It isn't like US public system, medicare, is great. I still end up buying my folks supplemental. This narrative of pubic vs private misses most of the nuance.

there's so much nuance in an insurance company having billions left over every year after subtracting payouts from premiums! it's sooo complex and nuanced

> why the US accepts

Because we don't have another option. Your job dictates your insurance, not you, and most jobs explicitly search for insurance companies that don't end up costing them much (but cover enough that people still think they have coverage, maybe).

There's stories going around right now about how BlueCrossBlueShield is going to be dictating the amount of time during a surgery that anesthesia will be covered. https://duckduckgo.com/?t=ffab&q=blue+cross+blue+shield+anes...

Of course, these stories are happening after individuals have made their elections for insurance AND after the companies that would be choosing the various insurance companies to pick from would have already selected their projected insurance provider.

> Your job dictates your insurance, not you, and most jobs [...]

This is answering the question with a very narrow focus on what any one person can do. Sure, when I filled out my job's open enrollment last month, there was no checkbox labeled "Evil Corporation Insurer (y/n)", but there's no inviolable law of nature that requires the US to be this way.

I agree! There's no inviolable law.

What there _is_, is too much pain and too many spoons that each and every person needs to manage every day, and most (nearly all) people are unable/unwilling to let even more important things drop.

We also have crab mentality in the US, where if one person hopes for, or even gets, something better, they're pulled back down.

And we have an efficient, powerful propaganda machine that tricks people into voting against specific areas of their interests - see "I love ACA, but I hate Obamacare" commentary.

The work to fix this is terrifyingly hard and *huge* and the people that will choose to fight and improve the situation will be making absolutely enormous sacrifices to do it.

>I love ACA, but I hate Obamacare

To be fair, ACA passed, and here we are. Healthcare companies are making more than they ever did. Have you considered that powerful propaganda machine works both ways?

https://www.axios.com/2024/08/08/insurer-profits-health-care...

Maybe that's because profit obsessed entities who are run by evil people are like the Borg in that they adapt and find ways around obstacles.

Think this is a failure of govt to use capitalism as an effective tool. More competition in the insurer space means non-evil players can afford to manage risk

When the company you work for is the one that decides on and buys your insurance, not you, how does a particular insurance company's "non-evil-ness" factor in?

If we had more insurance companies instead of a few that dominate the market, then your employer would have more choices. More competing insurance cos would lead some to differentiate by having a reputation of honest claim handling while also not being the most expensive option. It would then at least be possible for an employer to choose better insurance companies.

Why should your employer be the buyer? It's just a way of chaining people to specific jobs. I'm constantly perplexed by people's eagerness to rationalize the structure of an obviously dysfunctional ysstem.

I think that's a valid and even __good__ question.

The historical reason for why it's tied to specific jobs is because salaries couldn't raise for a period of time in US history and so jobs started offering other perks, like paying for all or most of your health insurance.

Now, companies get group discounts and still (often) pay meaningful percentages of many employees healthcare, and so getting private insurance is a nonstarter.

I think a main root cause of high insurance costs is failure of govt to break up health company monopolies and other impediments to a competitive marketplace like no individual mandate which should make it hard for smaller players to take on risk that they can afford to manage.

wrong take, companies started consolidated right after ACA passed.

It was less concentrated industry before the ACA.

the fundamental reason is as usual: too much government regulation that was erected with good intentions, but ended up becoming a competitive Moat that reduced the competition and entrenched big players. With that amount of regulation healthcare should be universal like in Canada or UK.

To maintain private healthcare sector, there should be less government

>too much government regulation that was erected with good intentions, but ended up becoming a competitive Moat that reduced the competition and entrenched big players.

While I agree with this, that regulations are often championed and even written by entrenched companies to increase the barrier to entry, the government can sue to block any merger they deem a harm to competition. Unfortunately they choose not to.

AI is a good example of this. If the government regulated AI, the only companies who will control and profit from AI are the ones who already have it.

It's not surprising that a law whose goal was increasing the customer base for a service also increased the profits of that industry.

Exactly. There's a lot of talk about trade and other countries "ripping off he US", but almost no mention that the US pay significantly more for the same drugs sold in other countries.

The narrative that we're getting 'ripped off on trade' is a myth. In the real world, when someone says "I got ripped off" it means they were overcharged for something. In politics, getting 'ripped off on trade' means we're being undercharged by foreign countries, which is apparently less desirable than being overcharged by Americans. Seems like the only trade here is a fake rip-off for a real one.

I wonder how people would respond to a survey that asked: "Would you support policies that aim to increase foreign drug imports to bring down pharmaceutical prices?" and a follow-up: "If yes, what about lumber, steel, etc?" My guess is that many would say yes to question 1, but not apply the same logic to other goods.

Propaganda is very effective when there's some kernel of truth behind it.

For this trade deficit question the important context is that some trade partners artificially devalue their currency (relative to the USD) to maintain strong export advantage (which therefore directly disadvantages their own people, since their wages are worth less on the global market, ie. when they are importing they have to pay more, when they are going on a vacation abroad they have to pay more, and this is a large chunk of the "missing trade" (the trade deficit), which translates to missing demand for US exporting sectors.

The other important piece of the puzzle is that US residents are also negatively affected by one distinct factor, which is the resource curse of the dollar's reserve currency status. Because due to the exorbitant privilege[1] (of the USD being the de facto global reserve currency) the financial sector is at an advantage compared to other sectors, and it slowly crowds out other economic activity.[2]

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

[2] https://www.phenomenalworld.org/analysis/the-class-politics-...

Changing the laws is an option. But it's not happening because many of our politicians are corrupt.

They're limited only because of poor regulations and caps on the market, exclusivity agreements of hospitals, tying of healthcare to jobs etc.

Privatizing hospitals further would not help the vast majority of Americans. Without non-privatization agreements, the average American could not seek or afford the medical attention they need.

As someone that's lived on the Canadian border for the past 20 years, I frankly think we need more regulations. Drug prices in the US are so absurdly high that most terminally sick Americans will happily drive back and forth to Windsor if it means treatment they can afford. It's a testament to America's core dysfunction, something that Canada can somehow get right on their first try but America... well, we struggled to put Shkreli behind bars.

That is absolutely true, even no matter the government, even a non-capitalist socialist commune must allocate and there's no right answer. It can become insidious in capitalism. We have organizations like Kaiser who say "we'll run the hospital and focus on preventative care, if we spend $50 today that avoids $50,000 a few years from now" - Kaiser notably does hospitals AND insurance in a vertically integrated manner. That's all reasonable. Then a United might see "we can spend $5,000 today and patient will be healthier-ish, or $200 yearly for a medically equivalent treatment". And so they do the actuarial math that the patient will die in a few years, they calculate revenue from that patient based on how long they might stay on the plan, and find the solution that maximizes profit. So the mentality isn't Kaiser-like "i.e. we're on the hook for this patient, let's minimize their health problems to save money", it's more like "we will minimize the cost of this patient full stop, if that means they don't get care then they don't get care"