prevent a farmer from growing crops to feed his own animals, then it can be used to regulate insurance sales across state lines.


The current is moving in the opposite direction now. Female genital mutilation is now legal in America because federal courts have decided that it's better than abuse of the commerce clause: https://www.nytimes.com/2018/11/21/health/fgm-female-genital...


Nice to know that people are still clinging to a document that can literally mean whatever we want it to when convenient while Americans continue to shuffle and get raped by the corporate class.


The US constitution is, like all other written law, mostly meaningless, given enough time.

If you don’t like it, changed it: they’re called amendments.


We don't need one in this case. The Commerce Clause in Article I gives the federal government the right to regulate interstate trade.


Emptying the bins and basic services - stripping things from the states that should be the same nationally would be a very good thing.

Yes I know the historical reasons the US is the way it is but it is the 21st century now not the 18th


Congress is actually very limitted in the areas it can supercede stare or local law. The courts and congress, on the other hand, have often decided to ignore those points of the constitution.


> courts and congress, on the other hand, have often decided to ignore those points of the constitution

Saying the Interstate Commerce cases ignore the Constitution is reductive. Many IC-buttresssd laws involve carrots, e.g. highway funds. In other cases, single-state violators are perfectly legal. They just don’t make economy sense in a connection national economy.


States with more people and costs usually have more coverage requirements.

You don’t want insurance to be like banking where banks domicile in “friendly” places like Delaware and South Dakota. Health insurance is awful enough.

Republicans want this so that high cost, low benefit plans can be hocked to less sophisticated people. The more right wing folks also like shared responsibility pools where the members are the insurers, and the organizers take overhead. Obamacare put most of these out of business.


[flagged]


Depends on your definition. They are dominated by big money people in extractive industries, whose entire purpose in life revolves around reducing overhead.

Most conservatives are, well just conservative people who have a point of view. They don't call the shots though.


No- They just favor business owners and the above average earners more and are highly distrustful of those not working or not making enough money. Extreme capitalists!

toastal 36 days ago [flagged]

Sounds pretty evil to me. This is where you get the idea of 'corporations are people' to give more rights and them some to businesses to defend against your average person.


The legal basis of Citizens United was that individuals don’t lose rights by coming together as an organisation. So the NYT has free speech rights because its owners have free speech rights. And if a propaganda film like Fahrenheit 9/11 or Bowling for Columbine can be sold by a film studio a group of people can come together, whether as a for profit or not for profit corporation to produce their very own propaganda films, of whatever political valence, or tv ads or books, etc.

The US has by far the strongest free speech protections of any nation. It’s not really that surprising that the Supreme Court ruled that forming a corporation doesn’t annual free speech rights.


Nobody is talking about annulling free speech rights, the issue is granting extra free speech rights to entities that are not people, as well as considering activities speech, and therefore protected, that are not speech. Like donating money to political campaigns.

People can still donate their money, but to allow corporations, which are explicitly created to concentrate money and power, to donate money to politicians, that has a massive impact.

The people working for a company can have free speech without the company itself having free speech. In fact, some companies having a tendency to curb free speech through contracts denying people the right to talk about certain things.

And then there's also the issue that corporations get used to dodge personal liability by their owners and employees. If corporations don't share their people's responsibilities, why should they get to share their speech? Corporations are very explicitly a separate entity, and not merely the group of people working for it.


> the issue is granting extra free speech rights

Nope. It is about prohibiting corporations and unions from using their funds to make independent expenditures for speech [1].

> In fact, some companies having a tendency to curb free speech through contracts denying people the right to talk about certain things.

Your example is strange. Such contracts are not imposed by the government.

> corporations get used to dodge personal liability by their owners and employees

You should clarify what you mean by this and how it is relevant to the issue at hand.

[1] https://www.supremecourt.gov/opinions/09pdf/08-205.pdf


I explain this is the comment you reply to. You say that corporations should have the same rights as people because they're made up of people. But corporations are quite explicitly a way for those people to avoid liability for what the corporation does.

My argument is that only people are people. Corporations are explicitly different, and there's no good reason for corporations to automatically have the same rights as people.

The whole problem with Citizens United is that it uses the 1st amendment right of free speech for people to grant corporations the right to make political donations, which makes no sense. Corporations are not people and donations are not speech. It's no wonder that this leads to a political system that represents corporations more than it represents people.


Interesting.

I apologize if I'm rehashing some points covered a million times. What you described sounds prima facie reasonable, but then doesn't it follow that organizations should speak with the voices of people they're grouping together? So using your example, NYT should speak with the voices of its C-suite, or board, or investors - and not with the voices of its 4300 employees[0]! That is, the "voice" should not scale with the company size. Scaling like this sounds like cheating to me, given that companies are mostly made of people who have no say in anything.

--

[0] - https://www.statista.com/statistics/192894/number-of-employe...


They're just doing their jobs.


Ah, yes, the Nuremburg defense.


You can't solve a problem without knowing the actual cause of the problem.

mcv 36 days ago [flagged]

> "Are Republicans basically evil?"

Usually those kind of generalisations are wrong and short-sighted, and I generally want to give people the benefit of the doubt, but at this point it's getting rather hard to deny.

I'm willing to believe that even the Bush jr. administration honestly believed in what they were doing, but everything that happened since then, from the way they tried to sabotage Obama in every possible way, and then electing Trump and the way they're trying to protect him, it's getting hard to deny that their primary priorities are apparently screwing poor and black people and women, ensuring corporate profits for their backers at any cost, and protecting anyone from their own party and screwing the other party, no matter how much it may hurt the country or the world.


Companies can offer the same plans in different states, but don't. Insurance plans are regionalized because each state has their own regulations and the markets are different. The "across state lines" argument is a red herring. Even if you could use a plan from another state, it isn't like a doctor in New York is going to accept some HMO from Indiana.


Yup. This has a decent overview of the "sell across state lines" red herring: https://www.factcheck.org/2017/07/selling-insurance-across-s...


A bit of googling leads to:

> Insurance firms in each state are protected from interstate competition by the federal McCarran-Ferguson Act (1945)

Basically this is Congress using its interstate commerce power, in this case to prohibit certain types of commerce.


No, it's the opposite of that. The act is congress abdicating its power under the commerce clause wrt insurance so that each state can regulate insurance as it sees fit.


I wasn't trying to take a position on what Congress should or shouldn't have done. Just pointing out that it was the Commerce Clause powers that enabled Congress to pass the referenced law.

I find your choice of "abdicate" confusing. There is no Constitutional obligation that Congress act in a particular manner on this issue so that word choice just seems out of place to me. It suggests "not doing something" as opposed to "doing the wrong thing".

I think you are advocating that Congress take affirmative action to enable interstate insurance transactions and to preempt state regulations in this area. That seems reasonable to me.


> it was the Commerce Clause powers that enabled Congress to pass the referenced law

No, I don't think so. The Commerce Clause gives Congress the power to regulate insurance. McCarran-Ferguson is Congress explicitly delegating insurance regulation to the states. Delegating regulation to the states is not a power derived from the Congress clause.

IANAL and I'm not sure exactly what the legal theory underpinning McCarran-Ferguson is. I believe it's probably an implied power.

> that word choice just seems out of place

Maybe abdicate isn't the best word choice, but what I was trying to impart is that when the SCOTUS decided that insurance does indeed fall under the purview of Federal law by way of the Commerce Clause, that Congress had to explicitly say that "Federal law does NOT apply to insurance." That's a sort of abdication to me:

SCOTUS: Hey Congress, it's your job to regulate insurance per the Commerce Clause. That means things like the Sherman Act apply to insurance too.

Congress: Oh, we don't want that. Let's pass McCarran-Ferguson to exempt insurance from Federal law so that the states can regulate it as they see fit.


The big insurance companies already are multi-state. Transparent provider pricing and reference-based pricing are a regulatory solution that allows free markets to do their magic.


single payer health insurance would be much cheaper if you just have the equivalent of what you pay now to the government. Single insurer=massive negotiation power. The US has the most expensive health care per person in the world


Many people do not trust that the government would achieve as good an outcome as their current private insurance. Probably a greater number fear that healthcare would become more inconvenient for them. (I’m 100% sure of the latter and maybe 50/50 on the former.)


The government can literally force healthcare providers to accept prices if it's the only payer. It can even write laws forcing them to accept those prices. It would take some time to adjust, but eventually you would ask win. Right now you both have the most expensive in total, expensive in median and the most unfair.

http://time.com/2888403/u-s-health-care-ranked-worst-in-the-...


> The government can literally force healthcare providers to accept prices if it's the only payer.

In the short term, perhaps. Long-term, though, the government can't force anyone to provide healthcare; they can only prohibit charging more for it than their chosen price ceiling. If that ceiling isn't high enough to make providing healthcare a worthwhile occupation the inevitable result is shortages, rationing, waiting lists, and—ultimately—people going without health care they could otherwise afford, were anyone allowed to provide it at the market-clearing price.


I don’t have any doubt they could do such things, just as they’ve done for driver and vehicle licensing. When I or a family member needs medical care, I don’t look forward to a DMV-like experience.


I routinely have spent less than half an hour at the DMV doing anything I need to, with productive and helpful staff who seemed educated about rules, requirements, and best practices.

I didn't even get a bill in the mail for it!

It's almost like some states/municipalities actually fund things and care about it, and they have good results.


Why do state lines make a difference? Is there some geographic location where health insurers have a competitive advantage that major metro areas (certainly where most rideshare drivers are) don't have access to? If there is, which states are already reaping the benefits of market based high access to health insurance?

Also, you do realize that this proposed solution essentially disempowers state governments from being responsive to citizen concerns about insurance policy/practice -- if a state can't control who sells in their state, then the only government shaping insurance policy is national.

Bonus points if you can address how these locales address the issue that health insurance is a weird good from a market perspective -- the more an individual needs it, the less an insurer probably wants to sell it to them, certainly for an averaged risk pool premium.

I totally want to see insurance decoupled from employment, but as far as I can tell, the state line thing isn't an analysis, it's just a mantra that was/is frequently dropped into the discussion without explanation or support.


You left out step 4, without which 1-3 would just make everything worse for everyone: just like with car insurance, everyone would be legally required to purchase health insurance up to some minimal level of coverage. Not for their own sakes, but for everyone else’s, otherwise you end up with even more uninsured people seeking treatment, which is how we got into this mess to begin with.

Any plan which doesn’t minimize or zero out the pool of uninsured Americans does nothing but drive up the cost of health care, and in turn the cost of insurance for everyone else, in a vicious circle. That’s the whole point of the last 30+ years of never ending ideas about what to do about health care in America. The whole point is to break that cycle, not even getting in to second order effects like exploding Medicare costs or actual public health issues.


> You left out step 4, without which 1-3 would just make everything worse for everyone: just like with car insurance, everyone would be legally required to purchase health insurance up to some minimal level of coverage.

So just like with car insurance, that minimal level of coverage would only include health care costs incurred by others as a result of your actions? The minimal required car insurance isn't there for you, it's there to ensure that others can recover their costs from you in the event of an accident. Unless you're paying extra for comprehensive coverage, the insurance company won't pay out for your own treatment or the repair of your own vehicle.

The only thing that might come close in the domain of healthcare would be mandatory coverage against the possibility of accidentally transmitting a contagious disease. It wouldn't cover the cost of your treatment, but rather the cost of treating others whom you accidentally infect. The premiums would be minimal (so long as one is vaccinated) and it wouldn't look anything like traditional health insurance.

Of course, even the "minimum" level of car insurance is only mandatory in connection with driving on public roads. Putting aside the minor issues of a power imbalance sufficient to imply duress at the best of times and the fact that you'll be paying taxes for those roads whether or not you're allowed to use them, this is somewhat analogous to terms and conditions for use of someone else's property. What you're proposing amounts to mandatory insurance just for being alive—essentially on the basis that denying you healthcare you can't or won't pay for might make others feel bad—which is a rather different proposition.

Really, though, a better question is what penalty you propose for not buying whatever "minimal level of coverage" you think people should have. My suggestion is simple and doesn't require any special intervention: If you're not insured, can't pay for it yourself, and can't convince anyone else to pay for it for you as a voluntary act of charity, you don't receive treatment. That is the natural punishment for not buying health insurance. There is no need for any other.


Suggestion 1 has been looked at. They've found it doesn't work.


It's not so much "doesn't work" as "people in the insurance business have reasons why they would take advantage to the detriment of consumers"


That's a pretty good definition of "doesn't work" in the context of lifesaving medical care


The solution then isn't to keep them in gold coins...



Who are “they”? And why should we trust them?


Here is one source: https://www.factcheck.org/2017/07/selling-insurance-across-s...

Why should we trust them vs a random HN commenter?


Many fact checking sites are actually heavily opinionated. To the point where even demonstrably true facts are labeled as "half-true" due to opinionated objections. Frequently, the veneer of calling oneself a "fact-checking" site lets them get away with some pretty significant bending of the truth.

It looks like this article isn't much different. It doesn't actually refute the claim that less regulation would result in lower healthcare premiums:

> In states with unregulated markets, “you could create a situation where you are selling very low-priced policies to healthy people without much [insurance] protection whatsoever,” Blumberg, who was a health policy adviser to President Bill Clinton’s administration, said in a phone interview. “But that ignores the fact that … what you’re doing is driving up the premiums to impossible levels” in states that want to have insurance regulations.

So removal of regulations would actually make healthcare premiums cheaper in the de-regulated areas. Potentially this makes the insurance more expensive in places that do have regulations, but it's actually agreeing with the claim that deregulation can make insurance cheaper.

> It’s a “risk-segmentation strategy,” she said, where eventually the healthy people are pulled into one set of plans and those with health problems are left in another. Premiums would go up so much in states with regulated plans that it would become impossible for them to sustain those regulations.

> Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, said that the lion’s share of a premium is the money a plan has to pay for medical claims, as well as utilization. Selling insurance across state lines wouldn’t change the price of medical services — as Antos said — but if insurance companies could deny coverage or charge more for health conditions, a carrier could “push down on utilization by screening out sick people” and then, “they can charge a lower premium.”

Again, the article does admit that premiums would likely go down with less regulation.

It looks like your article isn't actually disproving the claim that insurance premiums would go down with less regulation. In fact it repeatedly does say that premiums would indeed go down, but that it would result in other changes like different coverage from what people are used to, and potentially making it harder for unhealthy people to get insurance.


I agree that everyone is biased. But there has just been an incredible amount of debate on this issue. For OP to state that he's discovered the solution is a bit disingenuous.

Here's another source. There really is a lot: https://www.naic.org/documents/topics_interstate_sales_myths...


This hardly qualifies as a source, it's just a page of "Myth vs. Reality" bullet points with no data backing it up, nor any references to sources. I'm going to go out on a limb and say that the National Association of Insurance Commissioners is going to have more than a little conflict on interest here. Maybe what they're saying is true, but I'd need actual data if I wanted to believe them.

What they're saying breaches some of the most widely understood patterns of markets: that deliberate interference with markets through regulation drives up prices. Sometimes there are justifiable reasons for doing so, like making sure products are safe. If you mandate that all cars need airbags, prices are going to go up because now every car has the cost of a few airbags on top of whatever it cost previously. This claim that regulating the insurance market somehow keeps prices low goes into the same bucket of dubious claims like San Francisco progressives claiming that constructing new housing actually drives prices up and other claims of that sort.


To be clear, the NAIC isn't an industry group - it's made up of insurance regulators. I suppose the argument could be made that they have a conflict of interest in that they'd benefit from increased regulation from an "empire-building" perspective. But I've never gotten the impression that that motivates their decisions in practice. (I'm a former actuary and still work in the insurance industry.)

It's likely true that health insurance premiums would be lower, on average, in an unregulated free market. It's also true that people with pre-existing conditions would be denied coverage or charged substantially higher premiums in an unregulated free market. The current approach to subsidizing coverage for those with pre-existing conditions is less efficient than a tax-and-spend approach would be (see, e.g., [0]), but it's more politically viable since it doesn't show up in government bugets.

[0] https://johnhcochrane.blogspot.com/2018/06/cross-subsidies.h...


> To be clear, the NAIC isn't an industry group - it's made up of insurance regulators. I suppose the argument could be made that they have a conflict of interest in that they'd benefit from increased regulation from an "empire-building" perspective.

Having 50 different markets to regulate sure seems like it'd result in a lot more demand fore insurance regulators than one market to regulate.

> It's likely true that health insurance premiums would be lower, on average, in an unregulated free market. It's also true that people with pre-existing conditions would be denied coverage or charged substantially higher premiums in an unregulated free market. The current approach to subsidizing coverage for those with pre-existing conditions is less efficient than a tax-and-spend approach would be (see, e.g., [0]), but it's more politically viable since it doesn't show up in government bugets.

Sure, there may be people who find the reasons for regulating the market to be more compelling enough to justify regulation. But that doesn't excuse the mental gymnastics required to convince oneself that this sort of regulation will somehow not only reduce costs but actually make things cheaper. This kind of thinking led us to having the poorest and unhealthiest patients subsidized by the rest of the nation - effectively a levying a flat tax on most insurance customers - and patting ourselves on the back as though this was a progressive change.

Also, your source is pretty dubious. I'm very skeptical of how analyzing the cost of helicopter ambulances specifically is supposed to be a good means of trying to back up the claim whether subsidy is less efficient than paying through taxes. Contrary to popular belief, most universal healthcare programs (e.g. most the ones in Western Europe, the UK being the notable exceptions) still leave the actual healthcare up to the private market.


Well, it's a common talking point. Have you looked into it? It's an honest question, who has the onus of responsibility for research? OP or me?


The thing that feels bizarre whenever this comes up is the US willingness to pretend the many dozen cheaper systems that provide universal coverage doesn't exist.

The US spends more tax money on Medicare and Medicaid alone than what some countries spend per capita on providing universal healthcare..

Maybe copy one of the systems proven to work. They come in many flavours, many of which do include private insurers and healthcare providers that do just fine.


But then republicans would have a harder time preaching "free market fixes all" as holy doctrine.


re onus, everyone.

And the further reduced the tone of ambitiously taking any questions (especially on HN) the more you sound like somebody who migrated from 4chan to mess with us


Doesn't OP have the responsibility to at least admit that his main suggestion is extremely common and well researched, and to explain what gives him special insight or authority?


Who is Aetna, BCBS and why should I trust them?


You choose to have a car. Your body is a given.


Fascinating. Is there anywhere that illustrates this distinction in a form simple enough for us illiterate people to understand? /s

Your comment has nothing to do with state boundaries.


Also, deregulate the cable/satellite TV market so you can sell across state lines … we'll see costs to the consumer plummet.

/s

Not convinced the free market will work for health insurance.




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