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I had insurance purchased through the exchange for a few years after. It was just for me, a healthy(ish) man in my 20s. The year was $200 a month. The next y

I had insurance purchased through the exchange for a few years after. It was just for me, a healthy(ish) man in my 20s. The year was $200 a month. The next year was $300 a month. The next year was $450 a month. It had some good in it, such as not denying people based on pre-existing conditions (along with the limited period you can get insurance). Capping how much insurance companies can make as a percentage of revenue was a real poison pill that only served to make costs balloon. They have no reason to be more efficient, or to try to clamp down on healthcare costs. The more we all pay, the more they make, and it's their only path to do so apart from taking marketshare from a competitor. I think we'll probably end up with single-payer sometime, which will be a real mess and a huge amount of money will be wasted for decades. We could fix the insurance system, but it'd be politically unpopular: Everyone's insurance is insurance again. By that, I mean it doesn't cover routine care (apart from a yearly physical, just to encourage that), medications, etc. It's all very high deductible, possibly with some sort of low income subsidy (that still shouldn't go too far). Providers need to publicly list prices, or give good faith estimates for things that aren't routine. Cap medication prices to an average of...Canada, UK, Germany, and Japan - or some other list. This wouldn't be needed for cheaper drugs but for the ridiculously expensive ones that'd normally eat up your high deductible in a month. Bam. Done. There'd be a few years of pain, but you'd quickly see healthcare prices drop off a cliff as consumers would suddenly care that their clinic's sleep study costs $7,000 when the place an hour away only charges $1,500, or that they can do testosterone injections for $20 a month instead of taking a pill that costs $500 a month.

ffgjgf1 3y ago
Or just copy the Swiss system (which is entirely privatized, more so than in the US) if you want to maintain a high degree of direct government involvement in healthcare which exists know you could also copy one of the functioning mixed public/private systems (like the one in the Netherlands). Why try and reinvent the wheel?
- hotnfresh 3y ago
  Just need price controls (at least limited ones, and the credible threat of more) plus a good public fall-back option, and strong standards for what health insurance has to cover. That seems to be the minimum (Singapore model). Those elements seem to be the common factors in basically all OECD healthcare systems outside the US. Taking it farther can work, and may even help, but those seem to be the things you have to have (though price controls can also be implicit, via monopsony). “Credible threat of more” for the price controls may not work in places less authoritarian than Singapore, so you may have to swing closer to the price-book model of places like Japan, if not just go single-payer.
  - spiralx 3y ago
    Yup. The CBO have in the past even estimated a generic public option as being revenue positive due to replacing ACA subsidies for private insurance plans. https://www.cbo.gov/budget-options/2013/44890 https://www.cbo.gov/budget-options/2013/44890 Single-payer is unlikely in the US for many reasons, if you're interested in the topic though the CBO did a thorough look at all of the different things that would be required for such a system: https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf https://www.cbo.gov/system/files/2019-05/55150-singlepayer.p...
  - Auracle 3y ago
    The amount of pushback we'd see from doctors, nurses, pharmacists and the like if they got paid like they get paid in the rest of the world would be immense.
- spiralx 3y ago
  The Netherlands has a system very similar to the ACA and the Swiss system mandates insurers offer a not-for-profit plan with minimum requirements, as well as offering generous subsidies to those with lower incomes. Both have cost controls though, which the US lacks.
nradov 3y ago
A yearly physical shouldn't be encouraged for healthy patients. There is no reliable evidence that it improves outcomes. Waste of money.
smileysteve 3y ago
Re the annual increases; in the startup world (both pre and post Aca), I saw the small company switch brokers (and available plans) each year for the teaser rates in 2011, 2012, 2013 to avoid nearly 100% increases yoy. Still in startups, from 2016-2022, my company switched brokers with the exception of 2 years to get teaser rates. We're looking at a new broker this year to avoid a 9% increase.
IX-103 3y ago
The argument for having insurers cover routine care is that prevention is cheaper. Ideally insurance companies would gladly pay for that since it would save them money in the long run. The problem is that companies are penalized for long-term thinking. Why pay today when in the future it may be someone else's problem. That creates a sort of tragedy of commons among insurers. No one is insurer wants to pay today, but everyone would be better off if all insurers paid. That's a known market failure so some government intervention is necessary to improve market efficiency. Unfortunately healthcare ticks a lot of other "market failure" boxes in its mode of operation. So it needs to either be heavily regulated or socialized to prevent market failures driving prices up and efficiency down. Don't believe me? Ask any economist that studies market failures.

ffgjgf1 3y ago

Or just copy the Swiss system (which is entirely privatized, more so than in the US) if you want to maintain a high degree of direct government involvement in healthcare which exists know you could also copy one of the functioning mixed public/private systems (like the one in the Netherlands). Why try and reinvent the wheel?

hotnfresh 3y ago
Just need price controls (at least limited ones, and the credible threat of more) plus a good public fall-back option, and strong standards for what health insurance has to cover. That seems to be the minimum (Singapore model). Those elements seem to be the common factors in basically all OECD healthcare systems outside the US. Taking it farther can work, and may even help, but those seem to be the things you have to have (though price controls can also be implicit, via monopsony). “Credible threat of more” for the price controls may not work in places less authoritarian than Singapore, so you may have to swing closer to the price-book model of places like Japan, if not just go single-payer.
- spiralx 3y ago
  Yup. The CBO have in the past even estimated a generic public option as being revenue positive due to replacing ACA subsidies for private insurance plans. https://www.cbo.gov/budget-options/2013/44890 https://www.cbo.gov/budget-options/2013/44890 Single-payer is unlikely in the US for many reasons, if you're interested in the topic though the CBO did a thorough look at all of the different things that would be required for such a system: https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf https://www.cbo.gov/system/files/2019-05/55150-singlepayer.p...
- Auracle 3y ago
  The amount of pushback we'd see from doctors, nurses, pharmacists and the like if they got paid like they get paid in the rest of the world would be immense.
spiralx 3y ago
The Netherlands has a system very similar to the ACA and the Swiss system mandates insurers offer a not-for-profit plan with minimum requirements, as well as offering generous subsidies to those with lower incomes. Both have cost controls though, which the US lacks.

nradov 3y ago

A yearly physical shouldn't be encouraged for healthy patients. There is no reliable evidence that it improves outcomes. Waste of money.

smileysteve 3y ago

Re the annual increases; in the startup world (both pre and post Aca), I saw the small company switch brokers (and available plans) each year for the teaser rates in 2011, 2012, 2013 to avoid nearly 100% increases yoy. Still in startups, from 2016-2022, my company switched brokers with the exception of 2 years to get teaser rates. We're looking at a new broker this year to avoid a 9% increase.

IX-103 3y ago

The argument for having insurers cover routine care is that prevention is cheaper. Ideally insurance companies would gladly pay for that since it would save them money in the long run. The problem is that companies are penalized for long-term thinking. Why pay today when in the future it may be someone else's problem. That creates a sort of tragedy of commons among insurers. No one is insurer wants to pay today, but everyone would be better off if all insurers paid. That's a known market failure so some government intervention is necessary to improve market efficiency. Unfortunately healthcare ticks a lot of other "market failure" boxes in its mode of operation. So it needs to either be heavily regulated or socialized to prevent market failures driving prices up and efficiency down. Don't believe me? Ask any economist that studies market failures.