Get rid of the employer sponsored plans, that makes no sense at all and makes me hesitant to lose my job because my health relies on it? That is simply absurd. Get rid of this. I'm so frustrated with the healthcare here and I don't understand how Washington can't come up with any real solutions

A big chunk of Washington firmly believes that socialized medicine is evil, and they will fight it. It doesn't matter what the facts are, it's part of their identity at this point.

For the rest, the desires of insurance companies and similar get in the way. For example, the main, perhaps only reason the ACA didn't include a public option is because Joe Lieberman, Senator from a state where the health insurance industry is huge, refused to vote for a bill that included it and his vote was required for passage.

If lawmakers wanted to fix things, it would be easy: study the systems of other first-world countries and incorporate the things that work best into ours. But "something that works well" is way down on the list of priorities.

The problem with this line of thought is that the US is orders of magnitude larger, more diverse, and more complex than most European nations. For any single European nation I'd wager at least two of those are the case.

But we have a way to do this already without massive Federal overhauls - allow individual states to do what they want. This means the decisions are made closer to the people, so California can do what California wants while Mississippi can do what Mississippi wants. It also has the side benefit of California not paying for services in Mississippi.

Personally if one of the US states offered non-employer-based, single-payer healthcare I would move there in a heartbeat. If it's as successful as proposed, it would not take very long to most states to offer something similar. At that point, depending on individual implementations, it would be much easier to extend it to the Federal level.

I can't even figure out how diversity would factor into it. Medical treatment depends very little on people's race or culture. I don't get it at all.

That said, I do think we're moving in an encouraging direction. The percentage of the developed world that's willing to recognize others from different cultures and backgrounds as part of their own society seems to be growing, ever so slowly and fitfully. There will be years and perhaps even decades feel like regressions, but on average it feels like things are getting better.

IMO this isn't clearly true. Lots of states (especially those that currently have the worst health care outcomes) seem far more driven by the ideology that has caused their problems than by this kind of pragmatism. Example 1: the ACA's Medicare expansion.

Hell, it might even work the opposite way: proof that something worked in California could end up as an argument against it. "Candidate x wants to implement the same sort of government health care system that's taken over California. This November, send him a message that we don't do things that way here."

[0] http://www.people-press.org/2012/04/26/growing-gap-in-favora...

EDIT: also, I think this framing can badly mislead us: "If the people Mississippi don't want single-payer health care, and the people in California do, …". We get a picture in our head of Mississippi residents monolithically not wanting it while Californians monolithically do. In actuality it may be that 49% of Mississippi residents want it and 51% of Californians do. This is of course a broader topic (the benefits and failings of democracy and of various electoral systems) but I do think it's worth being aware when certain ways of phrasing might distort.

EDIT2: I don't at all mean to imply that your framing was intended to mislead; I don't think that at all.

But this is likely what will happen and we will get there eventually. If you are poor in a lower income red state you will be screwed for 20 years unless you move.

When you put this word here, they succeeded. Socilized has a special meaning here, and it's installed through near 5 decades of propaganda (number could be wrong, you get the idea).

WHY pooling the society's resource for health care is "socialized"?!

WHY WHY WHY WHY...

When anyone examine this idea, everything falls apart. WHY? I don't know, and I will surprised anyone knows.

Because it is pooling some of societies wealth into the government to distribute as a good.

The only difference between this and full socialism is that this does not extend to the entire economy.

Also, keep in mind that a self proclaimed socialist is currently the most popular politician in the US.

Because that's what the word means.

...there were 40 other senators who were not voting for the ACA. The bill didn't, and still doesn't, have enough popular support. You can't blame one play on a lost game and you can't blame one voter for a lost ballot.

Doubling down on employer provided healthcare with additional mandates didn't help their case.

You can't do this in popular elections but you can absolutely do it in the legislature where everyone has a different constituency, policy portfolio, campaign contribution history, etc. Lieberman wouldn't vote for a bill with a public option, full stop. The math worked out such that Lieberman was necessary. Ergo, Lieberman killed the public option if there was no other Senator for whom the existence of a public option would have changed their Nay to a Yea. There was not, so you can absolutely lay the lack of a present day public option for health care in the US at his feet.

Assumes facts not in evidence, notably that there is any bill oriented to the policy objectives the ACA sought to acheive that Republican Senators would have supported at that time, and (for relevance regarding the responsibility for the absence of a public option in the ACA) that such a bill would include a public option of the type Lieberman opposed.

Republicans were going to vote against the ACA no matter what it contained. That means they had no power over the content of what got passed. Lieberman had huge power over the content.

This is one of the reasons why the Constitution and amendment process exist. The Supreme Court ruled that the passage of the ACA was technically OK (I disagree, but that's moot I guess) but they didn't rule whether it was wise.

I'm saying given the political and practical mess on this issue, it was unwise. I think partisan finger pointing is likewise a bad idea.

I don't see how it's "partisan finger pointing" to explain why the lack of a public option is the responsibility of a single independent senator. It vaguely fits for stating that the 40 Republicans were never going to vote for any form of the ACA, but that's really just a statement of fact.

Edit: Don't forget to vote every November.

It would take a one line act of congress...removing the income cap...to make America a defacto single payer state. The only problem is that it would disrupt a huge capitalist market, and our society has judged the protecting markets is more important than protecting people.

Hospitals that have too high of a proportion of Medicare patients get a bonus subsidy from the government to cover up the fact that the coverage alone can't financially sustain the provider.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...

If we implemented single-payer in the form of Medicare as it is now, the healthcare industry would quickly collapse.

In addition to everything you said (which is true), Medicare's apparent success is also boosted by the portion of Medicare patients who receive their non-pharmaceutical Medicare benefits through a private insurer.

Original Medicare (which is the part of Medicare that is purely government-run[0]) has dramatically lower ratings for both medical outcomes and patient satisfaction scores[1] than Medicare Advantage, which is privately run. Medicare Advantage also consistently outperforms Original Medicare on cost as well.

Unfortunately, when statistics are cited for Medicare as a whole by laypeople and in mass-media, Original Medicare and Medicare Advantage are lumped together, giving the impression that Original Medicare is much more effective and well-liked than it actually is.

The same applies to Medicaid, but because that's state-run, the exact details vary from state-to-state. Overall, though, nearly ever state has some form of private management for Medicaid plans, and those consistently outperform the state-run counterparts, for reasons which are immediately clear to anybody who's experienced both firsthand.

[0] except for drug benefits under Part D

[1] In 2015, Original Medicare's patient satisfaction scores were lower than the very worst Medicare Advantage provider - they were literally the bottom of the rung.

Tangentially, note Medicare spends about 3% on overhead, compared to private industry's previous 30%. (There are now caps on overhead expenditures -- trying to keep it to 20% or less.)

The problem is that Medicare has no incentive to ensure that their rates are sustainable (without the indirect subsidies that come from private insurers).

Medicare can balance their budget either by increasing their revenue (ie, asking Congress for more money) or by lowering their costs (ie, cutting reimbursements). They have no mandate to ensure that their reimbursements cover the marginal costs of care (and as a result, they don't). On top of that, private insurers are guaranteed by law to pay more than Medicare does, so they can set their reimbursement rates as low as they want.

This is also why the best providers almost never accept Medicare - or, if they do, they do it through a separate practice from their main one. Accepting Medicare means that you're likely going to run a loss on those patients (unless you're operating out of a CAH). So, the best doctors either segregate their Medicare patients into a separate practice (which allows them to manage their losses by capping the number of Medicare patients they see, but also dramatically reduces doctor availability from the patients' perspective), or they just drop Medicare altogether.

http://visual.ons.gov.uk/how-does-uk-healthcare-spending-com...

If you include both government spending and private insurance the US leads the G7 in spending on healthcare (but doesn't seem to get results that match the massive spending); if you only include government spending the US pays more than Canada, the UK, Italy, and the OECD average. It pays about the same as (a bit less than) France.

> If we implemented single-payer in the form of Medicare as it is now, the healthcare industry would quickly collapse.

This is because of the pisspoor state of US healthcare that insists on huge amounts of over testing, over diagnosis, and over treatment - causing excess harm at every step.

The whole experience of pregnancy was an experience of reading the medical literature and then trying to evade the "care" of obstetricians in the standard US care model. I'm glad we have the facilities to deal with all the complications that arise, but we don't have to use them just because they're there when they're not appropriate care.

I think you are unlikely to see immedaite adoption but over time you would have many other/new/different problems to address just as we have many problems now. It is worth mentioning that it would like cause significant employment reductions in the non-governmental insurance providers which are not without an impact.

But for starters, both medicare and medicaid are effectively a concentration of very high risk/high cost customer pools (the elderly and the low income). Opening it up would likely positively impact that cost calculation as well

https://www.google.com/finance?q=NYSE%3AUNH&fstype=ii&ei=QD1... $184B in revenue and 230k jobs gets eliminated

https://www.google.com/finance?q=NYSE%3AAET&fstype=ii&ei=Zj1... $63B in revenue and 49.5k jobs get eliminated

https://www.google.com/finance?q=NYSE%3AANTM&fstype=ii&ei=yj... $84B in revenue and 53k jobs get eliminated

https://www.google.com/finance?q=NYSE%3AHUM&fstype=ii&ei=7j1... $54B in revenue and 51k jobs get eliminated

That's just 4 companies that total $385B and 383,500 jobs. More broadly, healthcare spending is about 20% of the US's GDP.

For all the issues of the US healthcare system, one thing it has going for it is most of the new developments in medicine comes from the US.

Let's stop subsidizing drug R&D for the world on the backs of US citizens who are being squeezed to death by Washington and a for profit healthcare system.

https://www.statnews.com/2016/03/09/drug-industry-advertisin...

> Ad spending soared more than 60 percent in the last four years, hitting $5.2 billion last year.

> And there’s no sign it’s slowing. On the contrary: Nine prescription drugs are on pace to break $100 million worth of TV ad time this year.

Did you know the CEO of Mylan, the company that makes epipens made $98 million last year? Is that reasonable?

http://money.cnn.com/2017/05/31/investing/epipen-mylan-chair...

The question was about how much R&D happens in single-payer counties, not how much one particular CEO made. I am a proponent of single-payer health care in the US but responding to unrelated, valid questions with, "yeah, but this one person made a lot of money and that makes me mad!" is ridiculous.

http://amp.timeinc.net/time/money/4502891/epipen-pricing-sca...

My point is that the entire for profit healthcare system in the US is broken, and it's time to burn it to the ground.

Excessive profits are waste.

> The problem with the pharmaceutical industry isn’t that they’re unregulated just like chairs and mugs. The problem with the pharmaceutical industry is that they’re part of a highly-regulated cronyist system that works completely differently from chairs and mugs.

http://slatestarcodex.com/2016/08/29/reverse-voxsplaining-dr...

Half of all medical and pharmaceutical research in the world is directly funded by the US. That number doesn't include indirect funding which takes place as well - for example, pharmaceutical companies that are based in Europe (such as Astra Zeneca) often receive the funding for their research from the US, and use additional indirect funding methods to essentially subsidize their research that takes place outside the research with the money they make in the US.

The US's market share of medical research has dropped a bit in recent years, but not because countries with single-payer systems are picking up the pace - it's because the research industries in China and India have grown incredibly fast in the last five years.

Outside of niche drugs for rare diseases, what has R&D done to reduce costs?

If the goverment wants to pay for R and D awesome. Dont put it on my bill to see the doctor.

You don't. You subsidize the massive advertising budgets of the companies in the US.

If all drug advertising went to 0, it would not significantly impact drug prices in the US. It might in fact increase prices as there would be less users per drug. (Which of course may be a better result for society, but I digress)

How will he take care of himself when he gets out of college (assuming he goes of course)? Will it consume half of his paycheck?

Through me, my son will have citizenship in France...maybe it's time to teach him French and consider steering him to moving to France when he's done with school.

We need to shift the conversation away from single-payer, insurance, etc and focus on either: universal healthcare or strict price controls. Until these options are shoved down the throats of our politicians, they're going to keep distracting us with b.s. 'solutions' like the ACA, its "replacement", etc.

Premiums increases can be mitigated by reinsurance. The ultimate payer of that should be the Feds (as it is with almost all catastrophic cases e.g floods/earthquakes/landslides).

Casinos use chips and vouchers to distract gamblers from actually grasping just how much money they're playing with. Health insurance sure feels like the same thing, but it's even worse in that when you're in need, you're not always in a state of mind to make rational choices nor are those choices even adequately defined prior to receiving a bill. Why is this acceptable? Since when are contracts entered into under duress admissible? I suspect it's probably a massive success on the part of lobbyists.

I don't know the solution, but I can confidently say it's probably not reached by tackling the insurance side of healthcare. Maybe the current system needs to collapse under its own weight before a new approach even stands a chance? Unfortunately, it's probably more likely it'd just receive a government bailout at taxpayers' expense so it could continue the status quo.

Certainly before Obamacare, private insurance companies spent about 30% on overhead (enrolling & dropping people, advertising, dealing with referrals, arguing with hospitals and doctors, auditing people, hiring lawyers to get someone else's insurance to pay for treatment). That's a lot of money and it figures into "healthcare costs" in the US.

We spend so much more than any other country on healthcare, so much more.

You are absolutely right that "the current system needs to collapse under its own weight before a new approach even stands a chance". I believe it will take people dying publicly to make the US consider a change. First we will be bamboozled by the "freedom" and "choice" we'll get with the new plan, foremost the choice not to have coverage or care at all :)

Note that I'm not saying that we can't eventually devise a market-like system for allocating medical resources. I do wonder if we have the technology today for building such a system though. After all, we'd ideally have very good information very quickly so that we can make decisions about where to spend. I'm just not sure we have anything close to such a thing yet, and perhaps we should stop pretending that we've got one.

* Insurers are not pulling out of the insurance market.

* Insurers are pulling out of selling to individuals.

* This is happening because selling to large groups (like entire companies) is easier/more profitable.

* It is easier to sell to larger groups because you have greater numbers across which to amortize risk.

* The largest group of Americans one could envision selling insurance to is...ALL Americans.

So, by pulling out of the unprofitable individual marketplace in order to focus on selling to larger groups, these insurance companies are practically shouting at us what anyone with half a head already knows: single payer is the only practical, efficient, and cost effective solution for universal coverage.

Given that, your fourth bullet point would point in the direction of insurance companies preferring the state pools to selling to companies one at a time.

The problem with the state pools is not (for the most part) one of size, but of adverse selection.

Regardless, if universal health coverage is a goal, the only way to truly amortize risk is to have everyone in one pool. Anything less pits some very perverse incentives against an inherently inefficient market. It's no wonder no one wants to participate!

I hear you about universal health coverage. I've come around to the idea that we should have it at the national level above some sort of cap. I think free markets can still work when it comes to your annual checkup or small expenses like a broken arm or a monthly prescription for non esoteric drugs.

1. https://www.balloon-juice.com/2017/04/21/catching-the-fallin...

This sounds like a scam.

https://www.usatoday.com/story/news/nation-now/2017/06/01/io...

> Iowa’s largest health insurer, Wellmark Blue Cross & Blue Shield, has cited the case as an extreme example of exploding health care costs.

Basically providing Obamacare was hemorrhaging so much money that Wellmark and BCBS left, leaving a single payer, that ACA users are forced to use.

http://www.thegazette.com/subject/news/health/medica-to-stay...

http://www.azcentral.com/story/money/business/health/2016/09...

Knowing that insurance companies can willingly just abandon the market makes the ACA even more of a joke than one would have originally thought.

And no, before anyone tries to suggest it, temporarily insuring a few million poor people and people in poor health (at the cost of fucking over young and healthy people) is not a success.

Well, they thought it was the former (in part because of the ways in which it was the latter; a sustainable public service not provided directly by government typically involves payment from the government to the service providers.)

Much of the collapse and withdrawal is due to payments they were mandated under the ACA not being funded by Congress (resulting in a giant stack of lawsuits and at least one $200 million+ judgement against the government in favor of an unpaid insurer), with the deliberate intent of causing a collapse of just the kind that is occurring. (And the recent acceleration is that exacerbated by additional uncertainty deliberately injected by the Trump Administration with the intent of producing exactly that result.)

Source: President of the AMA, 4:50 seconds in http://www.npr.org/2017/06/23/534056758/the-amas-take-on-gop...

"Free" medical and college would cause a hell of a disruption that corporations would not like.

As an entrepreneurship scholar, I see health insurance as one really strong limiter of entrepreneurial activity in the US. The lack of single payer significantly privileges those with the means, the young, and those without children to conduct entrepreneurial activity.

I attempted to run a company prior to ACA. Because I had a pre-existing condition, I had to buy COBRA. This forced me to get something running within 18 months. I also paid much more than "$100 per month" for my insurance.

18 months went by and I was nowhere. With the ACA, I might have lasted a few more months; but I'll never know if I would have gotten anywhere. Either way, after 18 months I did not have anything close to a viable business.

I think it's important that people are able to start businesses, and health insurance should not be an obstacle to that. There's a fine line, though, between fair access and an outright subsidy of a fledgling business. It's hard to see where that line is when reading this article.

This does not seem sustainable.

PEOs help early stage companies to a certain extent, but for a pre-revenue company the cost of healthcare is almost always going to be a significant burden that funnels valuable cash away from the product and shortens the runway. But without a decent benefits package, start-ups have almost no hope of attracting key talent especially if those prospective employees have kids, so they (and their investors) are forced to just suck it up.

Healthcare in the US is a ticking time bomb with the potential to significantly impact our long term growth (if it isn't already). Unfortunately we're in a situation where for-profit insurance companies, for-profit health networks, and for-profit pharma companies are all fighting for their share of the pie while pushing increasing costs onto the average consumer. I wish I knew what the fix was - other than an unattainable single-payer system - but we need to find something and find it fast.

Its maybe the penultimate stage of a truly free market.

I can't help but relate the entire industry to a ponzi scheme.

In what way is the insurance industry a fraudulent investment operation where the operator generates returns for older investors through revenue paid by new investors, rather than from legitimate business activities?

Seriously, I feel that phrase to be misused so often it has lost all of its original meaning. /rant

The reason we need to fix health care is simple: if you are dying or seriously injured, and you don't have health insurance, you are going to the ER regardless and someone, somewhere will end up paying for it. Let's all be adults about the situation and just implement something that works.

[0] http://journals.sagepub.com/doi/abs/10.1177/1476127004047617 [1] https://www.inc.com/kimberly-weisul/weve-got-the-relationshi... [2] https://www.forbes.com/sites/acton/2012/05/17/the-one-key-tr... (or you could just cite Schumpeter/Knight...this is just more readable) [3] Sarasvathy, Saras D. Effectuation: Elements of entrepreneurial expertise. Edward Elgar Publishing, 2009.

Dismissing anyone with an illness from entrepreneurship because you think they can't handle the stress is ridiculous.

This was prior to ACA, so I ended up paying through the nose for COBRA.

Pre-existing conditions aren't always debilitating. They can be things that, when treated appropriately, don't impact your ability to start a company at all: diabetes, amputation, cosmetic issues like severe hair loss, sleep apnea, amputation, ect, ect.