It's necessary given that the ACA restricts insurers for rejecting people for preexisting conditions. This only really works in a country where everyone has insurance. Otherwise, why not just hang around without insurance until you get really sick, then purchase insurance at that point? If this happens, it drastically distorts the insurance market and makes insurance even more affordable, because people who have insurance will be disproportionately sick.

It may seem like a tax on working people, but really, it is a payment for a very real benefit: a dramatic change in your personal healthcare risk. When you can purchase health insurance at any time even when you're unhealthy, you are essentially being granted an insurance policy for expensive, chronic conditions without even having to purchase anything.

You can't simply purchase Insurance and be covered next day. Insurance companies can have a waiting period of up to 3 months before providing you with benefits. It's not really a good idea to wait around with cancer for 3 months until you get your treatment covered

The ACA actually makes it very easy to purchase insurance only when you need it (you've moved, your employer drops your coverage), and drop it when you don't (you can go two months per year without insurance without penalty). This is a fundamental flaw in the program.

You must mandate participation through payroll taxes, but also ensure services can be affordably provided to participants. Insurance companies are still raking 20% off total premiums paid; that's money that could go directly into providing care.

Keep in mind that 20% is after executive salaries and bonuses as well, at best you are getting 75 cents on the dollar.

It is awful but the alternative is adverse selection. That is, healthy people see high prices and drop out, leaving the prices to get higher for the sick.

One angle of the employer-based system is the "healthy worker" effect. It's almost impossible to answer questions such as "is working in a plutonium factory bad for your health?" because almost any population of workers is healthier than the average population because less healthy people don't work.

> It is awful but the alternative is adverse selection. That is, healthy people see high prices and drop out, leaving the prices to get higher for the sick.

Not exactly. Obamacare has other provisions that make this much worse. For example, Obamacare only allows insurance companies to charge older people at most three times as much as younger customers.

"But it’s worth noting that prior to 2014, there was no federal standard in terms of how rates could vary based on age. It was common for health insurance companies to charge older applicants five or six times a much as they charged younger applicants." [1]

This is a way of subsidizing the old (a better organized interest group), but it makes health insurance massively less cost effective for younger customers.

[1] https://www.healthinsurance.org/faqs/why-would-congress-let-...

Is it fundamentally different from car insurance? It might not be very useful to them if they get in a fender-bender, but a high deductible plan can still save their bacon if they have a health catastrophe.

If you can barely afford the deductible, you will NOT be able to afford the bill at the end of the day for anything remotely complicated like a surgery. You will still end up with a >$50,000 bill you won't be able to pay, because you'll have to take time off of work to recover. There is nothing protecting someone from being fired from their job unless it was a workplace injury.

Everyone in the working class in the US is a single major medical event away from bankruptcy, insurance or not.

I can't speak to every insurance plan out there but there are typically out-of-pocket maximums and other limits on spending. A surgery does not routinely cost $50,000 out of pocket.

I learned a fun thing about out of pocket maximums - there's a thousand ways around them. You get a surgery, and they decide to use a "3rd party" doctor with this own billing that isn't in-network? You're still holding the bill.

NYT covered this situation extensively:

http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surp...

http://www.nytimes.com/2013/10/19/your-money/out-of-network-...

http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-wh...

Because entrepreneurs and small business owners is not a desired or targeted demographics by the Democrats anymore. Even though these groups provide a disproportionately large economic growth contribution, the number of votes the Democrats can realistically gather from them is relatively small. They target the lowest 30% and the salaried employees with their policy.

"Even though these groups provide a disproportionately large economic growth contribution"

No, most of productivity growth in industrialized countries arose from economics of scale from multinationals.

Its the same for China, Germany, South Korea, Japan, Soviet Union ...

Countries do not industrialize due to small business and entrepreneurs - regardless of much the average american likes to think that is true.

Very short-sighted thinking. Most multinationals were started by entrepreneurs, some even bear their names: e.g. Boeing, Ford, Dell, Bristol-Myers-Squibb. If you create a start-up unfriendly regime ( like in EU currently), they don't get started. Out of 1000 startups one becomes Boeing and 20 become sustainable medium size businesses that can be discarded for the microeconomic estimates.

The middle class just gets screwed, you mean. A large part of the working class are also poor.

I guess it depends on your definition. In my experience people who can barely support themselves make too much to be granted a subsidy most of the time. Myself when I was a cook included.

And what's the alternative? Allow them to go without insurance? Ok, but what happens when they do get sick or injured? Who pays for it then?

The alternative is a national Single Payer system where competition is negotiated in advance of any patients having a need (based on the historic rates of and future projections of patient needs).

You do this by making 'basic insurance' something everyone has, and a negotiating pool that more or less dutch-auctions per market with the practitioners. You might also include quality control measures like allowing patients to see any doctor they prefer from within the list (of doctors that met the group bid rate), and also allowing criminal mal-practice but not financial liability as a means of stripping titles from those who should not practice medicine. (The liability would be implicitly recognized as social; no big payout, but what life there is that is left you would be some degree of retired.)

I would love Single Payer, but you know as well as I do that it won't be on the table for some time.

No, the alternative is not to double down on madness. The alternative is to stop regulating healthcare out of existence while giving free handouts to billionaires.