What employers do have is the ability to sell you health insurance with pre tax dollars, which is also available to self employed individuals. But the people who are screwed are those who are employed by employers that do not offer health insurance. They have to buy insurance with post tax dollars.

There is similar bullshit with retirement funding, where employer sponsored retirement account limits are drastically more than individual ones (401k vs IRA), and especially if you are a married couple with 1 spouse with 401k access and one spouse without.

Out of curiosity, I went and looked up the plans in NJ for a 32 year old person(56k salary). This is someone in a lower risk pool. The bronze plans are in the upper ~280$/month and include a $6000 deductible. There are three plans out of 36 that are ~380 a month that have a $2500 deductible. Everything else is more. This is NJ, one of the better states and definitely not a shitty state. These plans are garbage. Every time someone on HN extols the virtues of Healthcare.gov, I recheck my options and they always come back much worse than what I get working for a private employer (typical S&P 500 corp). I wish people would look up their possible plans on Healthcare.gov before tossing it out as something other than a scam.

When I got quotes for insuring my employees in NJ, they all matched up with the premiums on healthcare.gov, also seen here:

https://www.state.nj.us/dobi/division_insurance/ihcseh/ihcra...

ACA compliant health insurance pricing is pretty commodified since all the rating factors are codified in law (age, location, smoking status, and that is it I think).

Edit:

>These plans are garbage

The plans simply reflect the cost of healthcare. The companies that sell the healthcare have profit margins in the sub 5% range. Mechanisms to bring the cost down would be to have taxpayer funded medicine in the public domain so the medicine is sold without patent, increasing number of doctors by greatly expanding residency positions and reducing training requirements so that you can start practicing before age 28, reducing the need for "certificates of need" so more hospitals can open and compete, etc.

Anyone who works in healthcare and looks at billing can tell you this is not actually the case, prices are not based on any reasonable metric and are rarely actually paid by insurers anyway.

>The companies that sell the healthcare have profit margins in the sub 5% range.

Point of contention here, these companies aren't selling healthcare, they're reselling it. Which is a service which should ideally not have any profit margins, and would be best suited for a large, collective entity that everyone paid into according to their financial ability, as opposed to smaller social-class exclusive pools.

Seeing as how that is not politically possibly, middlemen with sub 5% profit margins was the compromise. Obviously not the best situation, but still better than before.

Is there any evidence that these companies are concluding to increase revenue by making the system less efficient?

Low profit margins plus multitude of competitors generally means there is not much juice left to squeeze.

>Seeing as how that is not politically possibly

Basically every other liberal democracy has taxpayer funded healthcare, and even many US states have successful programs. It's extraordinarily silly to call that impossible, or to call what we have now a "compromise" rather than a clear case of corporate welfare being put before the welfare of the citizens.

https://www.commonwealthfund.org/publications/newsletter-art...

Seeing as how Republicans have zero interest in taxpayer funded healthcare, and they have held enough Senate seats to stymie any Democrat led effort for the past 20 years and probably next 20, I do not see why it is “silly” to call it politically impossible.

Yes but they get to deduct this, unlike an individual for whom no such deduction exists. Repeat after me: "a tax deduction is a subsidy." That is, welfare. An extremely biased, discriminatory welfare at that.

You can also buy a platinum level BCBS health plan yourself, without an employer, and get the same low deductible and low oop max.

https://www.healthcare.gov/choose-a-plan/plans-categories/

It is evident then that health insurance is NOT tied to employment. Buying it with pre tax dollars is tied to the type of employer you have.

NJ has a very nice pdf where you can basically see how much your insurance will cost based on your age and level do coverage you want:

https://www.state.nj.us/dobi/division_insurance/ihcseh/ihcra...

Furthermore you cannot use the exchanges if your employer offers plans IIRC. So your employer can control which plans you have access to.

The subsidies should just be given directly to the person who needs healthcare. There is no need to involve a third party. It just complicates the situation for no gain.

I do not think this is true. Everyone can sign up on healthcare.gov. Employers will want you to opt into the subsidized plans they offer, especially if you are a lower compensated employee, in order to pass their non discrimination testing requirements, but they have to make the portion they are paying for high enough to make it enticing enough, they cannot force you.

> The subsidies should just be given directly to the person who needs healthcare. There is no need to involve a third party. It just complicates the situation for no gain.

Absolutely. The whole employer tax benefit situation should be abolished, and all individuals dumped on healthcare.gov. Same with retirement benefits. Employers should not receive any beneficial tax treatment for providing benefits, and it would make compensation much more transparent and easier for employees to compare from one employer to another.

Also, note that you can buy your own health insurance in the US. You are not required to use health insurance provided by an employer.

If that was the only or even dominant reason, then the removal of those controls in 1945 would have seen that tie rapidly unravel, instead, health care has become more, not less, tied to employment since the end of that policy, reinforced by deliberate policy choices like tax policy and explicit mandates.

The historical reason a thing first became common and the reason the thing is still common are often not all the same.

One might rationally assume that, but human brains are weird: https://en.wikipedia.org/wiki/Loss_aversion

Pre-ACA, I was once a much healthier early-twenty something applying for private coverage. I have a genetic condition that has never manifested in a health consequence that has required treatment, and technically it was illegal even at the time to reject someone based on their genetic information. Despite that, I was denied coverage by every private insurer in the market because I had a preexisting condition. The only reason the private market functions at all for anyone with so much as a history of a sprained ankle is because of the ACA.

Insurance companies would routinely (and retroactively!) deny coverage and payment based on preexisting conditions. They would accept premium payments for years, then when you came down with breast cancer would dig up an old photo of you with a cigarette in your mouth and refuse to pay for your treatment because you claimed to be a non-smoker when you applied for coverage. This was considered normal.

And yes, it's a red state.

As someone who purchases insurance from the NY marketplace, that hasn't been my experience.

Initially, I had a plan from one of those (Anthem/BCBS), which provided pretty good coverage because they increased my premiums by more than 50%.

Now I have a local (New York State) provider (Fidelis Care) which costs less and has a (fairly) low deductible through the state's marketplace.

That said, many providers are actively hostile to marketplace plans. Back when I still had an employer-based plan, my company changed insurance providers. I called up my GP to make sure they accepted insurance from the new company, but before I could even describe the scenario, the office person at my doctor's office raised her voice and said, "We don't take any Obamacare plans!"

Which was quite interesting, since back then many of the major national insurance companies were offering such plans, including the companies (both old and new) my employer was contracting with.

All in all, I've been fairly satisfied with Fidelis Care, although I wish I could do database queries of their "Explanation of Benefits" records rather than having to wade through PDFs for each visit to a provider.

All that said, I don't know your circumstance (none of my business) so you may have needs that I don't. I wonder what those might be that a "national" insurer might offer than an in-state provider doesn't, especially since the ACA specified requirements for all health insurance plans, not just those on marketplaces.

Although I'm not sure how no insurance could be better than some, unless you're against medical care in general. But my use case isn't yours and I'm sure you make decisions that are best for you.

Edit: Added a few thoughts to address parent's issues, clarified my point about coverage to be more clear that I'm emphatically not calling anyone a liar.

So have I, and I stopped purchasing insurance because I cannot find the coverage I want. I need a specific variant of a certain operation which is only performed by a few surgeons in the country, and the one surgeon in New York who offers it only takes Aetna for that operation. Aetna reentered marketplaces starting 2022, but I'm moving and the operation has a year-plus waitlist, so I'm SOL. It has made a ton of sense for me to have no insurance because I'm fairly young and in fantastic health, making it cheaper to just pay out-of-pocket for primary care once or twice a year. Please don't call people liars.

That seems reasonable. As I said, "my use case isn't yours and I'm sure you make decisions that are best for you."

>Please don't call people liars.

My intent wasn't to call you (or anyone else) a liar. My apologies if you felt I was attacking you. Nothing could be further from the truth. I've edited my comment to explicitly reflect that.

I'm glad.

My initial statement was categorical and not specific only to me. You were right to call me out on that. Thanks.

It's sad that we have to jump through all sorts of hoops just to get the medical care we need. Which is often the case even when it isn't an edge case like yours (or mine with my PT -- my situation was, of course, much less consequential since there are many PT providers out there).

Now, there's a whole administrative system that drives up prices and puts a ceiling on availability and quality of care; with most Americans being (relatively) ill-traveled, ill-read, and fed a news product that beneath the packaging is some combination of entertainment and fear-mongering, it's easy for one to believe there's just something in the air that makes an NHS-style or even a German-style system impossible here.

Then, if you were around for the 2008, 2012, and 2016 elections, you'd have seen presidential candidates arguing about whether someone should have to pay for someone else's well-being. And it's not a debate along the lines of class—it's tied up with identity politics and a broader debate around the welfare state. Advantaged and disadvantaged communities alike are full of people who see how things are, and, knowing that it takes a lottery win to move up the economic ladder and a bad week to fall down, are skeptical that next time it'll be different.

Doesn't help that most Americans will never have the opportunity to get even an hour of education in macroeconomics, unless it's buried in disconnected lessons about individual economic downturns, nor that education on probability doesn't happen until second-year calculus (which is similarly rare in high schools), nor that most Americans don't learn about the mechanics of Medicare until their fifties or sixties

I think enforcing the law has been a government function from the times the first laws were laid down. Fire services were a private function, and this actually works fine in sparsely populated areas where fires are not likely to spread in temperate climates. The only reason fire services are public is because of the inherent risk to everyone that a fire poses in a dense, substantially flammable, city.

If a fire affects you and only you, then why not cover it under normal, optional, property insurance like every other disaster?

This is generally the model of government intervention I support - intervene when the actions of one group of people directly affect others. This covers regulation around rights of way, fire services, environmental protection, waste management, water supply, pandemic/disease control, police, and the military. It however does not cover supplying the personal necessities of life like food, shelter, clothing, medical care, entertainment, companionship, sex, fulfillment, etc.

These are fundamentally individual needs, and I therefore hold that meeting them should be an individual responsibility. Any cooperation to meet these needs should be strictly voluntary and consensual, not compulsory. I think this is where, to greatly simplify, "the left" and "the right" fundamentally disagree. For instance, in spite of the now well-studied and crushing effects of loneliness, it would be absolutely tyrannical for the government to mandate friendship. Similarly it is tyrannical for the government to mandate participation in public health care/insurance. Let people figure out how to meet their needs for themselves, and let them figure out how to cooperate voluntarily. Charity is exactly the virtue of helping those in need, but mandatory charity is indistinguishable from slavery.

There were only private police until 1838 in Boston:

https://time.com/4779112/police-history-origins/

And only private firefighters until 1853 in Cincinnati:

http://www.fireserviceinfo.com/history.html

Ben Franklin offered America's first fire insurance. Privatized insurance and firefighters in Phili in those days:

https://www.investopedia.com/articles/financial-theory/08/am...

Edit:

> The duties of the Watch, as appears by the order, were to be performed in turn by the inhabitants; they were not "citizen soldiers," but citizen Watchmen, and having an interest in their work, no doubt did it well.

- A chronological history of the Boston watch and police by Savage, Edward H.[2]

Savage seems to indicate that the night watch was performed in turn by the inhabitants of the community, by order of the government, and there is no mention they were paid. This doesn't seem like a private service to me.

1. https://en.wikipedia.org/wiki/Boston_Watch

2. https://archive.org/details/achronologicalh01savagoog/page/n...

Edit: also a much more significant factor only in densely populated areas

The idea that people who set bones and cure cancer should be included in this category is a more modern take, one that requires much more careful discussion of what should and should not be a "public service".

> people feeling entitled to a service they previously resented as soon as it's useful to them

I think we should expect people to prefer suffering and death with dignity, rather than greedily and desperately peering into the pockets of strangers, but that's just my take.

He sold it each time to a group in NY (MetLife each time if memory serves). He told me that his insight was that construction companies would have variable revenue and compensation requirements across TX building contracts (private vs government mostly) and to avoid discontent they would dump the difference into life insurance and other alternative compensation because as long as the take home paycheck was the same no one really complained about being put on lower compensation jobs.

Not sure if that was a similar origin for health insurance but I've always assumed it was.

I could get approximately equivalent insurance for about 40% cheaper if I went on the individual market. But, my employer pays 75% of my employer sponsored plan.

Compare Cignas global plan with and without US coverage. Somehow they can easily cover essentially all of the rest of the world for far less than the US.

https://www.cignaglobal.com/

Per capita numbers can be misleading on healthcare as health is labor intensive, so countries with higher wages will have higher per capita costs with otherwise similar systems.

OTOH, the US spends the second highest share of GDP on healthcare, globally, behind Tuvalu, and about a time and half the GDP share of the second highest large, developed state (Germany). [0]

[0] https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?most_...

Canada? Switzerland? Germany? Yes they pay a lot worse for some jobs (software developer, and, more relevantly, doctor) but ordinary fully-loaded employee costs aren't that different from the US. Admittedly, the countries more comparable to the US tend to be more in the 60-70%-of-US-spending range, than on the lower end.

That does mean that even allowing a generous premium over the most-comparable peers, we should be able to cut total healthcare spending 20% while covering everyone and removing a major drag from our economy, and a major factor reducing overall US QoL. As it is, we're struggling (and largely failing) to even keep cost increases to merely the inflation rate.

Companies had to include extra benefits beyond wages to compete on hiring. One of those extras was health care.

That's the original "design."

https://thehill.com/opinion/healthcare/469739-the-employer-h...

...and obedient to corporations.

Such mechanism give corporations the power to decide who gets terminated and loses health insurance. It's very effective at discouraging people from doing anything that goes again the grain, like getting into an union.

And the most obnoxious part of it all is that you knew this.

It's not clear to me that most employees do know that, actually. I see a ridiculous number of people that oppose nationalized healthcare "because they'd have to pay taxes", not realizing that there is already a deduction from their total compensation to pay for their healthcare (i.e. a tax).

Maybe don't generalize from a few personal anecdotes to the functioning of the entire 4 million employee federal government?

But to directly answer your question: if you want your dollars spent effectively, you should care about fraud rates in services you pay for (public or private).

https://www.cfo.com/risk-compliance/2021/03/ubiome-founders-...

The US government spends about as much per capita on healthcare as say France, but doesn't cover everybody and without part B is pretty incomplete.

See this plan for example: https://en.m.wikipedia.org/wiki/Healthy_Americans_Act

It would transition away from employer-provided health insurance, to employer-subsidized insurance, having instead individuals choose their health care plan from state-approved private insurers. It sought to make the cost of health insurance more transparent to consumers, with the expectation being that this would increase market pressures to drive health insurance costs down.

Health insurance is one of the least concerning things for the government to get involved in with healthcare, really. Worst thing that happens is they don't insure you or the procedure, and you have to pay for it yourself somehow.

I would question the viability of government for handling many things, but collecting taxes and distributing funds is one of the things they usually are pretty good at. Some of the leanest health insurers in the US in terms of overhead are public enterprises, e.g. the VA and various state assistance programs.

It's a very similar system, the real difference is that it's illegal to not have insurance, so you are "forced" to always be insured, and unemployment support is more generous.

This sounds more like a hypothecated tax.

American government is a uniquely incompetent form of government. Despite being one of the largest & most expensive governments it gets little to nothing done. Anything that is 'done' is often done far over the original projected budget.

Objectively untrue by any serious metric you'd like to go for, and in particular government-run health insurance programs (Medicare chief among them, but also the VA) are notably well-run and have low incidence of fraud while maintaining remarkably low overhead.

And yes, SS is absolutely welfare and it is extremely effective. It reduces the poverty rate of the elderly by nearly 30%. It also reduces, directly and indirectly, child and young adult poverty by meaningful amounts as well, 1.5% and 3% respectively.

Regarding your first point, I disagree. I think the intention is clearly to provide a direct benefit, but that isn’t always the effect. One example which seems to be entering the zeitgeist now is student aid. The presence of additional student aid has a high correlation with the rise in tuition over time, but I think we’d all struggle to say it was commensurate with to the cost.

Addressing your second point re: social security and perhaps generalizing my first point slightly, I think the statistics you cite are reductions in poverty vs simply abolishing the benefit. I don’t think they measure the counterfactual scenario of there never having been social security to begin with, and those current seniors having had their take home pay increase by some portion of the 15% of their gross pay which otherwise went to SS. Additionally, it doesn’t take into account the future debt servicing cost of current SS recipients on future generations.

SS also has always been a Pay Go system and doesn't have any debt servicing, actually the reverse is true, SS is owed money from the US government. That is, SS lent the US government money. That government debt would exist with or without SS as federal government spending is not constrained in any way by tax receipts, so SS's impact here is moot.

To your point about student aid, that is far more complicated. While it is likely true that the existence of the aid has resulted in some upward pressure on tuition, it is not the only factor. Increased demand both in quantity and quality of services, reduction in direct public aid to institutions, and increasing administrative costs among other things all play a part. Without student aid, it is likely true that prices would be lower, but probably not nearly as much as one would assume, and we would have a far less educated populace. The latter being a substantial negative in a world where the best paying work is and continues to be more knowledge based.

Also, education is rather interesting special case in that it's a highly price-insensitive good in the modern economy.

I think "annoying" is a better description. It's not shocking at all, it was a fairly predictable outcome given the situation. It is really annoying that we haven't managed to walk it back to something more reasonable since then.

But man, when you do have a medical emergency, it's great not having to think about whether you're going to have to remortgage your house, sell your kidneys, put your kids up for adoption or reconsider all of your life plans.

Personally I think Canada is a little bit over-dogmatic about rejecting a parallel private system entirely: I know there are problems with running two systems (mainly around inequity and brain-drain incentives for healthcare workers to move out of the public system), but IMO, nothing that can't be fixed by sufficiently high prices/taxes.

Keep in mind that medical bankruptcy isn't unknown in Canada either - not being able to work is a bigger cause of medical bankruptcy than medical bills themselves.

Tying your personal health and that of your loved ones to your employer gives your boss unduly leverage over yourself, particularly when there are life and death decisions to be made.

historically Protestant work ethic + unrestrained pursuit of profit + weak labor protections and domination of corporate interests in the halls of legislation = predictable outcome.

Recall the intense pressures on FDR from both sides. Eventually the unions won some important concessions, but the corporations still had sufficient representation to ensure the system calcified into one that continues to funnel capital upward.

I was born with heart defects, pre-aca it was literally impossible for me to get private, non-corporate coverage, I tried for years.

At least denying coverage for pre-existing conditions means that getting diagnosed between jobs isn't a complete family destroying death sentence like it was for mine.

But ACA did what it could with the political compromises that had to be made at the time. It provided out of pocket maximums, maximum age rating factor (age 64 only pays 3x age 21), and required coverage for all applicants (removing risk of disqualification from pre existing condition).

It is unfortunate the mandate was repealed and state level participation in functioning marketplaces was politically hampered.