Bronze ACA plans are pretty much catastrophic coverage. $7300 individual, $14,500 family deductibles.

There's plenty of people that could afford higher deductibles than that (and would prefer the accompanying lower premiums), but not really the majority of people.

Cutting the basic benefits out of them wouldn't even really save that much money (because insurance negotiates reasonable prices for basic office visits...).

Insurance certainly costs far too much money, but that's missing the forest for the trees. Insurance is the reason that the market is non-functional and broken. The misdirection inherent in an insurance-centric pricing regime is what's made it impossible for anyone to ever know the actual out-of-pocket cost of anything, and getting that is the first part of getting a functioning market established.

We need to stop looking at the individual level and "What can we eek out of people who don't qualify for Medicaid?", and look to the macro-scale effects. Insurance is the wrong model for routine services (indeed, insurance usually functions as a discount program rather than true insurance) and people shouldn't be able to sell it for that purpose due to the debilitating effects it has on the marketplace.

Docs and pharamacies should be up front about their real prices. Today, even people who are "posting prices" can't be up front about it because posted prices function as high anchors for insurance negotiations. This is why you can often get a massive "cash discount" if you call about a bill that you're going to self-pay. That's what they'd really like to charge you, but if they don't start out charging the sticker price they quoted the insurer, they're in big trouble.

For a market to work, there must be a real pricing dynamic where the consumer can be reasonably well informed about the actual total cost and vote with their feet. Hyperinflated 300% prices, necessitated by insurer demands for large discounts, don't count, they're still not real numbers. Markets simply cannot work without meaningful and accessible pricing information.

The medical system will remain a disaster until we can break this dynamic around pricing, and the only way to do that is to fundamentally change the way that medical insurance works, either by nationalizing insurance and/or medicine so that the government writes all the checks and price becomes only indirectly relevant to the public anyway, or by imposing law that mandates price transparency and seriously limits what "medical insurance" and "discount programs" can do, so that we don't immediately descend back into this.

IMO this is a textbook case of a market screaming for good regulation. Ideally we would identify the malicious actors (primarily insurers), develop rules and systems that minimize their ability to operate, and allow the free flow of commerce to handle everything else. "Nationalize it" is a clear power grab, but lacking any willingness to do anything else about such a breathtakingly large economic and humanitarian issue, even that would be better than "let's just keep crossing our fingers".

It's so sad that the level of conservative dialogue is not "let's find a good minimalist intervention that will get this market working again" but rather "Did someone say 'MURICA wasn't the best at something?!"

Yep. There's a book that does a good job outlining the main problems in the healthcare industry: "Catastrophic Care" by David Goldhill.

https://www.amazon.com/dp/034580273X/ref=cm_sw_r_tw_dp_U_x_-...

The big issue, as you mention, is health insurance companies themselves. They aren't actual insurance companies—they are payers, like others in this thread have called out. Real insurance exists when unlikely but disastrous events occur, like a house fire or a car accident.

Payers act more like surrogates—they bargain and make purchasing decisions on behalf of users like us. This is the fundamental problem in healthcare because surrogates cannot make financial decisions as well as a free market can.

Goldhill’s proposal for changing the industry is to eliminate the role of surrogates and replace it with a version of a health savings account that everybody would be required to contribute into and carry indefinitely, and require everybody to have a very high deductible catastrophic insurance plan. For example, all healthcare payments under $30k would be paid for directly by the patient and come out of the savings account. When something truly big and expensive occurs in a patient’s health (e.g., a cancer diagnosis) is when catastrophic health insurance would kick in and cover it.

This would allow for patients to make active decisions about which type of care to choose, and would force providers to become more competitive to earn the business of actual customers.

Why doesn't Germany have this problem? Their system is insurance-based. Why can't Blue Cross Blue Shield (a nonprofit) avoid this cost problem but a Krankenkassen can?

Because a tiny minority of the overall population profits from current inefficiency and if we revamped the whole thing even to massive public benefit some currently wealthy people would inevitably lose out.

In America we are happy to burn a dollar as long as a rich person somewhere can make an extra penny.

As a nation we have no notion of public ethics and haven't for decades. We believe in every man for himself and rather than resignation we feel pride. Venerating not caring about our fellow man as if it was self reliance.

We believe in the dysfunction of the public sphere as an article of faith, implacable as gravity, instead of it being the result of our collective failure to build a system that works.

We feel pride in ourselves when we ought to feel shame for all of us.

> if we revamped the whole thing even to massive public benefit

But this doesn't answer the question: what is the revamping that would be done to solve the problem? I get that "We believe in the dysfunction of the public sphere as an article of faith" is true and the answer to my next question "okay cool, so why haven't we implemented that", but I'd first like to know what "that" is.

(not that you're on the hook for the time to educate me on a complex public policy issue)

Taking away the employer tax deduction for health insurance would do a lot more than banning coverage for flu shots.

Do I need coverage from my food insurance every time I take a trip to Trader Joe's, Chipotle, or even Walmart? There is every reason for flu shots to be cheap enough that they don't require a special mechanism of payment. Yes, vaccine is delicate and it must be handled with care ... but the same is true for most foods and many other necessities that we somehow manage to buy and sell without an insurer butting in.

The goal has to be making medicine work like everything else we buy, including the daily non-negotiables like food, water, clothing, and energy resources. There's no reason medicine shouldn't or can't work that way in the general case.

But as long as we make it about moving numbers around so that Group X is slightly less inconvenienced by this farce, we're playing their game. We need to be talking about how to break their stranglehold, and I don't think just "move it into the government so we can get installed as bureaucrats, who are even harder to get rid than executives!" is necessarily a great macro-scale response (though I continue to believe it's better than doing nothing).

I don't suggest taking anything from anyone who is actually involved in the thing here. The only people I want to take out of the equation are the pencil-pushers leeching gargantuan quantities of otherwise-useful time and money away from the public.

That so many people find it so difficult to conceive of routine medical care without an insurance carrier of some type is a testament to the work we have ahead of us.

Isn’t choice also a fundamental part of a free market? I can choose to buy a certain product and decide not to buy if the market prices are above what I’m willing to spend. How does that apply to medical procedures?

Most medical issues are not emergencies. For most problems, there is plenty of time to comparison shop, consider the urgency and/or optionality of specific care, and so forth.

We do this just fine with other usually-non-emergent necessities of life like food, clothing, and housing. We didn't need to nationalize land ownership or food distribution to create vibrant economies for these, despite the fact that people can't really just "choose not to buy them".

Things are that way in part because there is a controlled regulatory regime in there, not trying to nationalize everything but also acknowledging the duty to protect the market from bad actors. Food, clothing, and housing aren't perfect analogs because medicine is a professional service, but this suffices to show that necessities aren't necessarily exempt from market forces just by virtue of their non-optionality.

Medicine needs a middle ground between "nationalize it" and "ignore it", but in this case, if those are the only two options, "ignore it" is clearly the worse one.

My wife and kids had 0 medical emergencies last year and we still paid over $10k in doctor and dentist bills just from deductibles, copays, and coinsurance. That's after having nearly $1k per month deducted from my paychecks for insurance premiums, not to mention the part that my employer contributed on top of that. It makes me sick to add those figures up, so I'll just leave that as an exercise. You can bet that if there were any actual optionality here, we'd spend a few days trying to sort out the most efficient way to handle this stuff.

Let's also not forget that insurance imposes a significant amount of rationing too. Our policy only covered up to 40 "habilitative care" visits per year, despite the fact that every therapist and doctor we saw recommended about 3x that. These are relatively mild speech and occupational therapy visits -- 40 visits is combined, every speech and pt/ot visit counts against it. "You need insurance because you'll have to buy medical care or you'll die" doesn't always play out that way.

Every medical procedure I've ever seen anyone forgo has been to their gross detriment. People really don't choose not to by like its a new car or chinese food. They suffer or die because they can't afford to do otherwise.