6 ms·

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.
      - ryandrake 3y ago
        Also, his definition of "low-wait" is different than others'. Last time I tried to get a new-patient appointment with a doctor, every doctor in my area had a 4-8 month waiting list. And yes, the cost weighs highly in mind every time we make a decision about whether we need to go to the doctor or not. Not knowing if this trip to the doctor is going to be the one that bankrupts us (cancer diagnosis?), I tend to simply not go unless a limb is falling off. My wife on the other hand came from a country with socialized health care, and can't shake the habit of just going to the doctor whenever she feels ill or injured. Then I have to be the bad guy with the "honey I know you feel sick but do you feel that sick? We're looking at a minimum bill of many hundreds of dollars out of pocket every time you go."
- blahedo 3y ago
  Your last paragraph suggests your understanding of US healthcare is entirely theoretical. In practice, COBRA is frequently so much more expensive that it wouldn't be affordable even if you hadn't just lost your job. In practice, millions of people are trapped in jobs they don't want but can't leave because they need healthcare and will lose access to healthcare if they lose the job. It's a stupendously shitty system that gives US employers even more of an upper hand than they would otherwise have.
  - db48x 3y ago
    I’ve paid for my own insurance via CORBA. I wish those checks had been entirely theoretical, but the fact is that my employer had been writing those same checks on my behalf and then they stopped. The insurance company isn’t going to give me anything for free.
- ericjmorey 3y ago
  COBRA is Where you need to start paying for the full cost of the insurance plan your employer was paying most of while your income has been entirely removed. It's such a dumb law.
  - db48x 3y ago
    Well yea. Insurance isn’t free and your employer isn’t paying for it any more. Someone has to.
    - fcarraldo 3y ago
      https://en.wikipedia.org/wiki/List_of_countries_with_universal_health_care https://en.wikipedia.org/wiki/List_of_countries_with_univers...
      - db48x 3y ago
        In those countries, your taxes pay for the health care. If you don’t have a job, you are freeloading. Your health care raises the amount of taxes that must be collected from everyone else.
  - koolba 3y ago
    The alternative is no income, no insurance, and no mechanism to continue your coverage. The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor.
    - oarsinsync 3y ago
      > The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor. Just a new source of income to pay the rent, or a free place to sleep since you can’t afford rent anymore, now that you’re paying for health insurance instead.
    - callalex 3y ago
      No, the alternative is universal healthcare.
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.

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.
    - ryandrake 3y ago
      Also, his definition of "low-wait" is different than others'. Last time I tried to get a new-patient appointment with a doctor, every doctor in my area had a 4-8 month waiting list. And yes, the cost weighs highly in mind every time we make a decision about whether we need to go to the doctor or not. Not knowing if this trip to the doctor is going to be the one that bankrupts us (cancer diagnosis?), I tend to simply not go unless a limb is falling off. My wife on the other hand came from a country with socialized health care, and can't shake the habit of just going to the doctor whenever she feels ill or injured. Then I have to be the bad guy with the "honey I know you feel sick but do you feel that sick? We're looking at a minimum bill of many hundreds of dollars out of pocket every time you go."
blahedo 3y ago
Your last paragraph suggests your understanding of US healthcare is entirely theoretical. In practice, COBRA is frequently so much more expensive that it wouldn't be affordable even if you hadn't just lost your job. In practice, millions of people are trapped in jobs they don't want but can't leave because they need healthcare and will lose access to healthcare if they lose the job. It's a stupendously shitty system that gives US employers even more of an upper hand than they would otherwise have.
- db48x 3y ago
  I’ve paid for my own insurance via CORBA. I wish those checks had been entirely theoretical, but the fact is that my employer had been writing those same checks on my behalf and then they stopped. The insurance company isn’t going to give me anything for free.
ericjmorey 3y ago
COBRA is Where you need to start paying for the full cost of the insurance plan your employer was paying most of while your income has been entirely removed. It's such a dumb law.
- db48x 3y ago
  Well yea. Insurance isn’t free and your employer isn’t paying for it any more. Someone has to.
  - fcarraldo 3y ago
    https://en.wikipedia.org/wiki/List_of_countries_with_universal_health_care https://en.wikipedia.org/wiki/List_of_countries_with_univers...
    - db48x 3y ago
      In those countries, your taxes pay for the health care. If you don’t have a job, you are freeloading. Your health care raises the amount of taxes that must be collected from everyone else.
- koolba 3y ago
  The alternative is no income, no insurance, and no mechanism to continue your coverage. The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor.
  - oarsinsync 3y ago
    > The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor. Just a new source of income to pay the rent, or a free place to sleep since you can’t afford rent anymore, now that you’re paying for health insurance instead.
  - callalex 3y ago
    No, the alternative is universal healthcare.

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.