Without a mandate for everyone to carry insurance, we have one industry footing the bill for what should really be paid by the government.

Instead, the indigent have insurance (in theory), and they can get healthcare other than at the emergency room, hopefully at lower cost.

The alternative is to end the mandate for hospitals to treat everyone.

Prior to 1986, hospitals were not required to treat the uninsured, but most nonprofit hospitals did anyway.[1] For-profit hospitals tried to dump them on nonprofit and charity institutions. The 1986 law makes all hospitals that take any Federal funding treat uninsured people with emergency conditions.

[1] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

> ... "if the bill remains what it is now, I will not be able to support a cloture motion before final passage." In other words, Lieberman will support a filibuster. "I can't see a way in which I could vote for cloture on any bill that contained a creation of a government-operated-run insurance company," Lieberman said.

[0] http://www.slate.com/articles/news_and_politics/prescription...

As an aside, I agree that Medicare expansion would have been a better policy. Good luck getting that through congress, though.

Because you do get fined for not buying health insurance.

We can argue the semantics of the word 'mandate' all day, but your analogy is upside down.

You are being fined for not paying mortgage interest. You are being fined for each kid you don't have. Buy your house and have your kids or you will continue paying more in taxes!

Person B -- the renter -- will pay more income tax, because Person B does not get to deduct mortgage interest while Person A does.

In much the same way, if Person A carries insurance all year and Person B doesn't, Person B will pay more income tax.

So yes, you do get "fined" for not buying a house. We just spin it as "encouraging the dream of home ownership" instead of as a "fine", a "penalty", as "the government holding a gun to your head and forcing you to buy a house", etc.

How would a renter feel if their rent increased because their landlord was unable to take a mortgage deduction?

I countered that the home mortgage interest deduction doesn't apply to rental properties. Renters and homeowners are thus currently unequal from a tax standpoint, since renters effectively pay a higher tax rate than homeowners. Removing the deduction would thus not create a new inequality; it would remedy an existing one.

https://www.irs.gov/publications/p527/ch01.html

If I choose to live rent-free in my parents' basement, I will not get fined for doing so. I keep ALL of my cash. But I'll STILL get fined for having not buying myself insurance.

I'm not sure what logical fallacy you're throwing here, some form of "Denying the antecedent" or something along those lines, but it's not the same situation.

Why people insist the two cases are conceptually different (i.e., that one and only one of them is a "fine" for not doing the thing), I do not know.

I don't mean this as a rhetorical question, so I apologize if it comes across as snide, but from the point of view of economics, what is the difference? I'm trying to understand why one kind of tax incentive is objectionable and not the other.

If I have $1000 in my pocket right now, I will still have $1000 in my pocket if I choose not to go after an incentive.

But if I have $1000 in my pocket right now, I will not have $1000 in my pocket even if I choose not to buy any health insurance.

In my eyes, being punished for peacefully doing absolutely nothing is as anti-American as it comes. That's another argument, but my point is that the analogy is off the mark.

There is a tax penalty for not having a home mortgage, so it's mandatory in exactly the same sense that health insurance under the ACA is.

You have to spend money on interest to have a portion of that reduced in taxes. It's not a penalty.

It's not a 'tax penalty'. You're keeping more of your money by not paying interest, and pay normal taxes on those. It's not a penalty.

That's really bizarre (although unfortunately, common) thinking.

There's an incentive for having a home mortgage under certain conditions only, and you do not owe anyone additional money if you have no outstanding mortgages on properties.

The same is not true for the ACA. You are fined for not owning something - e.g. if your net worth was $0, you could go into the negative for not having insurance.

If you don't own a mortgage, you cannot be fined into the negative.

There is no difference between a tax penalty and a tax incentive (more precisely, a tax incentive is exactly identical to a general tax cut plus a tax penalty for everyone who doesn't qualify for the incentive, and a tax penalty is equivalent to a general tax increase plus a tax incentive for everyone not subject to the penalty; so, except as concerns the general level of taxation, penalties are exactly the same as incentives.)

> If you don't own a mortgage, you cannot be fined into the negative

Since having a mortgage or not can make the difference between owing net income taxes or not, if you have $0 net worth before a particular year's taxes are considered, you absolutely can be "fined into the negative" for not paying interest on a mortgage (lenders, not borrowers, own mortgages.)

The healthcare mandate is a tax. What many people object to here is that most taxes tax an activity (making money, buying things, owning things, etc.), such that one does not HAVE to do any of those things, but if one CHOOSES to, they become subject to the tax. Here on the other-hand they are being TAXED for NOT doing something.

Using your analogy, the healthcare mandate is the same as taxing people for not owning a home.

It is being talked about but there is significant opposition from those that don't want to raises taxes to the level that would be required to finance such a proposal.

Many doctors don't take Medicare. Over a situation where say there are 3 doctors for a specialty in a town... the two better ones do not take it, and the new less good one will take it. So if that flat answer is let everyone take medicare, I think there are some serious quality of care problems.

(I have no better solution though, every angle seems bad).

But continuing with your theoretical environment: no, they would consider adding new patients until they had a critical mass and then stop accepting new patients.

No we wouldn't, we'd be in a much better position and we'd be paying much less for healthcare. Medicare has far less overhead than private insurance and it'd be the logical move to establish a far more effective and cheaper system of socialized medicine.

Except that Medicare more like ACA with a public default option than true single payer.

If you're self employed and make over $50,000 a year no matter where in California you live, you'll have to pay full retail premium prices without any discount. My company as a whole makes over 50k a year, but less than 100k a year (still getting off the ground). Thus a monthly premium of $460 a month for a standard decent PPO plan puts a large burden on me. Additionally, if I don't get health coverage I'll have to pay a heavy tax penalty at the end of the year. Essentially as a bootstrapped small business owner, health insurance is a large burden of cost and I was forgotten in the Affordable Care Act. Instead my cost to purchase a plan skyrocketed as I subsidy other people's care. That is not fair, everybody is not paying their fair share. Middle class self employed are the one's who got hurt the most.

Finally go compare CoveredCA.com and then go use https://www.blueshieldca.com. CoveredCA literally is one of the worst designed and functioning apps I've ever seen. It constantly errors and doesn't keep state that I am logged in. The UI/UX is terrible. I'm guessing CoveredCA was outsourced to a non-technically competent contractor overseas. Compare that to BlueOfCalifornia which is a great site, beautifully designed, and functions as it should. This is why government can't have nice things.

[1] - https://news.ycombinator.com/item?id=13353755

Between my employer and myself, we pay $1806 a month for my family of 3. My employer has 3000 employees, so it isn't a weird situation with poor purchasing power.

Insurance is expensive.

And it's wrong to call this insurance. It's not insurance, it's a health care payment plan.

Before ACA I was paying 1/3 the price, and had 1/4 the deductible. These higher rates are basically a tax to subsidize others, which is fine in principle, I just don't like the idea that this is going largely to a massive for-profit private bureaucracy. My problem with ACA is the private insurance industry is shit, and ACA made the expansion of shit mandatory. It should have been single payer, destroy the perversion that is the private insurance industry who have lobbied for all the anti-competitive behaviors they engage in to ensure near monopoly status in the vast majority of counties in the country. But the political capital just wasn't there to see how treacherous the insurance industry has been.

I don't see how the next round of politicians actually fix this though. Preexisting conditions are made feasible by mandates, mandates are made feasible with subsidies, subsidies are made feasible by some people paying more under mandate. So you can't take away any single one of those without the whole system unraveling entirely. Even the insurance companies have said this. They just don't want to say it loud enough that the blowhard in chief gives them a tweetirade.

The US is the only modern country without cost controls. Providers set prices and insurance companies do little other than pass those costs onto consumers.

When will we get cost controls? Likely never. It's very anti-capitalism to restrain free trade. (Yes, there's some sarcasm there. This issue pisses me off.)

Until we treat healthcare like we treat our regional monopolies (electricity, education, etc.) the the government won't be able to set prices lower.

This is what we need in the US. I should not pay a different price if I have insurance or pay cash. People that pay cash are routinely charged far more than people with insurance.

Secondly, hospitals charge people with insurance more. Typically if a patient is uninsured and paying cash, the hospital will work out ways to charge them less, because they are personally liable for way more than what insured are. Hospitals still want to get paid, and charging a patient into bankruptcy is not a way to achieve that.

Haha fat chance. But there is the subsidy.

One of the reasons that the ACA is broken from a financial point of view is that the Democrats didn't want to simply raise general taxes and redistribute to fund the program. Instead they played all sorts of games with the 'individual mandate' to try to force participation without 'raising taxes'. But this is just a way for healthy individuals to avoid participating in the insurance pool -- which is a great way to destroy the actuarial basis of insurance.

It is entirely possible to be for nationalized health care and still think the ACA is structurally unsound and needs to be replaced.

That colonoscopy was $6000, btw. This, for preventative care that could save hundreds of thousands of dollars from colon cancer (and quite possibly my life) down the road. In a well designed system, price controls would put preventative care like colonoscopies below actual cost (and make the money up elsewhere), to save money at the macro level.

On the assumption you're making ... $100K a year, this is 20% of your income.

Hard to imagine how it could be done less efficiently. Of course, the issue is then going to be "Say we reduce costs to even 5% of income", "think of the physicians/hospitals/etc"...

In the USA, income tax is a marginal rate, while Social Security and Medicare taxes are fixed rate (and therefore regressive).

"Medicare gives Australian residents access to health care. It is partly funded by taxpayers who pay a Medicare levy of 2% of their taxable income.

Your Medicare levy is reduced if your taxable income is below a certain threshold. In some cases you may not have to pay the levy at all.

If you don’t have private hospital health insurance, you may have to pay the Medicare levy surcharge (MLS) in addition to the Medicare levy. This depends on your income for MLS purposes."

If anything happened you'd be in the emergency room and would either pay outrageous amounts magnitudes more than $460/mo, or declare bankruptcy making your hospital debt a burden for everyone else.

Of course, choosing to accept work for 80% under market rate in a place where the high market rate for labor drives high cost of living is going to have short-term negative economic consequences.

Rates for 2017 increased significantly, from -3% to 116% depending on the state: http://www.thefiscaltimes.com/2016/11/01/Here-s-How-Much-Oba...

I think the ACA was responsible for temporarily suppressing rates. Now that the costs are better understood, we're back to around where we would have been without it.

Americans, we are all about freedom. Freedom to kill ourselves and eat twinkies. But we expect help when we are sick.

One side or the other has to budge a little. Do we give up being able to get the same insurance despite unhealthy habbits? Do we give up helping the poor and the sick?

Go skiing? Well there's a higher tax for the ticket because you have X% higher risk of breaking a leg. Twinkies right now are a grocery food so in fact it has less tax, where it probably should be taxed like booze or cigarettes (in effect a sin tax). Of course sin taxes get abused, where the money goes to the general fund rather than going to mitigation for the undesirable behavior.

I think for most things we are too stupid to really calculate the extranalaties of products.

I, for one, am very much looking forward to purchasing insurance from the best provider in any of the 50 states, not just the few available to me in CA.

The reason premiums are high is that costs are high, and our population is obese, disease prone and litigious.

If we want to contain costs we have some options:

1) Public option/Medicare for all could save us 10-20% in parasitical insurance company costs/administrative overhead.

2) We find solutions for obesity. Obesity is the #1 driver of increased health costs in America.

3) We stop holding doctors/pharma financially responsible for bad outcomes outside of their control through the legal system.

Part of the initial law were "high risk corridors" to limit the losses for insurers that initially mispriced their ACA plans. The insurance companies had to make a ton of assumptions about the age, health, and wealth of the populations who would sign up for their plans. To make sure they didn't accidentally bankrupt themselves, the law provided funds to limit their losses for the first three years of the exchanges (2014-2016). In the first year, they had a shortfall as the population was older and sicker than expected, so CMS was going to cover the $2.5 billion gap but congress refused to let them pay these user fees.

The GOP knew that the premium changes would come during the election season, so they denied funding for the high risk corridors last year. To give themselves room against mispricing, the insurance companies predictably raised premiums beyond where they would otherwise have been. Other insurance companies decided they didn't want the risk, so they pulled out of the marketplaces.

The election season was rife with announcements about "20% premium increases" and "xx Insurance company exits the exchange market". Millions of people get to pay more for health insurance but at least their guy won the race.

Aragorn: Ride out with me. Ride out and meet them.

Theoden: For death and glory.

Aragorn: For Rohan. For your people.

Theoden: The Horn of Helm Hammerhand will sound in the deep, one last time!

Somebody is gouging us, but we will never know who, and everybody can point to somebody else, or to "society," but we just don't know.

Chances are, everybody who can make money while covering their tracks through a web of business entities, is gouging us.

One potential advantage of the government owning the whole system, is that it would facilitate figuring out what the costs actually are. This may be why other civilized countries pay half what we pay. It's a saying in business, that you can't manage what you can't measure.

"let insurance companies shop for the best state"

Meaning, when customers have the ability to buy across state lines, the true competition becomes not consumers shopping for insurance, but STATES competing for health insurance COMPANIES to set up shop in their state- offering whatever it takes-- handing over amazing liability protections, tax giveaways, dropping regulatory standards-- all to get them to create jobs in the state.

The result is that (A) one or two financially strapped state governments give the industry whatever they ask for, promising them minimum regulation/oversight and low/no taxes, then (B) the entire industry moves there, where they further consolodate power. (C) companies regulated in other states (with safer products and actual responsibility to their customers) can't compete fairly, so they either move to that state or go out of business, resulting in (D) fewer choices for customers, poor quality products, higher prices, and more abuse and negligence from the companies.

I've heard this expressed as a "race to the bottom", which I always thought was a really confusing way to say it without context.

What makes me think this is going to happen? Watch the Secret History of the Credit Card documentary on Frontline about how this exact same thing happened in that industry.

http://www.pbs.org/wgbh/pages/frontline/shows/credit/

The CC industry "state-shopped" to find a state (South Dakota I think it was) that would let them get away with just about anything. At that point, every major player moved there, and suddenly credit cards became super abusive to customers and there was no recourse (until very recently with the consumer financial protection bureau...)

In advanced Western countries, you see many different configurations for functioning health care systems. Some do insurance based models, others do single payer, others are hybrids. The issue is not about choosing which configuration of system, it is about rooting out the disgusting level of corruption that exists currently in the system.

The ACA did nothing to tackle this underlying issue.

The UK is doing OK with the NHS at half the US cost as a fraction of GDP. Singapore is doing at least as good at about a quarter of the costs.

American combines the worst of government and private healthcare. The UK does a decent job with government healthcare. And Singapore combines the best of government and private healthcare.

http://econlog.econlib.org/archives/2008/01/singapores_heal....

And medical coding to figure out what you're paying for and what a normal price should be is ridiculously hard to understand. Some of this is going to be their response to a litigious society, but you can't use that excuse for all of it.

Also, if someone doesn't have insurance, the fact that the hospital puts you on the hook for the full bill is ridiculous. Insurance isn't paying 100%, they are discounted crazy amounts, even only paying 20% in some cases. But you don't get this discount from the hospital. If you show up without insurance, you will be charged the full amount, less what you can negotiate on the spot. And most people don't know they can even try to negotiate it.

I agree that the insurance companies are a huge problem, but I don't think the hospitals and doctors' offices themselves should be absolved from their share of the blame.

And what happens with the majority of people who don't have insurance, they don't pay it. So the costs get eaten by the hospital and eventually by everyone else that can pay.

In that respect, we have socialized healthcare already. It's just a horrible implementation.

Exactly so. They don't pay it because they can't. And they're ruined. Even people who have insurance -- good insurance -- can be ruined. This system is the ultimate form of price discrimination, perfectly tuned to extract the optimal amount of money from the consumer who has literally no pricing information, and maximize the profits of the business. When insurance companies pay out, it's referred to as "loss".

Markets and the profit motive may be "efficient", but they're not optimizing for health outcomes, and certainly not optimizing for morality. Insurance companies ultimately cannot be part of the equation.

AND, until we hit our $5K premium, it doesn't really pay anything. So we've got to pay $27K to get a real benefit. And it's not like we're young and healthy (nearly 50). Feels like we're getting shafted.

There's a lot of material out there about the likely effects of selling across state lines. To the point it is not even actually seen as a viable option, it's more something that Republicans say because it sounds reasonable at first. But it's not workable.

You say: "It's a race to the bottom in terms of regulation"

Consider your assumption that regulation is good. In point of fact pernicious and arbitrary regulation within states brought us as a nation to this desperate situation.

You say: "To the point it is not even actually seen as a viable option"

Check your prejudice at the door and look at reality. You may need to understand markets and human nature more clearly. You may "see" and understand other, better options.

When this was done with credit card companies, they all moved to the state with the least regulation and started instituting consumer-hostile stuff like mandatory arbitration.

I'd really rather not have this happen with my health insurance.

There are substantial challenges. One is that insurance companies don't actually provide care, of course. Any company wishing to do business with people in a particular state would have to actually obtain a network in that state -- partner with an existing network, or negotiate deals and sign contracts with hospitals, urgent care centers, pharmacies, labs, and doctors. They'd presumably have to be licensed to do business in that state, and adhere to that state's own regulations and requirements for doing so. (Because the US is a federal system, the federal government itself is unlikely to be able to strip away all of each state's specific laws and regulations.) This process would have to be repeated for every state in which they plan to do business. Insurance companies would probably set up state-specific legal entities or subsidiaries to provide financial and legal compartmentalization. So selling insurance "across state lines", as a practical matter, may not differ much from the current system. State-specific legal work and shoe-leather network-building would still be required. There's nothing stopping a national company from setting up a state-specific entity and selling insurance this way right now.

Another issue is that if local regulations were somehow stripped, as some in congress wish, insurance companies, as profit-seeking entities, would all gravitate to the most favorable and least regulated business environment. After the Supreme Court ruling in Marquette v First of Omaha, credit card providers migrated to Delaware, South Dakota, or Arizona because those states have the weakest usury laws and allow them to charge rates of 29% or more to borrowers in any other state. A similarly deregulated and "efficient" market for health insurance would have all the companies set up entities in whichever state would allow them to offer plans that provide the least care reimbursement (known internally as "loss control") and charge the highest premium. This could lead to a situation where a few very large companies offer only high-deductible plans without guaranteed issue, excluding procedures that carry risk of being expensive or are politicized, with lifetime or annual caps, thin networks, and retroactive drops. Lip service would be paid in the form of seemingly cheap policies that actually provide little real coverage, but allow insurance companies and politicians to claim "all Americans now have access to affordable health insurance". As bad as the credit card system may be, lending is at least a business that can be conducted at a distance. Health care is the most local of concerns.

What's needed is not a guarantee of "access to efficient health insurance markets". What's needed is actual health care. In a moral society, everybody should have access to that actual care itself without risk of ruin. The US system forces people to make terrible decisions. People remainining in hated jobs, empowering employers and distorting the employer/employee market. Not taking medicine, or half-dosing, because, even with insurance, the costs are too high. Not visiting the doctor after an injured ankle because of fear of the costs, then suffering forever after due to a poorly healed fracture. Especially pernicious: seeing a doctor but not reporting problems because of fear they'd be labeled as pre-existing conditions for which future coverage would be denied. And employers themselves have higher costs because of the historical accident of employer-based insurance, reducing their competitiveness with foreign companies who have no such obligation.

It's a huge political problem, but this focus on insurance, and access to insurance, begs the question.

No. I don't buy auto insurance on that basis. It is required by my state in order for me to legally operate a motor vehicle. I buy what is "best" for me (and my family).

Only in our closed highly regulated environments that denigrate personal responsibility and individual liberty do we get this extraordinary markets dislocations that come with the bizarre healthcare system that we have today.

Your selection of the best auto insurance policy is qualitatively a different kind of choice. Many millions have no car or need of one. You could live without one. I mean that literally -- it will not end your life if you don't have a car. There are alternatives to owning one, even if one of those is moving somewhere where you don't need one. Likewise, you may never use your auto insurance, and auto insurance doesn't pay for maintenance. But everyone needs health care, including its "maintenance" form. There's nowhere to move that obviates the need for health care.

Insurance is not the right model.

Before ACA, as a full-time worker at decent companies I paid maybe $50 a month for my insurance, my employer picked up the rest. When I went to the doctor, filled a prescription, or anything else routine, it was $10-$20 max. In the one year where I had a lot of care (broken wrist), I think I paid my out-of-pocket max of about $750 and that was it.

After ACA:

Catastrophic plan at pretty much every company I work for now (same for many of my friends in non government jobs). Minimum deductible of $1500-$2000 as a single guy. Probably 5x that for someone with a child and wife. When I go to the doctor, I pay for everything out of pocket at full price: $300 for a prescription (in the US they push up the drug prices to astronomical levels - we cannot buy from foreign sources), $200 for a simple doctor's visit. I have never hit my deductible which would then pay 80% of my costs.

Oh and I can't actually just go and get things like a hearing test or sleep study - I first need a referral from my primary physician at $200 / visit. In exchange, I get to put $100 away each month tax-free into a 'FSA' account. It is mostly use-it-or-lost-it by the end of the year, and will go back to my employer (i.e. a perk for them, not for me). At the end of this year, it basically turned into a $200 gift from me to my employer.

The real nadir for coverage was in the end of the Bush years: I worked at Home Depot as a developer. That means that the plan covers a lot of badly paid people, and a lot of old people. I was paying hundreds a month, my doctor visits were $75, 20% coinsurance in hospital visits up to 10K, and a maximum lifetime benefit of 1 million: So if something really bad happened, like a stroke, they'd stop covering before it was all said and done!

Since, my payments kept going up at similar rates, but at least things like maximum lifetime coverage has gone away.

The one and only time things have dropped in price was last year, now that I work at a place where the average employee's age is 26. The company still pays $1600/mo for their side of the coverage, but since it's mostly developers, they can afford it. No company in their right mind will pay that when the employees are making $15/hr

Healthcare has been less and less affordable since the Clinton years, it's just that it started very affordable. the ACA didn't make things noticeably different for the good plans overall: It's all still very expensive, and picking an employer that either has a young, healthy workforce, or has so much money they can pay for expensive plans, is the big difference between having good health coverage or not.

So I guess that what I am trying to say is that if you had the insurance you claim to have had in the bush years, you were incredibly fortunate, and your situation was not common.

I had childhood cancer and at the time it'd have costs millions without insurance.

While the healthcare market is hopeless opaque and corrupt and no doubt that does drive costs somewhat (or a lot), and probably there are things to do about it, but I think fundamentally the success of complex and expensive treatments is also driving costs - things that you'd have gotten painkillers and left to die even in '50s and '60s now can be cured/improved/fixed, it's just ridiculously expensive compared to popping some pills and expiring. Or look at prosthetics. There was a time you might have made do with crutches or a peg leg and now there are specially designed, fitted, and crafted prosthetics for various activities... that don't come cheap. Not to mention improvements to the standard of care or the sheer man-power requirements of health-care. A normal doctor's visit requires interaction with 3+ employees, across ~45 minutes, all of whom are presumably being payed more than $10 an hour, and possibly a lot more. It may actually be reasonable that budgeting $5k/person/year for healthcare is sane in terms of both risk and what you get, but just far more than people are used to thinking about or seems intuitively reasonable.

This is the entire theoretical reason for insurance: to spread costs out across a large group, so that by having everyone pay a little nobody has to pay a lot.

It's also why the logic of modern healthcare makes single-payer systems the ones that work the best; they spread the costs across the widest possible "risk pool." And why the ACA had to include a (deeply unpopular) mandate that everybody buy some form of health insurance -- as long as your system is based on private insurance, such a mandate is the only way to get the young and healthy into that pool.

> It may actually be reasonable that budgeting $5k/person/year for healthcare is sane in terms of both risk and what you get, but just far more than people are used to thinking about or seems intuitively reasonable.

Remember that most Americans' income has been stagnant in real terms for nearly 40 years now, while health care costs have done nothing but increase and seem set to keep on doing so. So, barring some major change in how the economy works, whatever figure you set for "a reasonable amount to save for health care" is only going to seem less and less reasonable as it grows to consume a greater and greater share of those stagnant incomes.

In other words, if peoples' wages increased by $5K a year at the same time as they were expected to bear $5K a year of health care costs, it'd feel a lot less painful than just expecting them to pull that $5K out of the couch cushions.

Edit: sometimes it's a good idea to call ahead and ask for "uninsured quote", you would be surprised your $200/visit physician might only charge $50 to someone without insurance.

Hospital billing is also pretty awful. I've seen them place every possible reimbursable item on every bill, full well knowing that some insurance companies would cover some items and others different things. This resulted in inflated bills that were never paid in full regardless of a person's insurance coverage.

Many hospitals will negotiate with the uninsured but it's rare for them to make this easy to do.

This article is pretty weak, but the best I could find on this relatively arcane subject:

http://truecostofhealthcare.net/hospitalization/

Most hospitals can't even quote you a price. We were researching a procedure our insurance doesn't cover. One non hospital place quoted $750 cash price within 20 minutes on the phone. We called a nearby hospital and after over 10 hours on the phone spread over a week, and claiming that we don't have insurance (because their policy is you MUST use insurance even if they don't cover it), they quoted us $350 cash price.

We chose the hospital, and when we got there they said that price didn't actually include everything. WTF? It's a frigging mess.

I am a software developer, I worked for a mid-sized community hospital. "It's a frigging mess" is a reasonable summary and also heart-breakingly accurate.

This is one area in which the ACA is making progress: providing an incentive to the hospital to know what a particular procedure actually costs. Your example, while disappointing and frustrating, was extremely rare in the 90's. High deductible insurance has given every customer a reason to shop for the hospital with the most reasonable rates. I can't say if that incentive is strong enough, but I believe it is progress.

The reason they are becoming popular is that they are intended to incentivize the consumer to pick and choose their providers since they have to bear the brunt of the initial cost. (And cheaper for employers to fund over non high deductible plans).

I recommend reading up on the history here: https://en.wikipedia.org/wiki/Health_savings_account

For profit corporations will always find a way to game the system? Just like the whackamole with tax cheats?

That trying to regulate a broken marketplace doesn't work very well?

Perverse incentives lead to perverse behavior?

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

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

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

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

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

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

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

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

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

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

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

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

https://www.healthcare.gov/fees/fee-for-not-being-covered/

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

You wouldn't just copy and paste "IRS" into the state law that a state might decide to create. You would use the state's taxing authority.

Yes, state sanctions don't generally sting as much.

But each state would have to independently decide, with its own constituents, if it could economically offer subsidized health care for all of its residents.

Many states already have some form of parallel subsidized/free health care system for certain segments of the population. Like their school teachers and their children as an example.

Anyway, hope that helps.

Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan).

And we (in Massachusetts) are still trying to figure out how to pay for it.

Massachusetts already had an incredibly low uninsured rate to begin with, which helped, but even then, the costs have been unsustainable. In each of the last three governor's races, the major issue on both candidate's platforms were their respective promises to find a way to pay for it all.

Most recently, MA elected Charlie Baker, a former health insurance executive who has promised to find a way to make the program sustainable.

There are a lot of details, though, that make this complicated and not necessarily viable for all states (MA is both relatively wealthy, has relatively wealthy neighboring states, and has a somewhat unusual healthcare market).

Btw, San Francisco has essentially had universal health care since 2007 (via Healthy San Francisco), though it doesn't cover non-residents on I-94.

It would be interesting to see if citizens and permanent residents represented a high proportion of founders in SF than, say, Silicon Valley.

Ah the classic "if you are middle class F U" program

No, because the Constitution mandates that states engage in a "race to the bottom." California could create their own healthcare program, but they couldn't preclude neighboring states from free-riding on their system by not having their own healthcare and enjoying lower taxes, and simply driving across the border when they needed care.

Finally, in Saenz, the Court breathed new life into the Citizenship Clause of the Fourteenth Amendment in finding that clause to be violated by a California law that set lower welfare benefits for newer residents than for long-term residents. The Court says the clause "does not allow for degrees of citizenship based on length of residence."

(http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresi...)

Smaller states may have not big enough to have a healthy market.

Assuming that it requires residency, that requires that the sick person quit their job, find a place in the new state to live and work for say a year or two while staying alive with a dire sickness. It's not just a bus ticket that you need to relocate, there are many more significant costs associated with a move.

And even in that case, unless the state is already overcrowded, this is essentially a way to grow the state's residency and thus it's tax base.

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

  1 in 3 Californians now receives free health care under Medi-Cal

Does this strike people as a long-term sustainable model?

First off, keep in mind the following:

1. Populous states like California pay far more in Federal Taxes than they get in return in return. [1]

2. California must have a supermajority in the legislature to approve taxes. [2]

So it's a complex issue, but simply put, there's not a lot of wiggle room for California to add billions of dollars of health subsidies to it's state budget.

Medicaid is basically one big government subsidy for the poor. When the Obamacare medicaid expansion goes away, millions will fall out of health insurance instantly. [3]

As for the managed plans, subsidies were used to make the plans more affordable to the taxpayers which made it easier for people to afford coverage. [4]

It's possible that some things may stay in tact like the pre-existing condition clause, but unfortunately the health insurance companies won't be able to cover everyone without the individual mandate. [5] Also, before the pre-existing clause, health care companies were rejecting people for health insurance with pre-existing conditions. [6]

The options besides subsidies for California are:

1. Government mandate of costs at doctors offices and hospitals, which may become illegal if the US Congress votes against it.

2. Government mandates on the behavior of insurance companies. This might drive many insurance companies out of California.

Neither appear to be a viable option.

1: https://goo.gl/paMrzG 2: https://en.wikipedia.org/wiki/California_Proposition_13_(197... 3: https://www.healthinsurance.org/california-medicaid/ 4: https://goo.gl/JVkaN0 5: https://goo.gl/STciup 6: https://goo.gl/Uoljhx

  California must have a supermajority in the legislature to approve taxes. [2]

That said, the Democrats have full supermajorities now.

Quote:

"In addition to decreasing property taxes and changing the role of the state, the initiative also contained language requiring a two-thirds (2/3) majority in both legislative houses for future increases of any state tax rates or amounts of revenue collected, including income tax rates and sales tax rates."

* Preserve some form of protection for people with pre-existing conditions (this covers the "save my life" part)

* Lower costs of health insurance for both individuals and the public (perhaps dramatically)

* Actually address the underlying healthcare issues directly, i.e. implement policies that will reduce the cost of healthcare itself, not just the cost of insurance

In particular, the risk of losing some important things (like coverage of preexisting conditions) seems extraordinarily low.

If insurance companies have to take all comers, that makes the system easy to game: don't get insurance until you're sick, and then jump onto the system. This would essentially destroy insurance markets.

What's the obvious solution? Mandate everyone sign up for insurance, at risk of facing penalty fees. Then you're always paying into the insurance industry, and insurance companies can survive and provide value to the healthy and the sick.

But this is tough: not everyone can afford health insurance. So, you provide subsidies to those who can't.

So, if you start from the 2008 status quo and want to add protections for pre-existing conditions, that game plan is pretty much set in stone. But the issue is that that essentially is the ACA. There are other aspects, but that's the core mechanic.

It's pretty much impossible to build a system from 2008 to cover pre-existing conditions without re-implementing the ACA. You can play with how high fees should be and how high subsidies should be, but that's pretty much it. And most of the Republican "alternatives" (insofar as they exist at all) work by putting a ton of loopholes in the pre-existing conditions protections, a strategy widely regarded as revolting and that only works because people are being bamboozled about what protections they would actually receive.

For example, one of my good friends is a lawyer with a very simple single-member law practice. He has no employees and is self-employed.

As I understand it, BY LAW, he cannot apply for coverage or subsidies for himself or his family (wife and single child) and the only way they can provide for their health care is to purchase it via the New York exchange.

Every year, their chosen coverage provider has closed up shop to be replaced by a new provider with worse insurance terms involving premium increases and higher deductibles.

The plan they had before ACA (essentially catastrophic coverage) was deemed illegal by NY state and is no longer offered as it didn't meet the guidelines for suitable coverage for a family.

SO...by his words:

"I had a hospitalization plan I liked that was $175/month. Covered only catastrophic shit. I loved that since I do a lot to be healthy and no deductible. ACA banned that. First ACA plan was 300 a month or so - w 2500 deductible. Then that company went out of business. New company HealthConnect - price 350 a month - but 6500 deductible for bronze plan. They went bankrupt. Now i have CareConnect - 450 a month - 10,000 deductible $80 co-pay"

So, if your good coverage went from $175/month to $450/month and covered less and less with each passing year and you had no choice to go elsewhere because as a "business owner" you were deemed ineligible for any subsidies or other assistance from the government that was pushing these changes down your throat, you'd probably think it was a shitty deal.

The part that people don't seem to get is that these deductibles are HUGE for the kinds of people that ACA is supposed to help.

If you're paying $450/month and don't even get a single dollar of benefit until your family needs more than $10K of healthcare, would you feel like the government made your situation better or worse?

The reasoning is that, if you allow bare bone plans, then someone could offer plans that let you pay a nominal fee but cover nothing. That, of course, is pretty much nixing the mandate, and you run into the same issues with pre-existing condition protections destroying the insurance market.

Neither of us really know enough about your attorney friend's exact situation to know what went on, but that $450/month plan certainly covers a lot more than the $175/month one. Before, he was essentially self-insuring for the less costly situations, and now that insurance is required to be externalized.

Not perfect, and I'd like if Republicans came up with a solution to ease your friend's situation. But if it comes to a tradeoff between people dying and an attorney being forced to purchase a more comprehensive health insurance plan, it's really not a hard decision.

The main political/democratic value codified into the law is that no one should have to go bankrupt from treatment costs. That means outlawing those practices, which meant a lot of plans no longer qualified. That was the moral argument part that Republicans generally disagreed with. We're all paying a little more so that a family we don't know doesn't go bankrupt from a family member getting cancer. (And we're all also paying a little less due to other parts of the ACA.)

Big Fortune 500 companies that used to offer 'PPO' plans (i.e. you paid your rate and then had $10-$20 copays) now only offer catastrophic plans.

So we are paying the same (and higher) for the plans as we used to, but now we don't actually get anything for them until we reach the deductible, which is higher and higher every year.

I pay the same as a few years ago every month, but get absolutely nothing until I hit $2K or so.

You're not the guy actually footing the majority of the bill, so it doesn't really matter as much to you, right?

BUT, if you own a small tire shop and some guy just tripled your healthcare costs, well....he might have a different opinion.

> if you own a small tire shop and some guy just tripled your healthcare costs, well....he might have a different opinion.

I have a few friends and family who can get insurance due to ACA, so no, I wouldn't. I don't fall in that group (thankfully), but I'm more than happy to pay the costs so they can not go bankrupt or have to play the emergency room shuffle.

Hell, we'll all be there someday. It's the unicorn individual who is never sick throughout their life until they simply drop dead.

Regulatory capture and conflict of interest made it impossible for government (itself the largest payer for healthcare) to find ways to drive down costs. All the incentives are lined up to deliver worse or less care for more money. That's a recipe for disaster.

I know people who are literally alive today because of the ACA. Do their lives have no value?

What I'm arguing is that the ACA, as written, has established a non-sustainable model for healthcare in this country. It's done so at a huge risk to future populations and seems to try and legislate an outcome instead of working with stakeholders to solve the ACTUAL problem: rampantly rising costs for healthcare.

HOW do you explain the crazy high costs for care in this country relative to almost every single industrialized neighbor? What are the factors for that high cost? Overconsumption? Regulatory capture? Lifestyle factors? Perverse incentives? Administrative overhead? PROFIT?

We've done very very little with the ACA to tackle these problems head on because every problem seems to be owned by an interest group that is incentivized to keep that problem alive.

That's the point I'm trying to make here.

Going back to 2008 would make things worse, not better. And sure, improve the ACA, but build on it or in parallel to it, don't tear it down and cost lives in the process.

What did happen was that a whole lot of people suddenly became the beneficiaries of a brand new government welfare program that wasn't paid for in any way by cost savings anywhere. I've got CBO studies to back that up.

Yes, we raised taxes on some rich people. Big deal. A pittance on what the spending required.

What we DID do was shift a whole lot of insurance costs onto people who were already paying a bunch: the middle-class.

If you want to know who really carries the weight of the ACA, look no further than a family of 4 with two incomes making about $125K between them. They saw their premiums rise, their deductibles grow, and their choices shrink.

There were winners: primarily, under or unemployed adults and those with pre-existing conditions that couldn't get coverage anywhere. Single mothers in some cases who couldn't otherwise get coverage under Medicare.

Everyone else who already had coverage they were paying for got screwed.

I helped get him elected. I wanted reform. I wanted better outcomes. I wanted people to participate.

Consider me disillusioned.

These are the situations the ACA is trying to avoid and it was clear from the beginning that these types of plans (a nominal fee for virtually no care) would not be allowed.

Even if plans like this were allowed, we'd be in a situation where the healthy essential chose the equivalent of no insurance for the smallest amount possible. That's nearly the same as not having insurance at all.

There's a moral question at the heart of this, the answer to which defines the solution space: do we, as a society, think it is important that all sick people receive care? If yes, there are a bunch of potential solutions, but they all involve healthy people subsidizing care for sick people. If no, there are, of course, a lot more options.

The thing that frustrates me about the current Republican approach is that they seem to want to answer "yes" to this question, while telling voters they will not have to subsidize care for the sick in any way.

Depending on your point of view, either the best feature, or the biggest failure, of the ACA was that it made this subsidy for the sick visible to anybody buying their own insurance, rather than hiding it behind taxes or complicated dynamics between governments, insurers, employers, and hospitals.

A little more succinctly: either we decide to let emergency rooms turn sick people away, or somebody will be paying for their care. There's no magical solution.

The way to make care available is to drive down costs. We haven't done a single thing with the ACA to improve the affordability of care, we've just made the un-affordability a problem borne by the people who were already doing a good job of taking care of themselves. That's not a scalable solution.

The ACA got us a lot of short-term benefit for a small group of people but set in motion a chain of events that will only drive UP costs while driving affordability down.

And I'd like to argue that until we do something to improve the market dynamics of healthcare we are very likely to see this sort of thing continue to get worse until it's so unsustainable that it's like trying to legislate away the force of gravity.

One thing I'd like to see in any future version of ACA reform is RIGOROUS price transparency by healthcare providers. It should be absolutely illegal for any healthcare provider to conceal, obfuscate, or otherwise obstruct the price discovery mechanism of the market.

Even if you argue that consumers aren't the best people to decide what services are necessary or needed, they can rely on the advice of trusted advisors and popular understanding to shop for healthcare at providers known for offering good value.

SO MUCH of health care isn't of the "emergent" kind but the kind that is for chronic issues that are the result of unhealthy living or plain bad genetic luck. We need to redouble our efforts to drive those costs of care down and start paying for results and not treatment. Paying for treatment encourages overconsumption. Paying for outcomes encourages optimizing for cures.

I will tell you that I've seen scant evidence that it's working.

A wishlist of initiatives isn't a plan for action that drives down costs. Allowing Medicare to NEGOTIATE prices for drugs is a plan to drive down costs.

The insurance companies wanted to GROW the per-capita spend on healthcare. That benefited them. It's really really unclear if it benefited the public right now.

Forcing people into a market they don't want to be in isn't reform. The way to solve this problem is to make being a part of the market ATTRACTIVE.

IMHO we really missed an opportunity to affect behaviors. For one thing, Romneycare incentivized people to skip insurance until they needed it. That was a recipe for adverse selection.

The way to help this is to provide incentives for people to get in WAY EARLY and pay for their OWN care long before they may need it while also providing a measurable benefit to those who get in early right away.

People are capable of responding to incentives and I'm convinced that there exists a Nash equilibrium in healthcare that helps everybody win.

Remember, the same people who gave you "the Internet is not a truck" are the same people you're expecting to solve healthcare affordability. Think about that.

A provision of the ACA sets a minimum medical loss ratio for us. In simpler terms: it puts a legal cap on our profit margin, by requiring a minimum percentage of the money we take in to be spent on benefits to our members (such as paying their claims).

That is almost certainly going to get repealed.

If your incentive is to maximize the absolute amount of actual profit you earn and the ONLY way you can do that is to push more money towards healthcare providers, then what do you think will actually occur?

Because once you have achieved that spend level on provider care, you're in the clear. The ONLY way for you to increase profit is to ensure that more procedures happen.

We profit when people are healthy.

In a perfect world, you'd keep 100% of the premiums and never pay a cent to a healthcare provider because everyone is healthy, right?

In a terrible world, every single one of your insured has a chronic, long-term expensive to treat condition that requires you to pay tons of money to providers.

In the first/perfect case, premiums are zero, right? In the second/terrible/worst case, you're not making zero money because your (collected premiums - minimum payout) > 0.

See where I'm going with this? In a world with healthy people, there is little need for health insurance and spending trends towards zero. There isn't a need for an insurer. Your company can only exist in a world with sick people.

Quality of care is a good direction but doesn't go far enough. We need to get real price transparency into the market so people understand what it costs to treat lung cancer and what the probabilities are that they'll actually get better.

Do you think the average person on the street really knows what it costs to undergo a round of chemotherapy? Does the EXACT SAME procedure performed in different hospitals across town cost the same? These are important questions and there doesn't seem to be any political will to actually answer them.

And my suspicion for this state of affairs is that the interests of the players in this game is for nobody to really know what things cost because if they did the game would change.

And we can't have that, now, can we.

Note that this doesn't mean the same procedure costs the same at every provider, though; Medicare rates include a geographic adjustment, among quite a few other factors, but it does mean you can work it all out for yourself.

I'd encourage you to read pages 23-28 of the following paper from the Mercatus Center. You'll find that prices for Medicare reimbursement are set by a committee largely stacked by the AMA, a de-facto lobbying group for doctors. They aren't likely to support any schema that cuts reimbursement rates for their members.

https://www.mercatus.org/system/files/Feldman-Medicare-Role-...

I agree with everything else you said though. Costs are too high and are a major reason this is so hard to solve and price transparency is a big part of the problem. A related (because it distorts the market in a similar way) problem is that most people don't see the true cost of their insurance, because they get it as a benefit from their employer. I would be highly in favor of any credible attempts to fix these issues. But that's not what I've been hearing from the party that's about to be completely in power.

Democrats don't just come out and admit that they want a wealth redistribution program that they can use to show voters how compassionate they are with other people's money.

They're politicians. They just aren't honest and voters aren't perceptive or concerned enough to call them on it.

I want a wealth distribution program that means that thanks to a genetic condition I had no role in acquiring (if you're "doing a good job taking care of yourself" and never get cancer or some other nasty expensive disease, why don't you count your fucking blessings that you're healthy instead of bitching about having to subsidize others) means that I don't get a death sentence if I ever am sick enough to lose my job for long enough to lose coverage and get fucked over in the future on preexisting condition exclusions. Or fucked over due to lifetime benefit caps.

And I want one that protects other people in similar situations too.

So maybe not everyone's motivations are as cynical as you make them out to be.

I was pretty sure it was going to make things more expensive for me, and I don't think it was sold any differently than that. I was not in favor of it, largely because I didn't think it would survive politically long enough for me to switch from the "loses" to the "benefits" category. We're sort of seeing that now, except that I'm actually sort of optimistic that its 6-year (or so) survival has enshrined it or something like it.

I believe a repeal-without-replace plan will be completely disastrous for the incoming government and that whatever government is next will have popular support to backtrack, and that a repeal-and-replace plan will end up settling on something very similar, maybe even with some free-market-based improvements!

Here is a nice summary: http://www.newsmax.com/Newsfront/wsj-nyc-insurance-market/20...

There is no way he had any kind of health plan for $175/month, not in New York pre-ACA.

Edit: It looks like you need to be enrolled in a plan to be eligible for a HSA

But that's not the case, because that $175/month insurance didn't meet current standards of "good." While the ACA made it happen a lot faster for health insurance, this is kind of like me bitching about how high my car payments are because they keep adding on stupid useless things like bumpers, seatbelts, airbags and antilock brakes and I don't need ANY of those because "I don't get into accidents and if I do I have enough savings to cover it."

As for the question of him not being able to get subsidies for himself as a matter of law, I'm 99% positive that the way you become ineligible for subsidies is by making too much money to qualify. It has nothing to do with owning your own business, and if he's telling you it does then he's blowing smoke up somewhere.

As for the amount you're paying before you get benefits, yeah, there are plans in there like that, and they tend to be cheaper. You might almost consider them catastrophic care plans, except they cost more than $175/month and cover things beyond hospitalization. They're the ones with "20% coinsurance after deductible" for regular doctor's office visits, while what you're probably looking for are the ones with a "$40/75 copay" for primary care/specialist visits. That coinsurance/copay bit is one of the things insurance companies can still do to game the system.

The thing that those plans all have in common though is a maximum out of pocket number. That means if your friend the lawyer has a heart attack, is hospitalized, needs a couple of stents put in immediately or god forbid a bypass and doesn't have the time to shop around for other hospitals that might be cheaper, he's not going to be leaving the hospital with $250,000+ in medical bills that he's personally responsible for. Sure, $10-15k is a lot of money to take on as unexpected debt, but for an awful lot of people that's not bankruptcy money it's "payment plans for a few years that are going to kind of suck" money.

https://nystateofhealth.ny.gov/

Let's start with how much money you need to make to see your subsidies completely extinguished: $50,000. That's the limit no matter if you live in Buffalo or Westchester.

Let's then get into the regulations associated with ownership of a company. Did you know that as the owner of a company no matter the size or organization, you're NOT considered an employee of your own company? Nor is your wife?

From the NY state website:

"Under 29 CFR 2510.3-3, an employee would not include a sole proprietor or the sole proprietor's spouse. The definition for Common Law employee can be found here.

The structure of the business does not matter. For example, the business could be a corporation, LLC or d/b/a.

Employees (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership.

Specifically, 29 CFR 2510.3�3 states the following: (c) Employees. For purposes of this section: (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership."

So it does matter that the self-employed seem to get screwed a bit harder than the popular opinion acknowledges.

So, tell me again, which part of shifting costs from people who didn't go to law school and dropped out to work at McDonalds to those who finished school and did sounds like a fair deal to you?

Does shifting costs to those more conscientious sound like a great plan for national unity? How do you feel when your co-workers play hookey, sleep in, and write bad code? Do you think those folks deserve the same promotion opportunities you do? Do you think that any society that punishes achievers is one that is set up for success?

Let's discuss facts and not opinions. Show me the costs for insurance and where the subsidies end and tell me if you think it sounds like a good deal to you in a county where the property taxes for a small condo run about $25K per year.

Great, so he's making more than $50k/year, I'd hope that to be the case if he was able to make it through college and get a J.D.

> [ownership of a company & employee status]

I'm not disputing that, though I suppose if he really wanted to he could form a C Corporation and give or sell a small percentage of the shares to someone else to make it possible for him to become an employee. He's an attorney, he'd have a far better idea of the legal issues surrounding that kind of thing than I would. It seems logical to me (though possibly not in NY law) that if by law he's not an employee that it then follows that he is also not an employer since there are no employees.

I don't see how any of the above is actually relevant. All it really means to me is that he'd be purchasing coverage in the "Individuals & Families" portion of the exchange. I've never lived in NY, but in my experience with the Illinois/Federal exchange I don't think I've never been asked whether I was an employer, only whether I was an employee of a company that provided health insurance (or was required to provide health insurance by virtue of being >50 people).

And quite frankly if he's paying more than twice my annual mortgage amount just in property taxes, my sympathy over his premium increasing from $175 to $450 is very limited.

Admittedly, I'd be perfectly happy to see a return to Kennedy-era tax rates for incomes over $4 million/year and I'd be ecstatic to have those rates apply to me (because it'd mean I was making at least that much in annual income, but my needs and wants are simple and easily met with less than $100,000/month of income), so maybe I'm not the kind of person likely to be incredibly sympathetic here.

Look, it all looks great but when you REALLY DIG down into the rules, what you see is a recipe for disaster. The plans in NY that had to shut down were staffed by a roster of amateurs because the laws SPECIFICALLY EXCLUDED people who had worked in the healthcare insurance industry from splitting off and starting their own companies.

They quite literally expected a bunch of community activists to run an insurance company and it failed MISERABLY.

Facts are sometimes inconvenient things.

Exchange-created co-ops bit the dust elsewhere as well. In Illinois it was Land of Lincoln Health, which was closed by the state because it was going to be unable to make a required payment into the program designed to help keep the newly-created companies stable. I believe whatever remains of LLH may actually still be suing the Federal government, because part of what drove them under was not getting ~$70m that they should have received through those same cost-sharing systems. (caveat: Not an insurance industry person and I didn't watch it that closely). Still, I'm sure that there were a lot of amateurs who got involved. I'm also sure there were a lot of professionals and investors who got involved and in many cases lost money because even minor fixes became impossible after the law was passed. NOTHING that was going to make the ACA's implementation better was going to make it through Congress, particularly the Senate.

The problem is that when you dig down into the rules you may find a recipe for disaster, but you also found the only way it could possibly work. There are minor nuances, but when you really dig down you find that the "liberal dream of Obamacare" is really "Romneycare" is really at its core a design created by the Heritage Foundation[1]. That's not to say that it's great or terrible or doomed because it was championed by Democrats or doomed because it was written by Republicans, it's just the only viable structure that doesn't have single-payer as its core. If the Republicans in Congress actually do come up with a replacement it's going to look almost identical to the ACA except for cosmetic differences and name changes, and if Democrats stick with "You broke it, YOU fix it" then it'll also never pass and we'll be right back where we were in 2008.

[1] http://americablog.com/2013/10/original-1989-document-herita... And a countervailing argument that "[The ACA is from the Heritage Foundation is bunk]" http://www.forbes.com/sites/johngoodman/2016/02/15/where-did...

Yes this is what both sides of the aisles won't admit. You can't have 20% of the people use 80% of the services and make things fair without forcing the users to eat the costs.

Same things with:

1. The US (like most Western countries) has a huge post WWII baby boom now approaching old age. The younger generations will have to pay for this.

2. The US refuses to allow chronically sick and dying patients to let death takes it course, managed only with pain killers. Instead, vast amounts of money (some say 80% - there's that number again) are spent on the last year of a person's life carrying out procedures that only prolong a few more painful months, with no chance for recovery.

The costs could be reduced by taking away some of the huge profits of the medical and pharmaceutical industries. But in the end, there will need to be societal changes.

Then they're not insurance companies any more.

Likewise, the ACA repeal efforts are disingenuously framed as "enhancing access to insurance".

The top two Democratic presidential contenders as well as many of the Democrats in Congress campaigned on specific reforms to healthcare. The thing is, Democrats and Republicans have nearly diametrixally opposed goals in reform.

The positive PR of... 20 million people losing health insurance?

I've been paying my own premiums for 9 years. Before ACA, premiums went up ~5% per year - 8% one year, perhaps. Since ACA, I've seen increases of 25%, 20%, 20%, 25%, then 11% then 13%. OK, yes, it's anecdotal. But "it goes up every year regardless" is missing data there - pre-ACA there were inflationary increases - post-ACA there are increases to cover millions of people who weren't included before.

Not only that, but they were increasing at a much faster rate before the ACA. Of course, most people didn't notice, because those who were employed were covered by their employer, and the unemployed were uninsured.

Could you expand on this?

There are thousands of people whose lives were saved by this. Nitpicking over on example seems rather unproductive.

The caveat is that it only works if you're collecting a paycheck, but not if you're bootstrapping from savings.

- not able to keep my existing health plan. I had a great low-ish deductible plan with good benefits cancelled due to ACA.

- not able to continue seeing my family doctor (that my folks and sister still see). I'm pretty sure the current doctor I have hates all his patients and staff.

And yes, it costs a lot more in terms of premiums, deductibles and prescription meds. But also in travel time because the other physicians in my town that accept CoveredCA stopped accepting new patients.