31 ms·

It's so weird how in the US, health insurance is tied to your job, so if you lose your job you lose access to health care.

bjornsing 3y ago
Didn’t Obamacare fix that?
- db48x 3y ago
  No, because health insurance has always been available to individuals (and families). We've never needed to go through our employers to get it. But back before WWII health insurance was pretty much not used at all; health care was so cheap that it cost less than food or clothes. During WWII Congress passed laws that fixed the price of goods, services, and wages. This started to lead to shortages. Combined with the draft, many industries were competing over fewer and fewer employees, but legally they could not raise wages. Instead they started offering perks such as tips from the customers or “free” health insurance. Even companies that don’t offer free insurance usually split the cost with their employees, and often they do get a slightly lower rate because all their employees are shopping from the same company. And it’s not like you can raise your salary by negotiating out of the insurance; the employer likely pays the same amount to the insurance company regardless. The insurance lowers our salaries no matter what we do; might as well take it. Gradually these perks started to become as important of a consideration as the salary itself. Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care. In fact, I think this guy overstated the risk to his health. If you get fired you don’t actually lose your insurance. You sign up for continuation of coverage from COBRA, taking over payments for the insurance from your employer, and then purchase an individual or family insurance plan of your own before COBRA runs out. Or get hired somewhere else and sign on to one of their insurance plans. Either way you’ve lost nothing, at least in terms of health care.
  - atq2119 3y ago
    > Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care. I don't think it's as simple as that. Empirically, lots of countries have health insurance systems whose incentive structure could be described in the same way, yet the US is an extreme outlier in healthcare costs. Something else must be going on.
    - twoodfin 3y ago
      I don’t think any other national system offers the same un-rationed, low-wait access to - top-skill, top-paid specialists - world-class research hospitals with near-luxury-level amenities - cutting edge pharmaceuticals, including absurdly expensive novel biologics that is enjoyed by, say, a junior Microsoft developer and her family in Seattle. One example of how this plays out as GP described is childbirth: There’s something like a 5X cost disparity for a typical birth process between a perfectly competent regional hospital and an elite research institution. But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food. Obviously, this is not every American’s experience with the system, but for the portion of outlier costs that aren’t related to outlier US population health trends (e.g. obesity), it’s an important part of the story.
      - zrail 3y ago
        > But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food. Your definition of "typical" apparently is very different from my own, or we are thinking about "well insured" very differently. Every pregnant person that I've ever talked to, if they have a choice at all, has weighed the projected cost heavily in their decision on where to give birth. The typical person in the US has a deductible that runs well past several thousand dollars and then they have to pay a coinsurance amount, which could be up to 25% of the cost, up to absurdly high out of pocket maxes.
- ericjmorey 3y ago
  Not even close.
- lotsofpulp 3y ago
  Yes, the ACA made it so everyone can go to healthcare.gov and buy health insurance. Health insurance and healthcare is NOT tied to your employer in the US. However, many employers pay 50% to 70% or even 100% of the health insurance premiums for their employees, and employees can use pre tax income to pay health insurance premiums if purchased by their employer. The problem has always been this tax advantage of your employer purchasing it, AND most Americans opting to not purchase it due to cost. Note that there are significant subsidies available if you earn less than 400% of the federal poverty level, although that may still leave many unable to purchase it (or the deductible/oop max is so high it would not make any difference). https://en.wikipedia.org/wiki/Premium_tax_credit https://en.wikipedia.org/wiki/Premium_tax_credit
  - monktastic1 3y ago
    The other problem is that ACA plans are garbage compared to group plans, with no out of state or out of network coverage available. If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by.
    - lotsofpulp 3y ago
      I have been able to find equivalent plans in 3 states, usually BCBS ones that are the same as any self insured or employer group plan. Might not be as good as the employers with especially high portions of young, healthy, higher paid office workers, but for most people, it should be comparable. > If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by. This is not true since the No Surprises Act went into effect Jan 1, 2022. Everything is considered in network in an emergency, and if a doctor works in an in network hospital, then the doctor is considered in network too.
      - monktastic1 3y ago
        Interesting. In the few states I looked, there were no PPO plans (including by BCBS). As for hospitals, I guess it's important to know which hospitals are in network near home and anywhere you might be traveling? Usually in an emergency I don't have the presence of mind to direct the ambulance to the right hospital (in case the emergency turns into an overnight stay), and it's all the more important if the plan doesn't have good (or any) out of network benefits.
- analog31 3y ago
  Obamacare was designed to address the access problem but not the cost problem. We still pay 2x with nothing to show for it.
  - lotsofpulp 3y ago
    Out of pocket maximums and simply being able to get insurance regardless of your health is pretty huge. Also, the age rating factors being capped at 3 allows older people’s health insurance premiums to be much lower before age 65, although I maintain that this young to old wealth transfer is not beneficial for society.
alamortsubite 3y ago
What's especially weird is the number of people here who are fiercely defensive of the arrangement, with the only rationale being it's the status quo. See also car-centric urban design.
- mlrtime 3y ago
  What is even more especially weird is that a relativiely new country with 330 million people stretching 2800 miles have different thoughts and opinions. See also group think.
  - gorjusborg 3y ago
    There's group-think alright, but I'm not seeing it where you think it is. The medical system in the U.S. is awful, and it really is broken that it is tied to a job. A system where you need to be well enough to work to get care to work is obviously not ideal.
    - edgyquant 3y ago
      The US has government provided healthcare as well for people without jobs or with a low enough income level. It isn’t “tied to your work” that’s just one of many ways in which people choose to get healthcare.
      - spamizbad 3y ago
        Medicaid is pretty complex and runs afoul of you accidentally having too much income or assets despite being functionally low income. When used car prices started trending upward during the pandemic people actually got kicked off medicaid rolls because their vehicle was now too valuable of an asset to make them eligible for benefits. Means-testing is just a very inefficient, clumsy way of providing benefits to people and functionally operates as a tax on those who would benefit from the service but would fail the test.
        3y ago
Aeolun 3y ago
It’s sort of the same in Japan, though I can get the same health insurance without a job, every time you switch jobs (or from job to jobless, or vice versa) you need to go to city hall to get a new card. On the other hand, as long as you have that card everything is really cheap, which is definitely not true in the US.
kgdiem 3y ago
Usually you have health insurance until the next month when you leave a job, it’s not the same day. This is really surprising to me.
- ttyprintk 3y ago
  They might get away with it by saying that he can always count on some care from the Veteran’s Administration.
andrepd 3y ago
It's very intentional. A strong leverage on the side of the employer to further skew the employer–employee """balance""" of power in favour of the former.
IG_Semmelweiss 3y ago
Not entirely true. You have COBRA after losing employment for some time COBRA is good insofar that it lets people know the real cost of health insurance. Thats the cost for covering everything under the sun + every bad habit + risky behavior. Instead of you know: emergencies, no fault accidents, and unexpected genetic problems. (Like, say car insurance)
- clarkevans 3y ago
  For the unexpectedly uninsured, COBRA is like throwing a drowning person a rubber weight instead of a life buoy.
- flashback2199 3y ago
  > Like, say car insurance Not only is this a strange opinion, that you want some kind of entity to decide whether or not each of our health conditions are at-fault, your analogy to car insurance isn't even true in no-fault states, of which there are many.
Ekaros 3y ago
Seems like easy solution would be to ban that entirely. So everyone would be forced to get health insurance from free market. The compensation could be moved to regular pay. And tax deduction given.
- School-Cotton 3y ago
  > Seems like easy solution would be to ban that entirely It’s not really “easy” to reform/change anything this significant in the US. It is not like a European country with a functioning modern parliament that can make laws. In the US system both major parties have to agree in order to pass anything of substance, which due to hyper-polarization means essentially nothing gets passed.
- koolba 3y ago
  That would be a double whammy of positive side effects. Besides decoupling the insurance from employment to facilitate career changes and even quitting, it would also bring down the average price of insurance for people who currently get it on the individual market as the average corporate worker is statistically healthier than the rest of the population. Eliminating the tax deduction is not enough as even at break even the company offering health insurance is a net win from the lower risk pool. It had to be an additional penalty / tax.
- muststopmyths 3y ago
  So… mostly the original design of Obamacare ? That went over swimmingly. There are enough “easy” solutions if the only goal is well-being of the citizen. That’s not always the priority for some obscure reason
- jandrewrogers 3y ago
  To some extent, that would just move the problem around rather than solving it. In the US, the individual States have a lot of control over how healthcare is implemented, as a Constitutional matter. Every time a State looks into eliminating employment-based insurance, rudimentary analysis shows systemic risk due to arbitrage and adverse selection that is nearly impossible to design out of the system legally. Due to fundamental differences in how individual States are governed and funded, and their respective Constitutions, this is a durable feature of trying to change the way the system works (i.e. harmonizing it is infeasible). The US healthcare system is stuck in a deep local minima. The cost of transitioning to a different equilibrium is so high that it is obviously politically infeasible any most if not all States. I don't like the current system but if there was a viable path to a different model, at least some States would have taken it.
lotsofpulp 3y ago
Procuring health insurance is not tied to a job in the US, since 2011 or so. Anyone can buy health insurance at healthcare.gov. They just usually cannot afford it, even though there are subsidies available, most people will not earn or save enough to pay the deductibles / out of pocket max. https://en.wikipedia.org/wiki/Premium_tax_credit https://en.wikipedia.org/wiki/Premium_tax_credit
- ghaff 3y ago
  And when I looked at COBRA ( which is basically your employer insurance without the company payins) it looked to be about the same as a similar marketplace plan. I ended up waiting for Medicare eligibility anyway which, with supplemental and prescription drug coverage is probably not nearly as much cheaper as a lot of people assume.
briHass 3y ago
These conversations never consider that the US does offer pretty robust welfare programs for cases just like this. He would undoubtedly meet the case for 'disabled' as defined by the Social Security Administration if he lost his insurance and had low/no income. Pennsylvania also offers additional medical assistance if you meet that guideline.
- pierat 3y ago
  Oh please. For any local/state/fed program, there's MONTHS of means testing, multiple assessments of various kinds, multiple times to prostrate yourself to show that you *really* are in need of help. Oh, and then you get denied. Multiple times. This country would rather "useless" (read: cant make money for capitalists) people die.
- zrail 3y ago
  I don't know if you've ever had to try to get that designation by SSA, but in my (second and third hand) experience it is extremely difficult to qualify. SSA regularly denies and then you have to get a lawyer and sue them for benefits and restitution. There are also asset and income tests that at this point are effectively punitive. I don't know anything about Pennsylvania, maybe it's easier there.
  - briHass 3y ago
    At least in PA, having a disability (I'd assume MS with motor difficulties would qualify) makes it pretty straightforward, based on my experience. Like most government interaction, there's lots of paperwork, but the employees administering it are generally helpful, competent, and pleasant. I'm sure the bar is higher without a disability, but the asset tests in PA are reasonable, considering they exempt your residence and 1 vehicle. There's probably horror stories of people falling through cracks, but I just find it disingenuous when people breathlessly proclaim that the US callously let's people die on the street from a loss of employer health care.
  - smdyc1 3y ago
    The fact that you have to spend time trying to get yourself designated such whilst you are probably looking for a job, struggling to pay your rent or mortgage, and dealing with other stressors is ridiculous.
spamizbad 3y ago
It's by design; we had salary caps during WWII so employers offered benefits. In the 1960s when healthcare costs began to rise there was a conversation around changing it, but by 1970s it was concluded that on balance tying it to employment had benefits in reducing labor action (strikes), which was a big concern back then. We've stuck with it since.

bjornsing 3y ago

Didn’t Obamacare fix that?

db48x 3y ago
No, because health insurance has always been available to individuals (and families). We've never needed to go through our employers to get it. But back before WWII health insurance was pretty much not used at all; health care was so cheap that it cost less than food or clothes. During WWII Congress passed laws that fixed the price of goods, services, and wages. This started to lead to shortages. Combined with the draft, many industries were competing over fewer and fewer employees, but legally they could not raise wages. Instead they started offering perks such as tips from the customers or “free” health insurance. Even companies that don’t offer free insurance usually split the cost with their employees, and often they do get a slightly lower rate because all their employees are shopping from the same company. And it’s not like you can raise your salary by negotiating out of the insurance; the employer likely pays the same amount to the insurance company regardless. The insurance lowers our salaries no matter what we do; might as well take it. Gradually these perks started to become as important of a consideration as the salary itself. Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care. In fact, I think this guy overstated the risk to his health. If you get fired you don’t actually lose your insurance. You sign up for continuation of coverage from COBRA, taking over payments for the insurance from your employer, and then purchase an individual or family insurance plan of your own before COBRA runs out. Or get hired somewhere else and sign on to one of their insurance plans. Either way you’ve lost nothing, at least in terms of health care.
- atq2119 3y ago
  > Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care. I don't think it's as simple as that. Empirically, lots of countries have health insurance systems whose incentive structure could be described in the same way, yet the US is an extreme outlier in healthcare costs. Something else must be going on.
  - twoodfin 3y ago
    I don’t think any other national system offers the same un-rationed, low-wait access to - top-skill, top-paid specialists - world-class research hospitals with near-luxury-level amenities - cutting edge pharmaceuticals, including absurdly expensive novel biologics that is enjoyed by, say, a junior Microsoft developer and her family in Seattle. One example of how this plays out as GP described is childbirth: There’s something like a 5X cost disparity for a typical birth process between a perfectly competent regional hospital and an elite research institution. But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food. Obviously, this is not every American’s experience with the system, but for the portion of outlier costs that aren’t related to outlier US population health trends (e.g. obesity), it’s an important part of the story.
    - zrail 3y ago
      > But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food. Your definition of "typical" apparently is very different from my own, or we are thinking about "well insured" very differently. Every pregnant person that I've ever talked to, if they have a choice at all, has weighed the projected cost heavily in their decision on where to give birth. The typical person in the US has a deductible that runs well past several thousand dollars and then they have to pay a coinsurance amount, which could be up to 25% of the cost, up to absurdly high out of pocket maxes.
ericjmorey 3y ago
Not even close.
lotsofpulp 3y ago
Yes, the ACA made it so everyone can go to healthcare.gov and buy health insurance. Health insurance and healthcare is NOT tied to your employer in the US. However, many employers pay 50% to 70% or even 100% of the health insurance premiums for their employees, and employees can use pre tax income to pay health insurance premiums if purchased by their employer. The problem has always been this tax advantage of your employer purchasing it, AND most Americans opting to not purchase it due to cost. Note that there are significant subsidies available if you earn less than 400% of the federal poverty level, although that may still leave many unable to purchase it (or the deductible/oop max is so high it would not make any difference). https://en.wikipedia.org/wiki/Premium_tax_credit https://en.wikipedia.org/wiki/Premium_tax_credit
- monktastic1 3y ago
  The other problem is that ACA plans are garbage compared to group plans, with no out of state or out of network coverage available. If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by.
  - lotsofpulp 3y ago
    I have been able to find equivalent plans in 3 states, usually BCBS ones that are the same as any self insured or employer group plan. Might not be as good as the employers with especially high portions of young, healthy, higher paid office workers, but for most people, it should be comparable. > If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by. This is not true since the No Surprises Act went into effect Jan 1, 2022. Everything is considered in network in an emergency, and if a doctor works in an in network hospital, then the doctor is considered in network too.
    - monktastic1 3y ago
      Interesting. In the few states I looked, there were no PPO plans (including by BCBS). As for hospitals, I guess it's important to know which hospitals are in network near home and anywhere you might be traveling? Usually in an emergency I don't have the presence of mind to direct the ambulance to the right hospital (in case the emergency turns into an overnight stay), and it's all the more important if the plan doesn't have good (or any) out of network benefits.
analog31 3y ago
Obamacare was designed to address the access problem but not the cost problem. We still pay 2x with nothing to show for it.
- lotsofpulp 3y ago
  Out of pocket maximums and simply being able to get insurance regardless of your health is pretty huge. Also, the age rating factors being capped at 3 allows older people’s health insurance premiums to be much lower before age 65, although I maintain that this young to old wealth transfer is not beneficial for society.

alamortsubite 3y ago

What's especially weird is the number of people here who are fiercely defensive of the arrangement, with the only rationale being it's the status quo. See also car-centric urban design.

mlrtime 3y ago
What is even more especially weird is that a relativiely new country with 330 million people stretching 2800 miles have different thoughts and opinions. See also group think.
- gorjusborg 3y ago
  There's group-think alright, but I'm not seeing it where you think it is. The medical system in the U.S. is awful, and it really is broken that it is tied to a job. A system where you need to be well enough to work to get care to work is obviously not ideal.
  - edgyquant 3y ago
    The US has government provided healthcare as well for people without jobs or with a low enough income level. It isn’t “tied to your work” that’s just one of many ways in which people choose to get healthcare.
    - spamizbad 3y ago
      Medicaid is pretty complex and runs afoul of you accidentally having too much income or assets despite being functionally low income. When used car prices started trending upward during the pandemic people actually got kicked off medicaid rolls because their vehicle was now too valuable of an asset to make them eligible for benefits. Means-testing is just a very inefficient, clumsy way of providing benefits to people and functionally operates as a tax on those who would benefit from the service but would fail the test.
      - 3y ago

Aeolun 3y ago

It’s sort of the same in Japan, though I can get the same health insurance without a job, every time you switch jobs (or from job to jobless, or vice versa) you need to go to city hall to get a new card. On the other hand, as long as you have that card everything is really cheap, which is definitely not true in the US.

kgdiem 3y ago

Usually you have health insurance until the next month when you leave a job, it’s not the same day. This is really surprising to me.

ttyprintk 3y ago
They might get away with it by saying that he can always count on some care from the Veteran’s Administration.

andrepd 3y ago

It's very intentional. A strong leverage on the side of the employer to further skew the employer–employee """balance""" of power in favour of the former.

IG_Semmelweiss 3y ago

Not entirely true. You have COBRA after losing employment for some time COBRA is good insofar that it lets people know the real cost of health insurance. Thats the cost for covering everything under the sun + every bad habit + risky behavior. Instead of you know: emergencies, no fault accidents, and unexpected genetic problems. (Like, say car insurance)

clarkevans 3y ago
For the unexpectedly uninsured, COBRA is like throwing a drowning person a rubber weight instead of a life buoy.
flashback2199 3y ago
> Like, say car insurance Not only is this a strange opinion, that you want some kind of entity to decide whether or not each of our health conditions are at-fault, your analogy to car insurance isn't even true in no-fault states, of which there are many.

Ekaros 3y ago

Seems like easy solution would be to ban that entirely. So everyone would be forced to get health insurance from free market. The compensation could be moved to regular pay. And tax deduction given.

School-Cotton 3y ago
> Seems like easy solution would be to ban that entirely It’s not really “easy” to reform/change anything this significant in the US. It is not like a European country with a functioning modern parliament that can make laws. In the US system both major parties have to agree in order to pass anything of substance, which due to hyper-polarization means essentially nothing gets passed.
koolba 3y ago
That would be a double whammy of positive side effects. Besides decoupling the insurance from employment to facilitate career changes and even quitting, it would also bring down the average price of insurance for people who currently get it on the individual market as the average corporate worker is statistically healthier than the rest of the population. Eliminating the tax deduction is not enough as even at break even the company offering health insurance is a net win from the lower risk pool. It had to be an additional penalty / tax.
muststopmyths 3y ago
So… mostly the original design of Obamacare ? That went over swimmingly. There are enough “easy” solutions if the only goal is well-being of the citizen. That’s not always the priority for some obscure reason
jandrewrogers 3y ago
To some extent, that would just move the problem around rather than solving it. In the US, the individual States have a lot of control over how healthcare is implemented, as a Constitutional matter. Every time a State looks into eliminating employment-based insurance, rudimentary analysis shows systemic risk due to arbitrage and adverse selection that is nearly impossible to design out of the system legally. Due to fundamental differences in how individual States are governed and funded, and their respective Constitutions, this is a durable feature of trying to change the way the system works (i.e. harmonizing it is infeasible). The US healthcare system is stuck in a deep local minima. The cost of transitioning to a different equilibrium is so high that it is obviously politically infeasible any most if not all States. I don't like the current system but if there was a viable path to a different model, at least some States would have taken it.

lotsofpulp 3y ago

Procuring health insurance is not tied to a job in the US, since 2011 or so. Anyone can buy health insurance at healthcare.gov. They just usually cannot afford it, even though there are subsidies available, most people will not earn or save enough to pay the deductibles / out of pocket max. https://en.wikipedia.org/wiki/Premium_tax_credit https://en.wikipedia.org/wiki/Premium_tax_credit

ghaff 3y ago
And when I looked at COBRA ( which is basically your employer insurance without the company payins) it looked to be about the same as a similar marketplace plan. I ended up waiting for Medicare eligibility anyway which, with supplemental and prescription drug coverage is probably not nearly as much cheaper as a lot of people assume.

briHass 3y ago

These conversations never consider that the US does offer pretty robust welfare programs for cases just like this. He would undoubtedly meet the case for 'disabled' as defined by the Social Security Administration if he lost his insurance and had low/no income. Pennsylvania also offers additional medical assistance if you meet that guideline.

pierat 3y ago
Oh please. For any local/state/fed program, there's MONTHS of means testing, multiple assessments of various kinds, multiple times to prostrate yourself to show that you *really* are in need of help. Oh, and then you get denied. Multiple times. This country would rather "useless" (read: cant make money for capitalists) people die.
zrail 3y ago
I don't know if you've ever had to try to get that designation by SSA, but in my (second and third hand) experience it is extremely difficult to qualify. SSA regularly denies and then you have to get a lawyer and sue them for benefits and restitution. There are also asset and income tests that at this point are effectively punitive. I don't know anything about Pennsylvania, maybe it's easier there.
- briHass 3y ago
  At least in PA, having a disability (I'd assume MS with motor difficulties would qualify) makes it pretty straightforward, based on my experience. Like most government interaction, there's lots of paperwork, but the employees administering it are generally helpful, competent, and pleasant. I'm sure the bar is higher without a disability, but the asset tests in PA are reasonable, considering they exempt your residence and 1 vehicle. There's probably horror stories of people falling through cracks, but I just find it disingenuous when people breathlessly proclaim that the US callously let's people die on the street from a loss of employer health care.
- smdyc1 3y ago
  The fact that you have to spend time trying to get yourself designated such whilst you are probably looking for a job, struggling to pay your rent or mortgage, and dealing with other stressors is ridiculous.

spamizbad 3y ago

It's by design; we had salary caps during WWII so employers offered benefits. In the 1960s when healthcare costs began to rise there was a conversation around changing it, but by 1970s it was concluded that on balance tying it to employment had benefits in reducing labor action (strikes), which was a big concern back then. We've stuck with it since.