> which is an insane idea

Swiss American here. It's not insane [1]. The state of healthcare in America is so poor, I would caution us from referring to anything as insane without empirical evidence.

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

If people are arguing over what I meant, this system is the one I was thinking of.

The US already implemented tax penalties on no-coverage and could adapt them to be auto-enrollement in basic coverage at a high deductible.

I have nothing against single payer, but I don't think it is worth fighting for the details of it in the US system when it can be emulated like it is in Switzerland.

(But for pricing to be fair, the more important problem in to reverse the incentive for removing lower risk individuals into group plans and make sure everyone is considering the actual price of their insurance.)

It's not too unreasonable if we could also have a transparent, competitive, reasonably priced healthcare market. Doing that would require a lot of changes to how we conduct medical school admissions, residency, and medical licensing that'd be fought tooth & nail by the healthcare industry, though.

I don't believe a transparent healthcare system is realistically achievable without essentially moving over to full government control - I wrote up a thing above[1] if it's of interest.

1. https://news.ycombinator.com/item?id=26187260

Part of the issue is that the insurance pool needs to include low risk individuals to work.

If everyone under 30 says “I won’t shell out for private insurance, and if something catastrophic happens, fuck it, I’ll declare bankruptcy”, the system falls apart for everyone. Unpopular as it is, this is the logic behind the ACA mandate.

It’s a terrible outcome, unless you’re rich enough not to care about insurance to begin with. You get coverage that’s unaffordable for higher risk people who need it, and uninsured “healthy” people one stroke of bad luck away from disaster.

That isn’t insurance. You don’t need low-risk people in the pool for insurance to work. Insurance premiums are technically derived from individual risk, not the risk of an arbitrary pool. Pooling is only done to reduce the tail risk of the underwriter, it doesn’t materially change individual premiums.

You do need low-risk people in the pool if you want low-risk people to subsidize the insurance premiums of high-risk people. That is not insurance, that is just socializing the premiums of high-risk individuals. These distinctions matter when discussing policy. Socializing medical costs may be the appropriate policy choice but lets not smuggle it in by abusing a term of art like “insurance” which means something very different.

That is how your employer provided plan works, however. They negotiate a rate for the whole group, not an individual medical workup and premium for each individual.

If you want to move away from that to “just pay me the equivalent comp directly and I’ll get my own insurance”, rates are going to get ugly.

If you only get insurance once it is too late it is not insurance either. Insurers have a financial incentive to avoid paying for expensive care. If early or preventative care is cheaper they will administer it while you are "healthy".

> Pooling is only done to reduce the tail risk of the underwriter,

Which, in the case of an universal service, is also the insured.

Was hoping a Republican Congress and President would at least attempt health care market reforms, but that didn’t happen.

Would be happy with a government run plan, too, just want our government to make some attempt to address the problem, whether from the left or the right.

A competitive market reduces costs and profits. Why would the Republicans do that?

If you use a market to reduce cost of healthcare, it'll reduce cost for easy to treat conditions by extracting maximum profit from more difficult or rare conditions.

Healthcare being a fundamental right, this fails by not ensuring people with rare conditions get it.

I don't know the details so I appreciate your comment. You cannot have privatized healthcare while simultaneously restricting the supply of medical professionals. That's not a free market. It's welfare for specific individuals.

The biggest drivers of health care cost have little to do with physicians, their training, or licensing although they do all contribute a bit. So to make any impact you'd need a much bigger list of things to change.

What are the biggest drivers? It feels like death from a thousand cuts.

I was maybe underemphasizing the labor costs - it's a real contribution. But you are right that everything is more expensive, and it's pretty interconnected. Big contributors: fee for service incentives, administration overhead, end of life care, inefficiencies due to fragmentation and licensing, insurance inefficiency (not the profit margin, but the tracking/coding level of detail), over subscription of expensive (e.g. capital heavy) procedures, pharmaceutical costs.

I'm reminded of https://slatestarcodex.com/2017/02/09/considerations-on-cost... when these discussions come up.