41 ms·

Affordable Care

• pavlov 10y ago
  I've always disliked how right-wing parties automatically get to enjoy the assumption that they are "business-friendly". That's not the case -- their policies tend to be friendly to existing big businesses, but may be deeply hostile to new or merely potential businesses. This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.
  • adrianparsons 10y ago
    Similarly, I wonder what awesome things could be done if we didn't spend such a high percentage of our GDP on health care.
    • verelo 10y ago
      Same. Probably a similar economic outcomes to what would happen if we didn't provide sanitation / water services to the general population.
  • nickff 10y ago
    These problems are all a result of the huge tax benefit given to employer-provided healthcare; if we got rid of that or extended it to apply to individual plans as well (and hopefully allowed people to purchase out-of-state insurance), it would reduce costs, and allow for more job freedom. I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.
    • lsiebert 10y ago
      A tax benefit works only if the person has income to offset. If you are a freelance developer and you get sick with a life threatening or chronic illness or even just injured, you may not be able to work while you are getting treatment. If you want more job freedom, a needs based subsidy based on tax income allows cost shifting from years of productive work and tax earnings to years where you can't work, even if your productive work comes later in life, after treatment. It also provides for those who may never be able to earn enough working to pay for current health insurance, those who are retraining latter in life, and those starting a company.
      • nickff 10y ago
        If I were campaigning for something similar to what you describe, I might sell it as a refundable tax credit, which would be no change for people with employer-provided healthcare, and a benefit for the unemployed or self-employed.
        • khuey 10y ago
          This is essentially what the ACA's Premium Tax Credit is.
    • cookiecaper 10y ago
      Insurance is a terrible model for health care. Everyone needs health care. Insurance only works when you have a large pool of persons paying premiums against an at-least-relatively unlikely risk. That might work for things like cancer, but it doesn't really work for anything else. We should not have to have an insurance policy for a doctor check out that weird lump on our thigh or come in and spend 10 seconds pretending to talk to us before scribbling out a prescription for something that vaguely sounds appropriate and walking out. Insurance is what distorts these markets. Patients need to pay doctors directly again. Real competition needs to be returned. Right now, the doctor inflates their bill 5x because they know the insurance is going to talk them down, the insurance talks them down because they know they're going to inflate the bill and not worry about it since it's an insurance company paying out, and round and round we go. There's no reason the market for medical care needs to be different than the market for food, which is cheap and abundant. People often say that you can't can have an efficient medical marketplace because medical care is emergent, but that's usually not true; most medical care, like most meal times, can wait long enough to allow the patient to make a choice between competitors, and providers who charge more than the average demographic in their area can afford will go out of business. The incentive to overcharge for emergent care is countered by the incentive to compete, which has already lead to many "urgent care centers" arising throughout the U.S. Good government regulations that prevent cartels from organizing and causing the markets to freeze up/fail can help. These regulations should include outlawing medical insurance. Whatever the solution is, the current situation is an abject failure. ACA band-aids a couple of warts but it gave us new wounds in the process. Whole thing needs to be torn down and rebooted based on sound market principles.
  • k__ 10y ago
    We have the same problem here in Germany. The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment. Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit. There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\
  • resfirestar 10y ago
    I see it as part of the DC bubble effect. What is considered "pro business" is defined by corporate lobbyists, what is "pro labor" by the unions with the largest bureaucracies, and so on.
  • phamilton 10y ago
    The ACA increases the opportunities for young people and people with chronic illnesses. By distributing those costs, healthy individuals pay more in premiums, which limit their opportunities. If we are optimizating for overall economic productivity, far more people benefit from not having the ACA.
    • bduerst 10y ago
      Not when you factor in more insured people means less expensive medical costs - i.e. more preventative care and less emergency room visits.
      • Amezarak 10y ago
        I'm not sure it is or will work that way, in practice - the more preventative care, less emergency room part, anyway. The total cost of my health insurance premiums is about 20k/year; some of this is subsidized by my employer. I have a $4500 deductible. The insurance does not pay for anything, outside of preventative care, until I've paid $4500. After that, they contribute 80% up to some number, $7500 I think, and then they contribute 100% until the end of the calendar year. Because I have such a high deductible, and due to the opacity of medical billing, I am not going to the doctor unless I'm pretty sure that not going to the doctor means I'm going to be put out of work or going to die. "Preventative" care is defined very strictly: you get a physical. For example, "preventing" the development of pneumonia by treating your respiratory illness early does not count as preventative care. The best I can do is squirrel away what I can in my HSA...but that's one health catastrophe from being blown away. God forbid I come down with any kind of chronic illness that lasts longer than the calendar year. That said, for the poor population, this is definitely true - Medicaid is a dream compared to private insurance. At least in my state, if you're on Medicaid, you don't even see medical bills. It's really lamentable the states were allowed to turn down the Medicaid expansion - the expansion of public health insurance was the best part of the ACA, in my opinion, and the most regrettable part of the bill is that the public option is not available to everyone.
        • bduerst 10y ago
  • BurningFrog 10y ago
    > their policies tend to be friendly to existing big businesses, but may be deeply hostile to new or merely potential businesses. There is a big distinction between "pro free enterprise" and "pro business". The former supports capitalism, the latter crony capitalism. > Under Republican policies, these businesses would not exist I think the GOP has yet to figure out what their health care policy even is. They really need to figure out how to be for something again.
    • rm_-rf_slash 10y ago
      They are for free market radicalism. It can hardly be considered "conservative" but it is certainly for something.
      • chimeracoder 10y ago
        > They are for free market radicalism. It can hardly be considered "conservative" but it is certainly for something. Neither party is really in favor of free markets in any meaningful sense. The GOP happens to use that rhetoric more than the Democrats do in order to gain support for their policies, but knowing how to leverage the rhetoric doesn't mean that's what they actually support, if you look at their actions.
    • lsiebert 10y ago
      I really think the GOP needs to go with evidence based policy analysis. If they think they can come up with a better health care system, fine, but what are the metrics for better? health care costs have gone up way past the amount of inflation, and to some extent that makes sense, because there are new treatments, but it seems like tax breaks are not going to help the working poor to the same extent that the ACA subsidies and medicare expansion do.
      • nerfhammer 10y ago
        The GOP essentially came up with the ACA in the first place.
    • 10y ago
  • misnome 10y ago
    "Pro Business" means, "Pro-me" which means, "Pro to the businesses that bribe^H^H^H^H^Hlobby me.
  • tasty_freeze 10y ago
    There is also the mantra that Republicans are the party of small government and fiscal responsibility. Nope, the difference between Democrats and Republicans is what they want to spend the money on. This is just a fact, easily verified by looking at the debt across decades of various administrations and congressional alignments. A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this: http://www.patheos.com/blogs/dispatches/2017/01/11/republican-budget-bill-raises-debt-ceiling-10-trillion/ http://www.patheos.com/blogs/dispatches/2017/01/11/republica... Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.
    • enraged_camel 10y ago
      We also know for a fact that Republicans aren't in favor of the government staying out of people's private lives. They are, after all, strongly anti-abortion, which by definition is an extremely private affair. edit: what I said is 100% correct, so I will assume that the downvotes are simply political in nature.
      • MrZongle2 10y ago
        "We also know for a fact that Republicans aren't in favor of the government staying out of people's private lives." I think it's pretty clear at this point that both parties love getting involved in the private affairs of individuals. Obama continued Bush-era spying policies, and in fact just this week (https://news.ycombinator.com/item?id=13390511 https://news.ycombinator.com/item?id=13390511) expanded the power of the intelligence community to snoop on Americans. Blaming just one political party is demonstrable nonsense.
        • 10y ago
• jchrisa 10y ago
  ""my only option was to work for a large employer with an established health plan that would provide me with the appropriate benefits to support my situation"" I think the anti-ACA lobby sees this as a feature not a bug.
  • epistasis 10y ago
    I'm not entirely sure that's true. I think a lot of the anti-ACA lobby is doing it for purely partisan reasons. If the ACA succeeds then its a counted as a big win for your opponents, so you fight like the dickens to make sure it doesn't work out. Similarly, a lot of people that support the ACA don't support the ideas behind it, as much as they support something being done from the previous, untenable situation. Obama took mostly Republican ideas and ran with them, now the Republicans have disavowed any involvement with them, and Democrats have adopted them as good (or at least better than what was there before, even ACA supporters acknowledge that it's a deep compromise from what anybody wanted.) I think that the attitude of "it's going to help my side or nobody" is a much stronger driving force than the desire to prevent people from taking entrepreneurial risks.
    • jchrisa 10y ago
      Tactically you are right, but the people who fund the think tanks that fuel the fires you are describing, are playing a longer game. Same people and motivations behind the de-education of Americans kicked off by Reagan.
• sergiotapia 10y ago
  It's a balancing act though, no? Health Insurance is stupid expensive in the US. In Bolivia I used to pay $300/month for my entire family full coverage, no copay. But they did screen for preexisting conditions when I signed up. So what's the answer? How can health insurance providers help people with pre-existing conditions, and also not gouge young healthy customers? Is the healthcare industry just charging too much money?
  • nradov 10y ago
    Asking everyone to pay into a shared risk pool is not gouging. That's simply the nature of insurance. We're going to have to pay for people with pre-existing conditions one way or another, whether it's structured as a tax, penalty, or insurance premium. Certainly there is some waste, fraud, and abuse in the healthcare system which could be cut. But ultimately the only way to significantly cut costs would be to ration care. It's a hard issue and no one likes to talk about it.
    • maxerickson 10y ago
      It's the nature of universal insurance with no lifetime limits. In terms of insurance, it's perfectly possible to write healthy young people a significantly cheaper policy that has limits and is no longer available as they age. It's probably pretty stupid for the young people to opt for that policy, but whatever.
      • cmdrfred 10y ago
        What is interesting is the really expensive portion of insuring individuals is already essentially single payer. When people age most of them end up on medicare and the majority of health expenses happen in the weeks and months prior to your death.
    • sampo 10y ago
      > But ultimately the only way to significantly cut costs would be to ration care. As far as I know, Western European countries spend about half (per capita) on health care as what USA spends. I don't know if US health care is that much better. And if it's not, then in theory there is a way to get the same results cheaper.
• Walkman 10y ago
  > I had no insurance and had stopped all physical activity beyond basic exercise for years, being too scared to hurt myself Now you can hurt yourself no problem, or you can hit by a bus if you want! What a stupid thought. Having no insurance is not an excuse for being active.
  • j2bax 10y ago
    Downvoted. It seems like a perfectly legitimate concern for someone that can't afford to pay for a fracture out of pocket.
    • Walkman 10y ago
      Come on, you really behave differently and put yourself at risk if you have insurance? That's at least thinking backward but I think it's stupid. I don't do things when the risk of getting hurt is not acceptable for me no matter if I would have insurance or not. Also it's mostly for disasters so you don't go broke, but if you scratch your knee or something, who cares?
      • j2bax 10y ago
        I'd be far less likely to engage in semi-extreme activities that I enjoy (mountain biking, snowboarding) if I didn't have the safety net of insurance to cover me should an accident happen. I love those activities, but if they have the potential to put me both forever in debt and bad health, I'm probably going to think twice about it. At a minimum I'm going to enjoy them a bit less and not take as many chances. It would be unfair to my family to expose them to that kind of financial risk just for my enjoyment. With insurance I'm confident even if I were to be killed enjoying one of those activities, my family wouldn't be left paying the bill for the rest of their lives. Exercise can involve a host of activities and anything more than geriatric routines expose you to potential injuries you could otherwise avoid.
  • mschuster91 10y ago
    > or you can hit by a bus if you want Given that cars are obliged to have insurance, said insurance will pay for victims' healthcare costs. In Germany, there is a special state fund to pay for the rare case of an uninsured vehicle being involved in an accident.
• nradov 10y ago
  For those with a Wall Street Journal subscription, they had an excellent unbiased article on the economics of providing healthcare for people with serious medical conditions. Anyone trying to reform or repeal the ACA will have to address this issue. "Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay" http://www.wsj.com/articles/health-cares-bipartisan-problem-the-sick-are-expensive-and-someone-has-to-pay-1484234963 http://www.wsj.com/articles/health-cares-bipartisan-problem-...
  • secabeen 10y ago
    Here's a non-paywalled version: https://www.msn.com/en-us/money/healthcare/health-cares-bipartisan-problem-the-sick-are-expensive-and-someone-has-to-pay/ar-AAlNV6S https://www.msn.com/en-us/money/healthcare/health-cares-bipa...
  • x0x0 10y ago
    It's an unwarranted assumption any Republican plan will deliver health care to very sick people. Except perhaps enough of a sham to get the legislation passed in the glare of the media.
• phamilton 10y ago
  Many of these stories suggest that you'll have less overhead (and more runway) as a 25 year old found than as a 27 year old founder. I'm not convinced that's providing productive selection criteria.
  • mjolk 10y ago
    The anecdotes illustrate that there were two main benefactors: young people without formal full-time employment and those with pre-existing conditions that had allowed insurance coverage to lapse. From someone too old to be on their parent's insurance, while I'm 100% behind the reform that disallows previous conditions from affecting ability to get coverage, the ACA was effectively a shake-down that made me delay taking the risk to go full time on my startup -- the options for coverage in my state were expensive and very low-quality, and the penalty for opting-out would have been $4000 for my domestic partner and I (on top of the additional taxes we paid to support ACA).
    • phamilton 10y ago
      Thanks for sharing. I alluded to this in another thread but got downvoted and stirred controversy. My claim is this: For the median entrepreneur, there is more financial drag due to insurance now than there was before the ACA. For those who are sick or young, there is less financial drag. Your story anecdotally supports that claim.
      • mjolk 10y ago
        Yeah, I think that there's a political type that is just a zealot scared of anything that will challenge his/her worldview and feels a need to flag/downvote/hide. The reform surrounding pre-existing conditions for people that let their health coverage lapse is the only good thing that came out of the ACA, and it was very expensive for the taxpayers and continues to be. This should have just been a piece of legislature and not a terrible government shakedown of the American public; a simple reform was needed, not another way to subsidize the non-working while compelling the public to give money to private corporations.
• senthilnayagam 10y ago
  Sam Altman should get a list of all YC startup employees insurance data made public, maybe with a a small questionnaire form with objective questions. That way analysis becomes easier and all perceived sample biases can be alieviated.
• justicezyx 10y ago
  Isn't the biggest part of health cost is from drug company and insurance company? If that's the case, addressing the cost is the foremost issue, instead of forcing everyone to join a universal plan. That does not help addressing the root problem above.
  • misnome 10y ago
    So basically, your argument is to do nothing to help anybody unless you have a magical fix-everything-in-one-go plan? Good luck trying to get political support for anything that hurts the insurance companies.
    • justicezyx 10y ago
      Isn't there plenty of fixes demonstrated many places already?
  • beat 10y ago
    The biggest cost driver is complexity, not profiteering. The Japanese system is not terribly different from ours - it still depends on private employer-provided health insurance. But per capita costs are less than half the US cost, with higher utilization and far better outcomes. The key difference is that Japan has strict national-level price controls. The price of identical products and procedures is identical in every facility. This eliminates both complexity and negotiation between insurance and providers. A government board carefully tracks costs for profiteering and makes adjustments. Do that, and you get rid of the whole "in network/out of network" nonsense of the American system.
  • maxerickson 10y ago
    No. Insurance companies have to spend a majority of premiums on healthcare or rebate them to consumers. So the money goes to providers and drug companies. We spend several times more in hospitals and clinics than what we spend on prescription drugs: http://www.beckershospitalreview.com/finance/17-fascinating-statistics-on-the-current-state-of-us-healthcare-spending-finances.html http://www.beckershospitalreview.com/finance/17-fascinating-... (nearly $1.6 trillion to large providers, $300 billion to drugs) So the costs are not concentrated in drugs and insurance. There are certainly some drugs that are very lucrative, it's just that they aren't the dominant spending.
• danjoc 10y ago
  Affordable Care Act? https://ycharts.com/indicators/us_health_care_inflation_rate https://ycharts.com/indicators/us_health_care_inflation_rate Health care is not becoming more affordable. The rate of inflation in health care is significantly higher than the US inflation rate. https://fred.stlouisfed.org/series/T5YIFR https://fred.stlouisfed.org/series/T5YIFR How is that affordable? How are $600 epi-pens affordable?[1] How is a 4000% price hike on a 62 year old generic affordable?[2] Google for "snake bite hospital bill." $153,000. That's not affordable. That sounds downright fraudulent. It seems they should have named it something more appropriate, like the Universal Health Insurance Act. Insurance that is no more affordable than the overpriced health care available in the country. But point this out, and everyone starts their partisan bickering and nothing gets done at all. [1]https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-sell-generic-epipen-to-quell-outcry-over-600-cost https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-... [2] https://www.washingtonpost.com/news/to-your-health/wp/2015/09/22/turing-ceo-martin-shkreli-explains-that-4000-percent-drug-price-hike-is-altruistic-not-greedy/ https://www.washingtonpost.com/news/to-your-health/wp/2015/0...
  • whatintheworld 10y ago
    You're blaming an act meant to increase access to healthcare (which it does) for the prices that drug companies choose to charge?
  • basch 10y ago
    Less Unaffordable for 20% of the Population Heath Care Act ? Mandatory Purchase of Service from Private Industry Act ? either way it was a redistribution to some at the expense of others. decide yourself which moral side you sit on.
    • giaour 10y ago
      Do you feel the same way about the liability collision insurance your state government requires you to buy to drive on their roads?
      • basch 10y ago
• thembones 10y ago
  One of the best experiences I had was actually going through a different site which seemed to have even more options than Healthcare.gov, https://www.policygenius.com/health-insurance https://www.policygenius.com/health-insurance I'm sure there's more as well, but this definitely helped several friends of mine. Seems like these kind of things would have been impossible without large swaths of the ACA.
• bruceb 10y ago
  If you have to read this thread then call your rep. It litterly is about a 30 second call. http://www.house.gov/representatives/find/ http://www.house.gov/representatives/find/ Even if you have a rep that favors the ACA it gives them an idea how much effort in to saving it.
• jMyles 10y ago
  This post, especially presented as it is through the voices of these founders, makes an important point. However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores: Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA. The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA. For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.
  • wonder_er 10y ago
    > The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA. Absolutely agree. The ACA (or repealing the ACA) are both "solutions" to the wrong problem. So much potential innovation in the health care space is illegal. If it wasn't illegal, someone might (gasp!) find a way to provide a valuable service for less money than in the current system. It will not, and cannot, be fixed by regulation, because of what you said - any regulation MUST be approved by the big companies. They'll never approve something that goes against their interests.
• feistypharit 10y ago
  Thanks for writing this. Whatever your view on the ACA, you can probably agree that health is important. It's a tough problem, how we handle it will define the US more than anything else in the future.
• alphabettsy 10y ago
  I have no pre-existing conditions, but being able to sign-up using the exchange was a big reason I was able to go full-time in a small business rather than continuing to work part-time for a large company to keep health benefits. The monthly premium is too high in my opinion, but one hospital visit made it worth it. Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.
  • DoodleBuggy 10y ago
    > I have no pre-existing conditions Have you been to a doctor before? Then you might have a pre-existing condition.
  • amyjess 10y ago
    The exchanges are terrible. In Texas, the only options available on the exchanges are HMOs, and in large chunks of the state, only a single provider is available. If you don't have employer-provided health insurance, you're still basically screwed even under the ACA.
    • alphabettsy 10y ago
      Texas. Need I say more? The state chose to make ACA as unworkable as possible.
• virmundi 10y ago
  When my wife and I looked for insurance just before ACA, the private plan without subsidies, because they didn't exist, was $250. It was a basic plan with a high deductible and an HSA. It was pretty much what my employer offered. After the ACA, same plan, by name, now cost $530. Sure it had more bells and whistles, but I didn't want nor need them. This priced me out. This same plan today is $780 a month without subsidies. We are now on an ACA plan. $270 with subsidies. Think about that. The government doubled the price of the plan or more, and is paying with our tax dollars the difference between my $270 and $780. The ACA helped many people. It helped people under 26. It helped people with pre-existing conditions. It helped give free or low-cost health care to people that couldn't afford it because now the government is picking up the lion's share of the tab. As much as people like to rag on the Republicans, and they deserve it, I don't think they will throw out the good parts. I think they will look at the industrial recommendations such as expanding risk pools across states (Commerce Clause allows this regulation), and other rational plans. Will it be perfect? No. Will it be better than the current ACA? Maybe.
  • alphabettsy 10y ago
    What evidence is there that the government itself doubled the price of the plan? The government doesn't collect the money, and it certainly goes somewhere...
    • virmundi 10y ago
      It's at least correlated. Within 1 month's time, the plan cost doubled. The ACA required insurance to cover things like mental health care. As a result, the plans had to be more expensive since they needed to cover more.
    • JonFish85 10y ago
      If you're looking for something directly in the law, you're not going to find the government saying that prices should be raised. It's a second-order effect; there was minimal cost control in the ACA, and plenty of room for companies to raise their prices. In a lot of ways, it was a sweetheart deal to insurance companies: they had essentially a mandate for people to buy their insurance, demand was through the roof, so they could charge more.
• nooron 10y ago
  The prevalence of employer-offered, private health insurance is – like many facets of American life and institutions – an interesting path dependency of WW2. The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.
  • beat 10y ago
    Labor unions as well, who picked up on negotiating health care benefits for their workers. It's an interesting bit of history. Still, we all know what it's like to have a major design flaw in the legacy codebase.
    • Apocryphon 10y ago
      Labor unions... we also know what it's like to be dependent on a crucial services that are no longer being supported...
• ftrflyr 10y ago
  "I had heart surgery when I was 18. I was virtually uninsurable. I now have health insurance. Why we need the ACA is no more complicated than that." I am a bit confused by this story. Was Zach not covered under his families' health coverage? He also went to: Westminster School - one of the most expensive private high schools in the US. Now, one could argue he had a pre-existing condition and thus, was not covered under any health care providers plan, but he states: "I was virtually uninsurable." This tells me there were options, but none that covered the entire cost of the surgery. Honestly, this story alone makes me seriously question the purpose of this post.
  • wrsh07 10y ago
    I think he's saying after the surgery and before the ACA, he was "virtually uninsurable."
  • Pfhreak 10y ago
    He seems to be implying that, post surgery, he had a preexisting condition that would prevent further insuring for the rest of his life. The heart surgery itself was (presumably) covered, but after that he was on his own.
  • illumin8 10y ago
    The ACA allowed adult children to stay on their parents insurance until age 26. Without this provision, Zach would have been kicked off his parents health plan and been uninsured at 18. He probably wouldn't have even been able to afford the heart surgery in the first place.
  • maxerickson 10y ago
    The heart surgery is now considered a preexisting condition when the individual tries to buy their own insurance. That's why it is mentioned, it is very likely it was covered by their family insurance.
  • mr_spothawk 10y ago
    This comment captures a feature of a lot of discussions I've read: somebody's got an axe to grind. It's unfortunate that we're not able to get these conversations going in a way that's ... what? "unbiased"? I don't know what I'm asking for, but I think it's some variant of honesty and openness. And I think that we're missing a lot of the truth, for ourselves and others, by having to couch our statements in ways that aren't entirely forthcoming. That said... I'm still glad that medicaid covered my uninsured ass when I broke myself trying something I'm not good at (skiing). I remember thinking (as I was bundled up in the medic's sled) that I was not too different from some New Zealander with a busted body part... about to be carted off to free medical care, to get me back on my feet and working as quickly as possible. Thanks, Obama.
• Jemaclus 10y ago
  Arguments against ACA: - It cost me money - It's not perfect Arguments in favor of ACA: - It literally saved my life Regarding increasing premiums, the complaints tend to be anecdotal. According to the National Conference of State Legislatures, in 2016, the average monthly net premium increased just $4 -- or 4% -- from 2015 to 2016 among the insured that take advantage of subsidies.[1] Furthermore, premiums have gone up year-over-year every year almost every year since I've been paying for my own insurance -- and that's well before ACA. There's an interesting chart on the Kaiser Foundation website, where it shows the average plan prices and percent increase year-over-year broken down by state. It also shows that, after tax credits and with very few exceptions, plan prices have remained stable (0% change) between 2015 and 2016. I understand and sympathize with the high premium prices, but I have serious reservations about the assertion that the high premiums are due to the ACA and not external factors. [1] http://www.ncsl.org/research/health/health-insurance-premiums.aspx http://www.ncsl.org/research/health/health-insurance-premium... [2] http://kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/ http://kff.org/health-reform/issue-brief/2017-premium-change...
  • enraged_camel 10y ago
    >>Furthermore, premiums have gone up year-over-year every year almost every year since I've been paying for my own insurance -- and that's well before ACA. Not only that, but they were increasing at a much faster rate before the ACA. Of course, most people didn't notice, because those who were employed were covered by their employer, and the unemployed were uninsured.
    • kmkemp 10y ago
      And also, it was very easy for insurance companies to drop a few expensive procedures in the small print to maintain the same premiums. Then, when customers actually had to use their insurance, they get screwed.
  • ErikVandeWater 10y ago
    > - It literally saved my life Could you expand on this?
• mr_spothawk 10y ago
  I quit my job and moved to Colorado ("Health First Colorado" === medicaid). Over the winter holiday I broke my collarbone. If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else. Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes. * - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about. edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P
  • turar 10y ago
    I'm confused, is Colorado Care actually working in CO right now? Quick search seems to indicate that Amendment 69 has failed: http://www.denverpost.com/2016/11/08/coloradocare-amendment-69-election-results/ http://www.denverpost.com/2016/11/08/coloradocare-amendment-...
    • mr_spothawk 10y ago
      Sry... I'm new to CO. Your'e right... Amendment 69 failed (72% against or something?!?! who knows... I voted in favor). The correct name is "Health First Colorado". I signed up the day I was hurt, they backdated the signup to the month prior. It took less than 15 minutes to become covered. I've been working for 20+ years, with spats of insured or not-insured throughout... mostly uninsured. After I left my SF gig, I gave up my insurance & didn't get any more since I'd already had 6 months for the year. By the end of December, I needed it. Edit - link: https://www.colorado.gov/hcpf/colorado-medicaid https://www.colorado.gov/hcpf/colorado-medicaid
      • rgbrenner 10y ago
        I'm in colorado.. just to be clear, we definitely do not have any type of universal coverage here, and Health First Colorado is not open to everyone. It's just normal medicaid. They didn't care if you signed up when you were injured because you would have qualified for it anyway... you just didn't complete the paperwork. You definitely cannot do this when you exceed the income limit for medicaid and have to get normal health insurance. The ACA increased the limits to qualify for medicaid. I know there were a few states balking at increased medicaid costs.. but you could have gotten this in most states, including CA.
• DoodleBuggy 10y ago
  Nice post, the stories echo multiple people I know as well. Having health insurance tied exclusively to a job is anti-entrepreneurial. That should be fairly obvious. The ACA has flaws but it also has some great features that need to persist: minimum care requirements, pre-existing condition exclusions banned (having a pulse is a pre-existing condition BTW), no lifetime caps on treatment. What's the alternative? Still haven't heard anything.
  • frandroid 10y ago
    There is no alternative. Profits for the healthcare industry all the way.
  • amitdeshwar 10y ago
    There is none: http://krugman.blogs.nytimes.com/2017/01/10/there-will-be-no-obamacare-replacement/ http://krugman.blogs.nytimes.com/2017/01/10/there-will-be-no...
• ThomPete 10y ago
  I am unconvinced that healthcare affects the number of startups as this have been going down also after Obama got on board and is going down also in Europe (ex Denmark where healthcare is completely free) But I am all for an alternative to what we have now or what we had. The most important thing IMO is to make sure that people don't get hit by pre-existing conditions. https://www.washingtonpost.com/opinions/why-is-the-number-of-us-start-ups-falling/2016/05/19/53fe8e04-1ded-11e6-9c81-4be1c14fb8c8_story.html?utm_term=.3786a4f853de https://www.washingtonpost.com/opinions/why-is-the-number-of...
• spoiledtechie 10y ago
  I am a Republican. More in fact, Fiscal Constitutional conservative. Now that thats out of the way. I hate the ACA. Its overreach by what the government should be doing. No where in the constitution does it say the government is allowed to force law abiding citizens to do something. ACA does exactly that. It forces people to do things against their will. Or they will be forced to pay a fine. Alright, don't down vote me just yet. Lets repeal the ACA. But I certainly see things that should be quickly made into law. * Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user. * Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself. * Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it. * Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs. * Lastly, I want hospital prices published. I want to shop around. * I am business friendly, but these are common sense laws. I think EVERY Republican can get behind these thoughts as every other Democrat, but forcing me to pay for it, when I just want to live off the land in some small town somewhere. Complete overreach and strictly unconstitutional.
  • beatpanda 10y ago
    How did you just read a long list of young entrepreneurs who were enabled and encouraged to start businesses because of having their healthcare covered, and you're still writing dumb shit like "GET A JOB!!"?
    • spoiledtechie 10y ago
      Because they are in fact living off the backs of their parents. They are in fact living off the money that was funded to them by people who earned that money. Either ask for more money, or work your way through it. Its not too hard.
      • FalcorTheDog 10y ago
• Spivak 10y ago
  Something just seems wrong about a lot of these stories citing the provision that they're allowed to remain on their parents insurance until they're 26. Because the story is really, "not having to worry about the high cost of health insurance afforded me the luxury of taking more financial and career risks." Surely we can do better for people who are older than 26 or who don't have the option of getting insurance through their parents. If we wanted to give everyone this kind of benefit we would just have universal healthcare with the state acting as everyone's 'parent'. The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?
  • Domenic_S 10y ago
    > What's special about healthcare except that it's expensive? Great question. Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item. My opinion is because the system we have today is basically a wealth transfer from the taxpayers to large interest groups (nurses' unions, big pharma, etc).
    • dragonwriter 10y ago
      > Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item. Programs exist to make food and shelter universally available, as well, and while imperfect, the proportion of the population unable to afford food or shelter is lower than the pre (or even post) ACA rate of people being unable to afford healthcare. The fact that the problem is less solved for healthcare is probably why there is more visible passion on the issue.
  • 2arrs2ells 10y ago
    I could decide to live in a tiny apartment, turn off the heater and eat ramen. With a chronic condition, there's no way I could have made healthcare a similarly manageable expense (other than maintain a full-time job and limit my entrepreneurship to nights/weekends). (I'm the first story in the article)
• c-slice 10y ago
  Having health insurance be offered by employers/ tied to employment is one of the biggest mistakes in American healthcare policy. It encourages a "consume as much as possible" mindset for employees and disguises the true cost of care. Creating clarity of price and cost in healthcare would be one of the most beneficial shifts.
• kobeya 10y ago
  Here's a counter-point, Mr. Altman: I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible. I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off. Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?
  • vinhboy 10y ago
    Are you saying that if Obamacare did not exist you would be better off?
    • kobeya 10y ago
      Yes, I wouldn't have gone down a road that was cut out from underneath me, and almost lost a marriage in the process.
      • colemickens 10y ago
        Oh come on, you've got to provide slightly more detail, because that just sounds absurdly hyperbolic and exaggerated.
        • kobeya 10y ago
          No, I don't have to vent my private life on the Internet.
          • colemickens 10y ago
            You just did, but in a vague enough way as to add nothing substantial to the conversation. Obviously, I don't think you're obligated to offer any details you don't want to. I guess I assumed you had a point and weren't just firing off scary sounding exaggerated anecdotes.
• losteverything 10y ago
  ACA works. But it seems to me that young people just starting out have it so much worse when it comes to healthcare. Example. Out of college. Got job. Had insurance and didn't think much of it. $2 all RX Mid '80s had kid. 5 days in hospital (C section) and it cost $500. Insurance was 59 per month. (I making $36k) Got thrown out of tech into federal job with federal insurance. Excellent coverage. Got $102k prostetic from New york hospital for< $5000 out of pocket. My life with health insurance was been charmed. I am so glad I dont have to start like these young people.
• petegrif 10y ago
  The health system in the US is a total mess. Single payer is the only sane way to go. That too will be imperfect and ragged but it is provenly absurdly cheaper - practically all advanced industrial countries are single payer and all spend far less as a percentage of their GNP - as in half to a third - whilst covering everybody. The admin savings are staggering, the drug costs are lower etc etc.
  • saosebastiao 10y ago
    We've eliminated the possibility of Single Payer in the US, and the reason for this is stupid: Nobody on the left can criticize the ACA anymore. Due to our ridiculously partisan shitshow that we've got going on, any criticism by Democratic Party politicians of the ACA will bring a shunning from the party leaders. The only thing they are allowed to do anymore is gloss over the ACA's failings with flowery language, and say they want to "improve" it. But you can't "improve" the ACA into single payer. You can only get single payer by starting over from scratch. The pathetic thing is that a public option, the original plan, could quite easily be improved into single payer. And despite the largest Democratic majorities in both the house and senate for several decades, with a sparkly new progressive Democratic president that campaigned primarly on health care reform, they couldn't pass it. It seems the Democratic party has something to learn from the Republican party on how to get shit done.
    • woofyman 10y ago
      Single payer is considered socialism by half the population due to decades of Republican rhetoric.
      • GFischer 10y ago
        That's because single payer IS socialism. The problem is that not all socialism is bad :) . We have single-payer here in my country, and anecdotal evidence is that it works incredibly better than healthcare in the U.S. for 99% of cases (the U.S. is far better at treating complicated health problems, but at staggering costs).
    • 10y ago
• baccredited 10y ago
  Damn. I saw the title and thought YC was starting a healthcare company. That would have been awesome.
• tptacek 10y ago
  Chiming in to say that we wouldn't have been able to start our last company or this most recent one without the ACA. One of these YC stories had a founder who was rejected because they had a sleep study done. Most people have never interacted with the individual insurance market, and so don't realize that virtually any interaction with the health care system beyond a strep throat test would, prior to the ACA, get you declined automatically: you were uninsurable at any price. That's what happened to us; for instance: my daughter had an unexplained seizure when she was 4 (she's a healthy 15 year old now), and was thus declined.
• rdtsc 10y ago
  > One thing the ACA definitely did was help a lot of founders start their companies--without it, being a founder would make sense for less people Hmm. I've heard many small companies could not afford to provide health insurance for their employees after ACA passed ( I don't know the details of exactly the causal chain there ). So they stop providing it and pushed people to use ACA which had ridiculous price hikes and also in some states companies withdrawing from the exchanges. In other cases I've heard companies have pushed people part time status in order to avoid having to provide health insurance and other benefits. I think that is mostly lower wage employment. My own rates working for a small company a few years before the ACA and after went up much high even before ACA was about to pass in anticipation. There the insurance representative who we talk to every year stated clearly why there is an increase -- because of the volatility and unknown effects of ACA they decided to increase prices. After it passed and was being phased in our rates were going up much high. Some things were nicer, like no pre-existing conditions, no lifetime maximum, some free preventative checks overall it has been worse. Now, no doubt it has helped many people, but I am not sure if small businesses and their employees (especially in the tech sector) saw a benefit.
  • BryantD 10y ago
    > I don't know the details of exactly the causal chain there... This is a really sincere recommendation: if I were you, I would research that and figure out if it's true or not. There is plenty of propaganda going around on this subject from all sides; it's dangerous to rely on things you've heard.
    • rdtsc 10y ago
      Have you? What do you think is the reason?
      • BryantD 10y ago
        The reason for what? I can't even seem to validate the original claims, so...
• RRRA 10y ago
  It's frustrating to see so much energy wasted in fragmenting health coverage solutions in the US. This makes it so costly, that it _looks_ like it's too expensive or inefficient, making right wing politicians justify the fact that it should be everyone for themselves. As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly. Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts. In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.
• kevinburke 10y ago
  I'm currently working as a consultant and I'd not be able to do it without the ACA.
• noobermin 10y ago
  Of course, it's better to have a nationwide health service, now that ACA is toast, may be it is time for states to start considering health care systems within their borders. Many states have populations multiple the size of many countries which have universal health care. It could be very possible.
• gm-conspiracy 10y ago
  I disagree this is a "party" doing. Mitt Romney had similarly reformed Massachusetts law in 2006 as Governor. https://en.wikipedia.org/wiki/Massachusetts_health_care_reform https://en.wikipedia.org/wiki/Massachusetts_health_care_refo... I see the article briefly touched upon the American notion of health insurance being tied to employment. Nobody seems to want to really solve this problem, just band-aids and lip-service. Neither mainstream party would consider a single-payer system, nor direct government negotiation with drug companies. It's as though the drug and insurance companies are better represented (and have more rights) than its citizens. Heck, even Medicare is divided into at least four regions to "negotaiate" regional prices. How do other countries perceive this? The US falls further and further behind in healthcare and affordable and available high-speed internet. Let's see some real progress.
  • neonnoodle 10y ago
    > just band-aids INSURANCE EXPLANATION OF BENEFIT Adhesive bandage. . . . . . $300 | Covered: $.02 | You Owe: $299.98
• elihu 10y ago
  A few years back, I quit my job and founded an (ultimately unsuccessful) startup. A big factor in deciding to do it was that the ACA would go into effect before my Cobra coverage expired.
• general_ai 10y ago
  A fine example of confirmation bias: ACA aligns with Sam's ideological position, so he hand picks some examples to support it. Don't get me wrong, I think it's great that people with preexisting conditions can't be denied coverage. But is it OK that plans are three times more expensive now, with three times the deductible? I don't think so. Seems like a trillion dollar money trough for Big Pharma and Big Insurance to me.
  • deleted 10y ago
    [deleted]
  • lsiebert 10y ago
    Well strictly speaking, if Obama could have passed single payer, he would have. He went with a compromise based on a republican idea and negotiated with the insurers to get their support. The thing is, expensive as it is, you have the ability to get health coverage. The ACA made health care affordable to people who previously couldn't afford it at all, particularly the working poor through medicaid expansions.
    • frandroid 10y ago
      > if Obama could have passed single payer But he gave up before even trying. Way to move the Overton window.
      • richieb 10y ago
        LOL. They had to drop the public option just to get the Democrats to in the Senate to vote for the bill. Single payer would not have gotten anywhere. Never mind that it's the Congress that passes bills, not the President.
      • learc83 10y ago
        Because Joe Lieberman refused to support it. Without his support there was no chance of single payer passing.
        • 10y ago
• swalsh 10y ago
  It seemed weird to me that ycombinator wasn't at Trump's Tech meeting (considering they're at the center of silicon valley in a sense). This post makes me wonder if that was not an accident...
• tmaly 10y ago
  I would like to see prices published and anti-trust exemptions for the industry scrapped. There is absolutely no transparency in the pricing.
• edblarney 10y ago
  I have nothing to say for or against Republicans, Dems, Trump or any other political entity. BUT If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts. It's inhumane for the wealthiest country in the world to take away basic healthcare for it's most vulnerable citizens. If you are so 'smart' and so 'great' - then figure out a way to introduce efficiencies, pricing intelligence etc. to get people more and better coverage - instead of just smashing some law because it's not perfect and it was written by 'Obama'.
  • Gargoyle 10y ago
    >If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts. Which should be a very strong indication that's not going to happen. Despite the endless propaganda, Republican lawmakers are neither stupid nor evil. People are not going to be left uncared for, that's just political fearmongering, and we don't have to fall for it.
    • edblarney 10y ago
      They can definitely be stupid, and they can sometimes be borderline evil - making jail time for crack 80x greater than for cocaine because of the offender demographics, that's pretty evil (and stupid). 1) They are voting to repeal ACA in real time. 2) They have not offered even a hint of an alternative. This is not only going to be potentially damaging those who will lose their coverage - but it's also incredibly difficult for business: there is no roadmap. Insurers, and all other businesses small and large now are left in the dark with respect to their future. Introducing such ambiguity is definitely stupid, and it's 'anti businesses'. They have at least two years of unlimited power, they should debate solutions, narrow it down to an actionable plan, and then modify ACA in a well thought out process. As it stands, they're just rolling back laws and haven't discussed anything else, which I think is irresponsible. They don't need to be in such a panic.
      • Gargoyle 10y ago
• temp-dude-87844 10y ago
  Healthcare is a touchy subject because people's quality-of-life and their actual lives (vs. death) are on the line. But food and shelter are similarly crucial to existence, yet they aren't provided at no cost, but must be acquired through their own labor, or reliance on family, charity, etc. It's interesting to me that we as a society have long accepted that people have to work for food and shelter, leaving a permanent underclass in the dust, while we're uncomfortable to say the same about healthcare. But of course, it doesn't matter. Those who oppose the ACA or the individual mandate or employer requirements or the notion of healthcare subsidies are dancing around their justifications and are reluctant to come out and say that people with health complications should just be out of luck. Instead, they'll dismantle, maybe introduce an alibi entitlement scheme to save some political face, and leave a status quo with the exact same result.
  • brixon 10y ago
    There are a lot of social programs for food and shelter in the US. The food one works fine, the shelter one is more hit or miss.
    • dragonwriter 10y ago
      The shelter one may be hit and miss, but it's a lot better than healthcare support (even under, but much moreso prior to, the ACA.)
• altoz 10y ago
  the seen: people it helps the (mostly) unseen: the higher burden on everybody else Is the tradeoff worth it? That's the question.
• zmitri 10y ago
  Something of note - not a single woman on here. Pregnancy, birth control... so many expensive, and common medical procedures that are very relevant to all female founders have been overlooked or neglected.
• ccrush 10y ago
  GWB upped the age of coverage to 25 and the ACA only moved it a bit but gets all the credit. DJT wants to keep the preexisting conditions part and do away with the fines for not having insurance and increased costs of forcing insurers into the ACA by repealing it and replacing it with interstate insurance competition without the bureaucracy of a government managed program. Too bad everyone thinks Obama was a holy man for putting together the garbage that is the ACA, and thinks of any improved solution as an assault on his legacy.
  • fencepost 10y ago
    > keep the preexisting conditions part and do away with the fines for not having insurance Mandatory enrollment is what makes it possible to have that preexisting condition part - the basic idea of this (or any) insurance is that it spreads the risks over a larger pool of people, with the insurance companies taking a cut of the money for administrative costs and profit. If you want to require that the insurance companies cover high-risk preexisting conditions without providing an increased customer base to spread those costs over then you'd better be prepared to see insurance companies go under. > increased costs of forcing insurers into the ACA Insurers don't have to participate in the ACA exchanges, and in fact many don't do so. Some participated in the beginning but decided there wasn't enough profit to be made or were losing money, so they've pulled out of the exchanges since then or have significantly raised their rates for their exchange plans. As an example of this, I believe United Healthcare (or its exchange-specific subsidiaries) no longer participates in most exchanges as of 2017 (http://money.cnn.com/2016/04/19/investing/unitedhealthcare-obamacare-exchanges-aca/index.html http://money.cnn.com/2016/04/19/investing/unitedhealthcare-o...). Interstate insurance competition isn't going to make it any cheaper to insure someone with a preexisting condition, or do you think that your local hospital is going to suddenly say "Oh, ccrush has insurance provided by a company in Montana! We can't charge San Francisco rates, we have to charge Montana hospital rates!" If you do think that, go talk to some hospital billing folks and they'll be happy to correct you. One thing that the ACA did put in is capping the amount that insurance companies could spend on non-medical expenses, including both administration and profit. All the stuff early on about non-compliant plans having to shut down? That was for crap insurance with high premiums, higher deductibles, crappy service, etc. but with EXCELLENT profit margins. After all, if I can sell insurance but drop you when the bills start to come in, then all of those premiums you paid me are profit.
• jakewins 10y ago
  If I start a fire insurance company, and I have a policy that you can sign up even if your house is currently on fire, I'm unlikely to stay in business. Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact. This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered. Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand. Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).
  • losvedir 10y ago
    > Either we deny coverage to those that are already ill, or we force everyone to have insurance This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
    • tdaltonc 10y ago
      What would you call it?
      • ianai 10y ago
        Shared bargaining power.
  • ctdonath 10y ago
    It's more like winning a state lottery, where the monthly payout will be terminated if you leave the country for any reason. There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time). This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
• clbrook 10y ago
  Had ACA existed when I graduated from college, I would've been able to remain on my parent's health insurance plan until 26 (5 extra years). This would have allowed me to take a job with a startup company that could not offer health insurance instead of joining a large multi-national corporation that offered good health coverage. Wow...thinking how different my path could have been with that opportunity. I heard about YC two years out of college (it started the year I graduated), all I wanted to do was apply and talked myself out every time as I am unable to go without health coverage and would not have qualified for an individual plan due to past health history.
• hamilyon2 10y ago
  That's a pity american people have to think about healthcare that much and as far as i can see not long time ago didn't even have a backup plan in case their employment goes wrong. Post soviet countries all enjoy pretty affordable health care, free in most cases. Govermment pays all the salaries so it is pretty simple. Of course it is overused, as every public good is, but maybe that is not actually the problem. Sick people with huge debts because ot their sickness looks far worse in comparison.
• WhatIsThisIm12 10y ago
  As a young, healthy male in my 20's pursuing entrepreneurship, the best health insurance for me is the ability to declare bankruptcy. I have chosen to go uninsured and pay the ACA penalty because it's so much cheaper than paying for a catastrophic health insurance plan. Why would I pay $4000 per year for a $6000 deductible? I do not see any benefit from that except in the case of catastrophe. It's just flushing money (that I don't have) down the toilet. If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years. This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.
  • wonder_er 10y ago
    This was what I did, until I got married. Now we've got a potential baby in the next ~ 1 year, so "uninsured" is not an option. So, to pursue some things on my own time I had to negotiate a sabbatical with my company (which they generously allowed), so I could stay on employer health insurance. If I wasn't able to do that, I'd be up shit creek, because there's no way in hell I'd risk my wife getting pregnant without health insurance. I hope more and more people decide they feel no social obligation to things. Mass peaceful "law breaking" is really the best option, imo.
    • kevinburke 10y ago
      > I hope more and more people decide they feel no social obligation to things. This is incredibly naive and ignores a lot of the political and theoretical underpinnings of our society and our country. https://en.wikipedia.org/wiki/Social_contract https://en.wikipedia.org/wiki/Social_contract
      • chatmasta 10y ago
        There is not one single social contract that we all must subscribe to. It's much more nuanced than that, with lots of little obligations here and there. Some are more valid than others, and the individual should have a right to decide which to be a part of. Not paying taxes is a much different violation of a social contract than not paying for health insurance, especially considering the very legitimate argument that the ACA penalty is unconstitutional in itself.
• noobermin 10y ago
  I posted a comment already, but I have another thing to say, or rather ask: honest question to sama and the rest of the YC people, why don't you lobby congress to keep parts of the ACA? Money in politics is the reason we are here, and until we fix that, the only way it seems you can play is to pay. I'm curious is people from SV have considered lobbying congress.
• trvlngsalesmn 10y ago
  Simple question: Why is there little or no start up innovation in the insurance space? Why aren't YC17 companies able to attack this?
• waivej 10y ago
  As someone that has worked for myself for 16 years, I will sorely miss the the ACA. Let me know if you have any recommendations because surely I'm missing something. - Before the ACA we had Blue Cross and I inquired about maternity coverage. My wife was looking at a shoulder surgery so we were locked in. Blue Cross offered us a $1000/month rider that had to be in place for 21 months before birth and then they would cover anything over our high deductible. It worked out to about $25,000 on top of our regular premiums before they would pick up the bill. We jokingly priced getting an apartment in another city instead. - Then the ACA came out. Maternity was included free and the premiums are about the same. We had a baby and had to cover twice the deductible. The marketplace gave us some trouble due to stupid bureaucracy so we priced out getting a plan directly (non-ACA) but the price was so much higher and it covered less. So, even with the marketplace, the coverage and affordability made it an easy decision. Anyway, I could live without the subsidies (we haven't qualified for them every year) and I wish the marketplace was a little easier to work with. Though I feel like our coverage is so much better now. Why take it all away?
• frandroid 10y ago
  These individual stories are nice. But when are you Americans going to fight to save your healthcare?
  • kevinburke 10y ago
    Many, many people have been calling their elected representatives every day and otherwise lobbying behind the scenes
• pkulak 10y ago
  I love this idea that we can "save the best parts". What part would that be, exactly? The part where insurance companies can't deny you coverage? And the part to get rid of would be the part where you are required to carry insurance? Are people really so dense that they can't see how one absolutely requires the other?
• notalaser 10y ago
  I twitch a little every time I read something like this: > Precision CNC milled from aircraft grade aluminum to 1/1000ths of an inch tolerance What you need aicraft-grade aluminum for? And a 1-mil tolerance? Are you building a really tiny aircraft? "Premium design" stops when the design choices are the best you could ever need. Beyond that, it's no longer a matter of engineering, it's about far less respectable traits.
• Founder123abc 10y ago
  This is rent-seeking by Ycombinator plain and simple.
• throwyfoundr134 10y ago
  This is rent-seeking by Y-combinator.
• gwbas1c 10y ago
  I tried running a startup in 2010 before the ACA took effect. What ultimately made me give up? My only health care option was Cobra, and I ran out of time. At the time, I had sleep apnea and had to pay almost $500 a month for health insurance. That was more then I spent on food, almost as much as I paid for rent. (It was more than my car payment, which I paid off two years prior.) 18 months is a very short time period when you're trying different things to see what sticks. If the ACA was an option, I'd probably had another 4-6 months to go. Would I have found something that "stuck?" I'll never know.
• zaroth 10y ago
  Faced with a similar decision pre-ACA, the fact is that CA already had guaranteed issue small business health insurance. ACA roughly tripled the cost of the same plan, but made it more accessible to people by putting a web front-end on top of what was otherwise a fairly opaque process. But it's untrue to claim ACA provided benefits to any CA startup in terms of coverage, guaranteed issue or pre-existing conditions. If you wanted to start a company in CA pre-ACA and you had prior credible coverage, you could get a great plan at a competitive price (the so-called "rating adjustment factor" was capped for the guarantee issue plans) with immediate coverage for pre-existing conditions.
• marknutter 10y ago
  I recently quit my six figure salary job at a startup here in Minnesota to start my own startup. Just before I quit I was looking at around $650/month premiums for my family of four as the absolute cheapest plan with the highest deductible. Right after I quit, the two largest health insurance providers in MN pulled out of our MNSure health insurance exchange, causing premiums to spike up across the board. Now I am faced with a $1200/month premium which is more than I'd pay for my former employer's health plan through COBRA. Having to cover such a high premium expense is significantly impacting my ability to start my company. So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses. What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.
  • fencepost 10y ago
    Then if you're still on it, pay COBRA for the year. Based on what I can see without making up fake info to look at the Minnesota exchange[1], a Silver plan for a family of 4 went from $905 in 2016 to $1405 in 2017, but with $68k/year in income there'd be a $725 tax credit so the monthly premium would have gone from $622 to $680. I assume since your numbers were a bit lower that you were looking at the Bronze plans instead. Just take hope! If you can just make it through this year you won't have to worry about the question of purchasing insurance as an individual, because as a family with several preexisting conditions (fertile female, children/disease and injury vectors) without the ACA you'll be effectively uninsurable unless you can grow your startup fast enough to make a group plan feasible. [1] https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-coverage-plan-rates.pdf https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-cov...
• yarper 10y ago
  Can someone explain the benefits of a US-style healthcare system vs nationalised tax funded healthcare? All I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now. What happens if you don't have insurance? To me any system where you make sick people pay more than rich people seems bonkers no? If most people's employers already pay it on their behalf, isn't it a business tax already?
  • kmicklas 10y ago
    > Can someone explain the benefits of a US-style healthcare system vs nationalised tax funded healthcare? None. > I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now. Because actual change is near impossible these days. (Ultimately this is largely a result of flaws in our electoral system. Most notably, gerrymandering gives Republicans a near permanent lock on the House.) > What happens if you don't have insurance? You die. > To me any system where you make sick people pay more than rich people seems bonkers no? Republican congressmen are bonkers and/or evil. > If most people's employers already pay it on their behalf, isn't it a business tax already? That's a large part of the problem. It got tied to employment in during WWII when the government mandated salary caps for some industries so firms competed on benefits. I think almost everyone agrees this is bad but it's impossible to change because of gridlock.
• FrancoDiaz 10y ago
  The fact that Obamacare was mandatory meant it had to go. Obamacare was really a fascist's wet dream and why the insurance companies ended up being pretty giddy about it. Good riddance!
• l3m0ndr0p 10y ago
  We can replace ACA by opening up Medicare to all US Citizens. IT works and it is well managed.
• gorbachev 10y ago
  If only Mr. Altman had a pre-existing relationship with someone very close to Mr. Trump. He could then perhaps raise these arguments with that person.
• chatmasta 10y ago
  The healthcare and health insurance system in the United States is a complete mess. There are multiple distinct problems, but politicians like to group them all together into one single problem. The way I see it, all the problems fall into one of two major categories: (1) Healthcare costs are out of control, and (2) Health insurance costs are out of control. 1) Healthcare costs are out of control. In the US, healthcare spending is 17% of GDP, the highest of any country in the world; the next highest is France, at 11% GDP. [0] The reasons for this are very complex and intertwined, but there are a few major issues: (1a) Intellectual Property protections: When only one company can sell a drug for the first 10 years of its existence, they effectively have a monopoly and can set the price to whatever they want. (1b) R&D costs: If it costs $10mm to develop a new drug to treat a deadly disease that affects less than 1% of the population, then naturally the company must set a high price for the drug to cover costs of R&D; this is related to (1a). (1c) Primary care providers and pharmaceutical companies are accountable to nobody when setting their prices. Because the majority of people pay for healthcare via insurance, they are price insensitive. After all, if insurance is paying for your healthcare, what do you care if the cost is $100k or $1k? (As an example: A family friend of mine ran a "compounding pharmacy," where he compounded multiple drugs into a single pill, so people who are prescribed 15+ pills to only need to take one. The insurance companies considered the resulting compound to be a "new drug" and therefore he was able to set its price to literally whatever he wanted.) 2) Health insurance costs are out of control. This is a complex issue but it comes down to a few major factors: (2a) Risk pools cannot cross state lines. As far as I can see there is literally no reason for this. (2b) The requirement to cover pre-existing conditions increases insurance costs for everyone. As many have mentioned in this thread, it makes no sense to call coverage for pre-existing conditions "insurance." If you already have a disease, you aren't insuring against it; you're just paying for it. I do think that people have a right to healthcare, and even as a republican I think that taxpayers have a duty to subsidize those with pre-existing conditions. But I don't think we should be including this obligation in the cost of insurance from private companies. It should be a separate budget item, like social security or medicare or medicaid (or better yet, take it out of the defense budget...). If private companies need to insure (read: pay for) pre-existing conditions, then they effectively become the gatekeepers for this tax, and they have every incentive to make it as high as possible. [0] http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective http://www.commonwealthfund.org/publications/issue-briefs/20...
• thomasthomas 10y ago
  sam, i'd like the choice to buy or not buy health insurance. thats a little thing called freedom
• samfisher83 10y ago
  I don't understand why we don't have Universal Healthcare? Every other first world country has it. They also spend a lot less money than us. We should borrow what works best from around the world.
• drawkbox 10y ago
  I went full-time in my business in 2010-2011. I got denied for months for health insurance. I was in my early 30s, wife, and one child with no major health issues and barely ever used insurance. I got denied from the same companies I previously had insurance working full-time non-stop for years and years from. Finally I did get some by putting me and my family on differing plans across companies. It was insane, I was actually taken back at how messed up that seemed. It caused more panic than it needed to. The ACA (or similar basic rules: no pre-existing, must cover, supports small business and self proprietors as the market goes more that way) is needed for entrepreneurship and in cases where you can't get it through a job, it is a must for starting business today. Other places have a competitive advantage to starting a company in a country that has healthcare figured out and away from the job. We should be able to get insurance as a pool of individuals. The current insurance companies are not setup for non employer based healthcare and need to either change or go. They group based on company or individual not pools of people across companies and individuals, which is a broken legacy system. We need consumer facing companies to be in healthcare if private healthcare is the main thing, companies in auto insurance and other insurance are more consumer focused (Geico, Progressive, Nationwide etc). I wish for more competition in this area that is consumer focused not employer focused. Insurance needs to be remove from employment (probably through legislation or market benefits) to ultimately solve this consumer facing insurance problem for healthcare. We also probably need a separate health insurance plan for catastrophic events and a healthcare plan that handles day to day healthcare needs, bundling them is a bit wrong when compared with other insurance i.e. car maintenance is not covered under auto insurance, home maintenance is not covered under home insurance. Ultimately, fixing healthcare is needed for business and quality of life reasons. Our system is becoming a competitive disadvantage to businesses in the US.
  • intellegacy 10y ago
    >Insurance needs to be remove from employment ding ding we have a winner. This is a no brainer that anyone, Republican or Democrat, should agree on.
• amyjess 10y ago
  The flip side is that the ACA has enabled small businesses to screw over and exploit their employees by exempting businesses under a certain size from having to provide health insurance to their employees.
• deleted 10y ago
  [deleted]
• Joof 10y ago
  I'm still left wondering how our government manages to spend more money on healthcare than the vast majority of countries, but we have the highest out of pocket expenses of any country and our life expectancy and infant mortality still look a bit worse than other developed countries.
  • y_u_no_rust 10y ago
    follow the fucking money.
• dnautics 10y ago
  isn't there a bit of a broken-windows fallacy here? How many founders can't afford to leave their normal 9-5 / and do a startup because their premiums have gotten more expensive and they can't build up a runway?
• rdl 10y ago
  ACA doubled or quadrupled my monthly insurance costs, which actually put a strain on my budget when doing a startup at the time.
• mas644 10y ago
  I comment rarely, but had to chime in as the ACA was very important to me in terms of starting a company. The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture. What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk! For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1. I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it. Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it. Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.
• dmode 10y ago
  Perhaps I am being overly simplistic, and I do support ACA reform, but I don't believe there is a silver bullet to reforming ACA. If there was Republicans would already have come up with it and would have been publicizing it for the last 8 years. The fact remains - covering pre-existing conditions, kids till 26, and low income households is expensive. You can pay it by increasing the insured pool - which is what ACA tries to do via the individual mandate, or by introducing a single payer system whose buying power would be so big that they will substantial leverage over healthcare provider. As a society we have decided that a single payer system is socialist, so it cannot be adopted here (and it has its own problems - wait times, lack of R&D incentive etc.). So now we have to choose between not providing healthcare to 40-50 million people or pay increased premiums to cover for those. Some reforms that may somewhat bring down the premiums: - Offer subsidies to even middle income people, not just poor. May be set the income limit by geography - Make the individual mandate more expensive to incentivize healthier people join the pool - Offer a public option
• SmellTheGlove 10y ago
  We need something like the ACA. Shit, we need more than that, but the very imperfect ACA is a good start. I look at it this way: Right now, I'm with a large company - I have a wife who left corporate life to raise our daughter. It's all riding on me. And on that, I have some ideas, one has become a small side gig, but if they grow enough to become my focus, that essentially opens the basic question of how I'd provide health insurance to my family. Thankfully, I have a backup plan to some degree, as I happen to be a citizen of a European country as well as the US, but it's an imperfect backup plan as my "other" nationality is a place with notoriously difficult small business bureaucracy, and while I could live in another EU country, I'd need to establish the ability to support myself before anyone's going to let me stay. Ideally, we'd stay in the US, because let's face it, this is a pretty great country to found a company, warts and all. But we have to not be having to worry about something as basic as healthcare if we're to take the kinds of risks that lead to innovation.
• drc37 10y ago
  I think the point most of the people that Sam referred to where basically saying that they would like others to subsidize their health insurance. That's what insurance is. We all put money into a bucket and some people will use it and some not so much and others a lot. The people who use it a lot want to pay the same amount as those who are healthy and have the healthy subsidize their health issues. That is what is currently going on and why prices have gone through the roof. All those "unisurables" are on the same insurances as healthy but now the bucket of money needs to be much larger to cover the cost of the "unisurables". If this is how the government wants to do it, don't call it insurance. Just call it socialized medicine, because I am definitely not getting what I paid for.
• MicroBerto 10y ago
  Altman acts like buying insurance was impossible when self employed pre-ACA. Give me a break. I shopped online and bought a sensible plan just like anything else. There were tons of choices and plenty of competition. This whole notion that we'll all be doomed without it is utter rubbish. The entire Healthcare system is broken, starting from our agricultural subsidies to our ridiculous prescription drug prices (which many pharma-lobbied Democrats just voted to keep high) to the artificially low supply of doctors (you don't need 12 years of school to prescribe penicillin). ACA is just 2000 pages of nonsense on top of all of that. We can do better at all facets.
  • nodamage 10y ago
    > Altman acts like buying insurance was impossible when self employed pre-ACA. Give me a break. It was impossible if you had any pre-existing conditions, no matter how trivial.
    • MicroBerto 10y ago
      So, is the argument here that more expensive healthcare shouldn't make for more expensive insurance?
      • nodamage 10y ago
        I'm not making any argument except pointing out that for many people with pre-existing conditions, buying health insurance pre-ACA was indeed actually impossible.
  • mikeyouse 10y ago
    I'm not sure why I bother but; 1. I shopped online and bought a sensible plan just like anything else. There are literally more than 50 million Americans with pre-existing conditions that would disqualify them from buying insurance at any price. Many of them were fortunate to have employer-backed insurance, but that doesn't change the fact that they were desperately dependent on it. 2. (which many pharma-lobbied Democrats just voted to keep high) 41 Republicans voted against it, 13 Democrats did. Singling out the Democrats calls into question your intentions.. 3. you don't need 12 years of school to prescribe penicillin The ACA and other changes have greatly expanded the responsibilities of PAs and NPs. They can treat and prescribe in nearly every setting. CRNAs and DNPs are working more independently than ever. In addition; over 25 new medical schools have been established in the past 8 years, along with over 6,000 additional residency positions (which are paid for via CMS funds.)
• deleted 10y ago
  [deleted]
• deleted 10y ago
  [deleted]
• deleted 10y ago
  [deleted]
• davidf18 10y ago
  Countries that offer universal care such as Canada, The UK, France (also also NY State/NY City where I live) have a tobacco tax in the $5 to $7 range or more that helps to pay for the higher health care costs of smokers. NYC tax is $6.85 for city+state+fed. The US Federal tax is about $1. If the tax were increased by $5 for the 13 billion packed smoked each year it would yield approx $30 to $35 billion which could be used to mitigate the high cost of insurance for others. Also, the medical ratio of youth to elderly is 1:6 and before the ACA, youth would pay about 1/6 of elderly costs. Congress unfairly mandated that ratio to be 1:3 meaning youth pay 75% more than they should. They already have to pay for student loans, save for a house, and now they have additional burdens paying for smokers and those who drink daily sugar Cokes and thus obese. Tax tobacco like other countries and NYC/NYS and use that money to make premiums for youth and middle class more fair.
  • chimeracoder 10y ago
    > Tax tobacco like other countries and NYC/NYS and use that money to make premiums for youth and middle class more fair. Tobacco taxes are incredibly regressive (they very disproportionately tax the poor). So you're essentially proposing taxing the poor in order to pay for the middle class.
    • davidf18 10y ago
      > "Tobacco taxes are incredibly regressive (they very disproportionately tax the poor)." They disproportionately tax smokers making smokers at least pay a portion of the additional health care costs they incur by smoking. Taxing tobacco contributes over half the effect of ensuring teens never start and smokers quit smoking.
• brandon272 10y ago
  As a Canadian, I hit CTRL+F and searched for "Canada" in this thread with over 600 comments and didn't find a single result. (Edit: My mistake, missed one other Canadian!) I searched for a few other nations with universal healthcare and couldn't find any references to them, either. It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse. Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with. I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?
  • bduerst 10y ago
    In the early 20th century, both Canadians and U.S. citizens formed unions to push for better living/working conditions in their country. The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers. This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less. Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.
    • 10y ago
• nodamage 10y ago
  A lot of complaints about the ACA seem related to monthly premiums going up compared to pre-ACA plans. It goes something like this: prior to the ACA I was paying $X, now I'm paying more, therefore the ACA is bad. But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA. Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place. So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement. It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations. This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.
  • dragonwriter 10y ago
    > drop your coverage if you got sick and became too expensive to insure (recission) Yeah, the significance of rescission and the ACA's prohibition is often overlooked. Prior to the ACA, if you got sick enough and expensive enough, insurance companies could -- while you had outstanding claims, and this happened while people were in the hospital -- retroactively cancel your insurance, refund your premiums, and walk away leaving you fully liable not only for any future healthcare, but for anything they hadn't paid for yet from the time when you had coverage. Now, this could generally only be done based on an omission or inaccuracy in initial disclosures, usually related to a preexisting condition, but there was no requirement (federally, some states had controls) that the be intentional or significant, and insurance companies would hunt out errors once care got expensive. The ACA elimination of exclusion for preexisting conditions itself elominated most of the basis for rescission and the onerous disclosure requirements that it was based on errors in, but the ACA also explicitly prohibited it except for fraud or intentional misrepresentation of material facts.
• dforrestwilson1 10y ago
  I don't like subsidizing poor lifestyle choices to any degree. I hope whatever comes next takes things like choosing to drink, smoke, and eat too much into account.
• lend000 10y ago
  People seem to think that without ACA, the US healthcare market is free, which is why it has so many problems. This could not be further from reality. We have more government distortions in our healthcare market than countries with completely socialized healthcare. For example: Medicare: socialized medicare for the elderly, which alone creates more distortion than a universal program would cause by inflating demand/prices for non-qualifying citizens. Medicaid: socialized healthcare for specially qualifying poor people, which creates the same distortion as Medicare. An oppressive FDA: which, coupled with overly-powered IP laws, grants de-facto monopolies in the medical product industry. We have an incredibly expensive and subjective medical equipment pre-approval process (as compared to a less-terrible FDA that would just be in charge of labeling, preventing fraud, and maintaining accountability in the event of incidents). Then there's the length and flexibility of patent protections in our current system (maybe we could cut those protection times in half, and patent trolling would not be a lucrative industry). Oppressive occupational licensing: It's way too hard to become a doctor of any kind, even the kinds that don't manually put things into your heart. This will be a major battle as AI comes to the point where it can better diagnose conditions and largely replace generic/non-specialized pediatrics. Of course, the government will not make this easy. Plus a slew of more minor things like malpractice regulation, and now the ACA (which is not so minor). If we cleaned up/removed all of the problems in the above and replaced it with single payer, it would be OK and we would have something similar to Canada/other countries with long wait times, not much access to specialists, and a system where the government gets to decide who gets the last liver transplant and who dies. Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL.
  • nodamage 10y ago
    > Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL. Is there any country that has implemented this successfully?
    • lend000 10y ago
• grellas 10y ago
  The ACA passed on a purely partisan vote and will be repealed on a purely partisan vote. The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster. In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn. There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome. I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be. Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece). Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows. Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.
• jeffdavis 10y ago
  I am optimistic that we have a chance for real solutions here: * Pricing: How about transparent pricing up front for all non-emergency services? That means the price you pay, and that your insurance pays. Not some mystery of "you are responsible for some unknowable amount if the insurance company doesn't pay" or "we might make you pay your entire deductible". * More effective implementation of high deductible health plans that's simpler for people. * Medical expenses and insurance tax-deductible, full stop. No messing with HSA, FSA. * When you are diagnosed with a condition, your current insurance is responsible for the rest of your life for related expenses. No new insurance company would deny you because it wouldn't cost them anything for your preexisting condition. * Subsidize normal health insurance for poor people.
• dkresge 10y ago
  Trump aims to be a job creator. As a member of the uncountable funemployed, and while I may be working on the Next Big Thing(tm), it doesn't count. But take away my affordable, subsidized, health insurance policy and force me to seek shelter under the corporate umbrella? Then I'm +1 job.
• sjg007 10y ago
  Easy fix is to require all insurers to provide ACA plans. Also cross state plans sound nice in theory but then you need cross state normalization of insurance regulators. That may only happen at a Fdderal level and will be an interesting constitutional issue. Same with Medicare and Medicaid.
• itsatwap 10y ago
  Our insurance the past few years has tripled in cost. That is not affordable. The whole thing was a sham to score illegal Hispanic votes for the Democrats and to create a windfall they could steal from, the same way the did with Social Security.
• tomohawk 10y ago
  There were many issues with health insurance prior to Obamacare. Obamacare did not fix very many of these things, and broke a great deal of other things. Sure, it's nice that pre-existing conditions are covered better and 26 and under people can get insurance with their parents, but those kinds of benefits could have been covered by a one or two page bill. What's in the rest of it? Special deals for corporations such as AARP. The law does nothing about making malpractice insurance more affordable, or making the malpractice lawsuit environment more rational. Why is that? Why is my employer still involved in my health insurance? Why not move the tax benefits from my employer (it's a company, and cannot get sick) to me? My employer doesn't need the insurance. I do. Why can't I buy insurance across state lines like other insurances? Why are there separate 'risk pools'? The US is a single market - there should only be one risk pool. This would put maximal pressure on the insurance companies in terms of cost as they would have to compete for my business instead of negotiating cozy deals with companies (and companies don't get sick). Why does the gov't get to tell me what's in my plan? If I'm a single male, why do I need to buy a plan that covers ObGyn? Why can't I buy a high deductable plan anymore? Why does Obamacare think its wrong for doctors to own medical facilities? If controlling cost is so important, why is it practically impossible to find out the cost of anything ahead of time? This makes making decisions based on cost impossible. Why is the price one person pays radically different than what another person pays? Why does cost have no relationship to quality? I can get an MRI with a brand new machine or with a 15 year old machine that produces crap images, and the crap will cost more. Why not require publication of prices? Why is it that my dad, a wounded combat veteran, cannot get decent health care at the VA in a major metropolitan area? The VA is completely controlled by the gov't. It is the gov't. And yet, if he goes to a private hospital to get decent care, he gets penalized.
  • fattire 10y ago
    Let me just answer this one: Why can't I buy insurance across state lines like other insurances? Because then pretty much EVERY insurance company will pick up and move to the one most desperate state that writes laws in their favor, doesn't tax them, allows them to sell substandard insurance, gives them liability protection and forced arbitration and in every way abuse the customer. And the industry will become abusive, fraudulant, manipulative, and untouchable. Every state will lower its standards and revenue streams to keep insurers from leaving and taking jobs with them. And the customer will have very few if any good choices and no recourse when screwed over. Over time, the industry's power over the state will become even more entrenched. Exhibit one: The credit card industry, and south dakota. Go watch the Frontline episode I refer to in another thread. I'd like to answer some of your other questions like "why do I have to buy a plan that covers obgyn" but I'm too pissed over having to pay for rear seatbelts I'll never wear, a space program I'll never use, fire hydrants I'll probably never need, and taxes for schools I'll never attend. Living in a society sucks. I mean, I have to pay for roads I'll never drive on. It's bullshit. I mean even my freaking insurance-- I have to pay for all these diseases that it'll cover! I'm NEVER gonna get ALL of them at once. And only one of them can even possibly kill me, maybe two max. Why should I pay for protection from a heart attack AND cancer treatment?!!! Bullshit, man. That's how they get you. I mean, I saw tonsilectimy on the list and I don't even have tonsils any more. Tyranny. I want an a la cart health insurance plan where I can figure out what I'm likely to get and only get insurance against that specific disease!!!
• grandalf 10y ago
  The problem is that middle class Americans are charged outlandish rates for the plans. The plan for my family last year cost over $1200 per month, and this year rose to $1400/month. Previously, with employer-provided plans I paid at most $400/month for my family. Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users. A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month. In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan. The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what. I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price. I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment. One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.
  • jbarciauskas 10y ago
    It's meaningless to compare employer funded plans to ACA plans without knowing what amount was being subsidized by your company. It's also a different risk pool. The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage. If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.
    • grandalf 10y ago
      > what amount was being subsidized by your company Around $200 per month. The risk pool aspect would be true if the risk were the dominant factor in the price, which I think it isn't. > The idea is self-insuring $15-20k is absurd for most people People who can afford $1400/month even if no healthcare is used? I'd much rather save the money and if someone in my household has a catastrophic scenario put it on a credit card or spend the next <12 months on a payment plan of $1000/month. > subsidize more of the cost of this care The key word in that sentence is this. What care are we talking about? The ACA plans cost a minimum of $900/month even if I use no care at all (and that's for the plan with very high co-pays, etc.). I've been on an ACA plan for the past two benefit years, and the plans keep getting much more expensive and offering worse coverage. The question is, why is this happening? And why is it that on the so-called "marketplace" there is not a high deductible plan that had been available via non-ACA plans via employers? I think the answer is that it is far from an actual marketplace. There must be some incentive for providers not to offer high deductible plans or actual risk-based plans. A risk pool is a way of packaging a lot of people into one financial model, but the larger and more heterogeneous the group, the more the prices should reflect actuarial reality. The exact opposite is the case. Considering that so much money and research has gone into building the healthcare.gov website, why can't I simply adjust sliders to optimize the plan the same way I book a flight? I'd like to slide the monthly premium slider to the bottom, slide the maximum out-of-pocket to about 15x the mid-high premium price, adjust the "worst case event" slider to about $20K and (hopefully) find a plan for a few hundred dollars a month, which I know exists in the actual market because I had it a few years ago! If anything, a larger risk pool should have allowed insurers to offer plans that strongly discourage adverse selection (such as high deductible plans) and reflect the actual risk of cost incurred to the insurer. The plans on healthcare.gov not only fail to offer this, but the wording, the pricing examples, and fine print is all out of some sort of bureaucratic nightmare scenario. I actually had a physician and a lawyer sit with me to try to understand the fine print and the likely cost of a few scenarios other than pregnancy and diabetes (which are shown), and we sat there confused for several hours. I'd like to see our president sit before the nation sharing his desktop screen and watch him navigate through the site and explain the answers to the very simple things we were wondering about, as well as explain some of the more confusing terminology, as well as things like "why are there two separate plans that are so similar being offered by this company?" or "which of the priced items on this list are excluded from the individual deductible?" I'm quite sure that he'd need to do quite a bit of research and rehearsal before he'd be able to give such a demo with confidence. When we put trust in our officials to handle things for us, there is a tremendous amount of responsibility that they take on in that capacity. Here we were, one highly computer-literate person, one doc, and one lawyer, utterly flummoxed for several hours. Imagine the average person after a long day trying to make this very important choice for his/her family. It's just wrong. Maybe the idea is to make all the plans more and more similar until there is really just one choice that is priced based on income and nobody feels it's worth the time searching or reading any of the coverage descriptions because we all realize that the plans are all nearly the same by design, and that we're just meant to pay our "share" based on income and be grateful that such great care has been provided for us. One thing is for certain. It's not a marketplace. There are simply not competitive plans. There is no way to sort the plans according to any differentiating factors. The "wizard" that the site offers tries to partition people into three groups based on expected usage, but does not offer any consideration to low users or users who are comfortable with the idea of getting a large bill and either taking on debt to pay it off or going on a payment plan with the provider. And, far worse, all any of the plans I reviewed do to create an incentive for low use is subsidize non-emergent primary care visits. There is zero incentive beyond that to reduce one's use of care. Since the spread between the cheapest and most expensive plan is so small, anyone who expects to need any healthcare at all is better off choosing a silver or gold plan. If this incentive is different for people whose coverage is subsidized, I'd consider it discriminatory fwiw.
• em3rgent0rdr 10y ago
  Regarding the concern about health insurance being tied to an employer, it is important to consider why employers have historically been the source of health insurance in US. A primary reason is the higher marginal income tax rates, which makes it hard for companies to effectively reward valuable employees with heavily-taxed salaries. So the companies instead resort to providing non-salary benefits such as health insurance. If mid-to-high marginal tax rates weren't so high, then employees would be paid more in salary and could purchase insurance themselves so they aren't "locked-in" to their company for providing essential needs.
  • pcvarmint 10y ago
    Health insurance became tied to employment in WWII, when the government imposed wage controls. To attract employees while getting around wage controls, fringe benefits were added instead of increased pay. [1] [1] http://www.nber.org/papers/w14839.pdf http://www.nber.org/papers/w14839.pdf
    • em3rgent0rdr 10y ago
      Sure that was one of many contributing factors. A couple sentences later that study affirms the point I was making: "Finally, in a landmark 1954 ruling, the Internal Revenue Service clarified an earlier administrative court ruling regarding the income tax status of ESI by exempting such benefits from income taxation and adding this provision to the tax code."
• patrickg_zill 10y ago
  Sorry, but Sam Altman (and many others) are missing the point. Without actual PRICE DISCOVERY nothing(in terms of reform) works. I got a tetanus shot (booster as an adult, Tdap) and called around to different clinics. Prices ranged from $131 to $39. For what is required by law to be exactly the same thing. That "well your insurance might mean you will pay a different amount" is EXACTLY the problem. No one can easily determine the price of anything. Is there a base-model Chevy that is sold at one dealership for $35K and at another dealership in the same city, for $65K? No, because people would very quickly do price discovery...
• discodave 10y ago
  Id only people cared about the Affordable Care Act this much, before! The election...
• k__ 10y ago
  Why can't the national health be handled as infrastructure? I mean, we pay taxes for streets, so people can get everywhere. We pay taxes for schools, so people learn everything. Why not pay taxes, so people are kept healthy? The whole public healthcare stuff doesn't even work like a real insurance, so why not throw this stuff away, make a health tax everyone pays, call it exactly that, and be done with it?
• codemusings 10y ago
  As a European watching from afar I feel like the US government should rather come after the insane pricing schemes of hospitals and pharma companies that make insurance so expensive in the first place. Need your appendix removed? Better get a loan from the bank. Just because they can.
• daodedickinson 10y ago
  My last four insurance companies have gone under since the ACA. I get fewer worse choice every year. My plan is now 5 times the cost as it was before the ACA. Entrepreneurs are clearly hurt worse than the largest companies who werr hit by ACA later. The subsidies are unsustainable and will end soon.