6 ms·

Good article in general but such a misleading headline and framing. The problem, as described in the article's body, is employer-provided health insurance, not

Good article in general but such a misleading headline and framing. The problem, as described in the article's body, is employer-provided health insurance, not private healthcare.

Taikonerd 3mo ago
Yeah, the article sort of conflates the two. It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!
- ajross 3mo ago
  With all respect: what exactly is the alternative you're imagining? The market emphatically did not provide accessible private health care to individuals, largely because of the wellness trap (no one buys insurance until they need it). It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA. Employer health care may have bad externalities, but it has the extremely important (but... maybe invisible to the median libertarian) property that it constitutes collective bargaining. You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table. It's so weird that even now, with the ACA having been proved out over decades, that we have to have these weird free market arguments. It didn't work, guys. It's not a good that works well in an efficient market sense.
  - Taikonerd 3mo ago
    My point was there are lots of models available, not just 2. My post above wasn't endorsing one in particular. I would say that the ACA is on the free market-ish side of the design space: individuals purchasing (subsidized) insurance from private companies.
    - ajross 3mo ago
      > My point was there are lots of models available, not just 2. My post above wasn't endorsing one in particular. Yeah, so... my question stands: name one you're thinking of, even if you qualify that it isn't an "endorsement". I contend there isn't one and you're fooling yourself.
      - Taikonerd 3mo ago
        Name a healthcare model that's neither a 100% free-market model, nor a fully-socialized model like the NHS? OK, how about... * Medicare in the US (single-payer, private providers) * Medicare Advantage in the US (government provides capitated payments to competing private companies, which then do all the administration work) * The Singaporean system (complicated, but revolves around mandatory payments to HSAs) etc.
        ajross 3mo ago
        That seems like a strawman. Upthread you were pretty clearly arguing from a libertarian perspective (I genuinely thought that your "only NHS" quip was humor, not that you were being literal -- the article obviously doesn't say that at all). Now you're saying I'm wrong because there are other socialized forms than NHS that work too. Well, OK! I submit. Use one of those.
        Taikonerd 3mo ago
        I think that you misread my earlier post -- I'm not endorsing a libertarian approach. I was just saying that the Cato Institute presumably would.
  - mattmcknight 3mo ago
    > It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA. 100% untrue. There were affordable catastrophic coverage plans available, and many were made illegal by the ACA and the requirement to provide boutique services for "free" (i.e., forced to pay for even if you don't use).
    - ajross 3mo ago
      > There were affordable catastrophic coverage plans available Not for anyone who needed them! If you were already sick, you would die poor without coverage. Are we really continuing to have this discussion?[1] The market failed in this case. We all know it. [1] Just to short circuit: you'll want to deflect to a non-economic discussion of whose "fault" it was that they were stuck with a pre-existing condition. But my point is: who cares? There was a product and a consumer which could not be exchanged at a reasonable price in an unregulated environment. And that's bad regardless of fault (doubly or triply so because it's a really important product).
      - mattmcknight 3mo ago
        Guaranteed issue can be achieved without requiring "free" checkups. However, it can't be achieved without the individual mandate. And no one has shown any interesting in enforcing the individual mandate (despite the forced taxation approach being a much more expensive and less flexible version of the same).
  - therealdrag0 3mo ago
    Markets are made by the government, just cuz the government is involved doesn’t mean there’s not dichotomy of private and public healthcare. Countries like Switzerland or the Netherlands or Singapore have competitive private insurance markets as the primary form of healthcare. Similarly, even in the United States car insurance, for example, is private even though it’s mandated and expected to be universal. There is no car wellness trap.
  - akramachamarei 3mo ago
    > You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table. The word you're looking for is "convince," not "force." This whole discussion is replete with misuses of words like "free" and "force," and it's a little worrying.
    - ajross 3mo ago
      Arguments about words are a little woke for my taste. Fine fine, pretend I said "convince" and then reply to that. Thanks.
      - akramachamarei 3mo ago
        I'm beginning to think you don't understand the words "argument" or "woke" either.... But anyway, I'm merely pointing out for the sake of readers that insurance companies are engaging willingly (and very gainfully) in this arrangement, so as to not oversell the power of the collective bargaining enabled by uniting coemployed health insurance buyers. I guess I would just question whether this collective bargaining is working quite well for us employees (the self-employed have it better.) I may be in a collective, but I don't seem to have any influence within my collective whatsoever over which insurance company I have. This is like a union with no voting. No bueno. I'm also curious (since this is closely related) whether you favor the tax break to employer health insurance. You wanna talk about my woke focus on words, well well, take "externality." I'm not familiar with these bad externalities of the institution of employer provided insurance of itself, but I can see negatives from the tax break. Namely, by subsidizing my employer's health plan, my private health insurance purchasing power is effectively nerfed. Bit of a stretch to call that external.
        ajross 3mo ago
        [dead]
kiicia 3mo ago
it's connected via vicious cycle private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age
- lotsofpulp 3mo ago
  It’s not connected at all in the US since 2011. The only thing employer provided health insurance gets you is the ability to pay for it with pre-tax income (which is a significant saving). Otherwise, you can go to healthcare.gov and buy it without an employer.
  - reticulates 3mo ago
    > Otherwise, you can go to healthcare.gov and buy it without an employer. using what money? Most people get their money from their employer.
    - lotsofpulp 3mo ago
      We don’t describe shelter, food, entertainment as being employer provided, even though those are also acquired with money obtained from an employer. The distinction in the US before 2011 is that couldn’t buy health insurance as an individual, hence it was a benefit dependent upon being employed. Post 2011, health insurance became attainable without an employer.
      - reticulates 3mo ago
        What are you basing that on? The ACA did not make individual insurance legal, it was already legal and widespread, it was not dependent on employment. The ACA made improvements, the ACA made individual insurance more accessible.
snarf21 3mo ago
It is also frustrated that this was meant to be a temporary hack during WWII that never went away. People should just get $$ into their HSA from their employer and but whatever plan they want.
- ajmurmann 3mo ago
  AFAIK it's even worse and want never really "meant" to be anything but it was a workaround of mandated salary caps to compete for workers. Pretty much every time someone tries to limit the market, unintended consequences result. We are still paying for this one.
tdb7893 3mo ago
You can get healthcare outside of employers and it's incredibly expensive. The cost of private healthcare (either employer sponsored or not) is what is responsible for what the article is talking about, it's certainly not just employer provided plans. Are you saying that if employers didn't provide health insurance that it would help the situation somehow?
- Ajedi32 3mo ago
  Yes. Employers get huge tax incentives for providing insurance, while individuals don't. This ensures that the only economical way to buy health insurance is through an employer, which means you are not free to change plans without changing employers (or change employers without changing plans).
  - mminer237 3mo ago
    The only tax incentive for employers is deducting it as a business expense. I.e., paying with pre-tax income. Individuals can also do that if self-employed. Individuals are the one with huge tax benefits under the ACA. Last year, the government paid 73% of my health insurance premiums as a tax credit.
    - ajmurmann 3mo ago
      "if self-employed" is a big if here
      - Ajedi32 2mo ago
        Yeah and to be more precise the problem isn't really that individuals don't get tax incentives for buying their own plan, it's that employers don't get tax incentives for giving individuals money to buy their own plans, only for buying a plan for them. So even if you could get a tax break for buying your own health insurance, you'd still have to give up a bunch of free money from your employer in order to take advantage of that, which isn't realistic.
- ajmurmann 3mo ago
forshaper 3mo ago
There are just so many middle steps that are unnecessary, though I think the easiest policy lever is simply mandatory price transparencies, with zero exceptions.
Cyclone_ 3mo ago
So how would private healthcare happen without employer provided insurance?
- therealdrag0 3mo ago
  Same way you buy anything else without your employer getting in the way?
- bluGill 3mo ago
  Same way my auto body repairs are done. I have insurance on my car that isn't through my company. I can choose who the provider is. I'm not limited to the two plans my company offers from the same provider. There are dozens of companies who want my business.
  - Cyclone_ 3mo ago
    Except your company covers a lot of the cost for your health insurance.
    - ajmurmann 3mo ago
      They can just give you that money instead. The current situation is even worse than it might seem: Employers must provide the same plan options to all employees. A high-earner might prefer a more premium plan over a barbones, catastrophic coverage-only plan while a low-earner at the same company might prefer the extra cash in their pocket. Even if some of the cost of the premium plans is forwarded to the employee the cost to the employer is still higher and they must price that case into their calculation of the overall comp package. The market is more competitive, by definition for high-earners. So the employer will offer plans that cater to them. But this cost still impacts the comp package of the low earner. For many years this dynamic has eaten up most raises to take home pay got low income earners. See: https://www.econtalk.org/mark-warshawsky-on-compensation-health-care-costs-and-inequality/ https://www.econtalk.org/mark-warshawsky-on-compensation-hea...

Good article in general but such a misleading headline and framing. The problem, as described in the article's body, is employer-provided health insurance, not private healthcare.

Taikonerd 3mo ago

Yeah, the article sort of conflates the two. It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!

ajross 3mo ago
With all respect: what exactly is the alternative you're imagining? The market emphatically did not provide accessible private health care to individuals, largely because of the wellness trap (no one buys insurance until they need it). It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA. Employer health care may have bad externalities, but it has the extremely important (but... maybe invisible to the median libertarian) property that it constitutes collective bargaining. You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table. It's so weird that even now, with the ACA having been proved out over decades, that we have to have these weird free market arguments. It didn't work, guys. It's not a good that works well in an efficient market sense.
- Taikonerd 3mo ago
  My point was there are lots of models available, not just 2. My post above wasn't endorsing one in particular. I would say that the ACA is on the free market-ish side of the design space: individuals purchasing (subsidized) insurance from private companies.
  - ajross 3mo ago
    > My point was there are lots of models available, not just 2. My post above wasn't endorsing one in particular. Yeah, so... my question stands: name one you're thinking of, even if you qualify that it isn't an "endorsement". I contend there isn't one and you're fooling yourself.
    - Taikonerd 3mo ago
      Name a healthcare model that's neither a 100% free-market model, nor a fully-socialized model like the NHS? OK, how about... * Medicare in the US (single-payer, private providers) * Medicare Advantage in the US (government provides capitated payments to competing private companies, which then do all the administration work) * The Singaporean system (complicated, but revolves around mandatory payments to HSAs) etc.
      - ajross 3mo ago
        That seems like a strawman. Upthread you were pretty clearly arguing from a libertarian perspective (I genuinely thought that your "only NHS" quip was humor, not that you were being literal -- the article obviously doesn't say that at all). Now you're saying I'm wrong because there are other socialized forms than NHS that work too. Well, OK! I submit. Use one of those.
        Taikonerd 3mo ago
        I think that you misread my earlier post -- I'm not endorsing a libertarian approach. I was just saying that the Cato Institute presumably would.
- mattmcknight 3mo ago
  > It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA. 100% untrue. There were affordable catastrophic coverage plans available, and many were made illegal by the ACA and the requirement to provide boutique services for "free" (i.e., forced to pay for even if you don't use).
  - ajross 3mo ago
    > There were affordable catastrophic coverage plans available Not for anyone who needed them! If you were already sick, you would die poor without coverage. Are we really continuing to have this discussion?[1] The market failed in this case. We all know it. [1] Just to short circuit: you'll want to deflect to a non-economic discussion of whose "fault" it was that they were stuck with a pre-existing condition. But my point is: who cares? There was a product and a consumer which could not be exchanged at a reasonable price in an unregulated environment. And that's bad regardless of fault (doubly or triply so because it's a really important product).
    - mattmcknight 3mo ago
      Guaranteed issue can be achieved without requiring "free" checkups. However, it can't be achieved without the individual mandate. And no one has shown any interesting in enforcing the individual mandate (despite the forced taxation approach being a much more expensive and less flexible version of the same).
- therealdrag0 3mo ago
  Markets are made by the government, just cuz the government is involved doesn’t mean there’s not dichotomy of private and public healthcare. Countries like Switzerland or the Netherlands or Singapore have competitive private insurance markets as the primary form of healthcare. Similarly, even in the United States car insurance, for example, is private even though it’s mandated and expected to be universal. There is no car wellness trap.
- akramachamarei 3mo ago
  > You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table. The word you're looking for is "convince," not "force." This whole discussion is replete with misuses of words like "free" and "force," and it's a little worrying.
  - ajross 3mo ago
    Arguments about words are a little woke for my taste. Fine fine, pretend I said "convince" and then reply to that. Thanks.
    - akramachamarei 3mo ago
      I'm beginning to think you don't understand the words "argument" or "woke" either.... But anyway, I'm merely pointing out for the sake of readers that insurance companies are engaging willingly (and very gainfully) in this arrangement, so as to not oversell the power of the collective bargaining enabled by uniting coemployed health insurance buyers. I guess I would just question whether this collective bargaining is working quite well for us employees (the self-employed have it better.) I may be in a collective, but I don't seem to have any influence within my collective whatsoever over which insurance company I have. This is like a union with no voting. No bueno. I'm also curious (since this is closely related) whether you favor the tax break to employer health insurance. You wanna talk about my woke focus on words, well well, take "externality." I'm not familiar with these bad externalities of the institution of employer provided insurance of itself, but I can see negatives from the tax break. Namely, by subsidizing my employer's health plan, my private health insurance purchasing power is effectively nerfed. Bit of a stretch to call that external.
      - ajross 3mo ago
        [dead]

kiicia 3mo ago

it's connected via vicious cycle private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age

lotsofpulp 3mo ago
It’s not connected at all in the US since 2011. The only thing employer provided health insurance gets you is the ability to pay for it with pre-tax income (which is a significant saving). Otherwise, you can go to healthcare.gov and buy it without an employer.
- reticulates 3mo ago
  > Otherwise, you can go to healthcare.gov and buy it without an employer. using what money? Most people get their money from their employer.
  - lotsofpulp 3mo ago
    We don’t describe shelter, food, entertainment as being employer provided, even though those are also acquired with money obtained from an employer. The distinction in the US before 2011 is that couldn’t buy health insurance as an individual, hence it was a benefit dependent upon being employed. Post 2011, health insurance became attainable without an employer.
    - reticulates 3mo ago
      What are you basing that on? The ACA did not make individual insurance legal, it was already legal and widespread, it was not dependent on employment. The ACA made improvements, the ACA made individual insurance more accessible.

snarf21 3mo ago

It is also frustrated that this was meant to be a temporary hack during WWII that never went away. People should just get $$ into their HSA from their employer and but whatever plan they want.

ajmurmann 3mo ago
AFAIK it's even worse and want never really "meant" to be anything but it was a workaround of mandated salary caps to compete for workers. Pretty much every time someone tries to limit the market, unintended consequences result. We are still paying for this one.

tdb7893 3mo ago

You can get healthcare outside of employers and it's incredibly expensive. The cost of private healthcare (either employer sponsored or not) is what is responsible for what the article is talking about, it's certainly not just employer provided plans. Are you saying that if employers didn't provide health insurance that it would help the situation somehow?

Ajedi32 3mo ago
Yes. Employers get huge tax incentives for providing insurance, while individuals don't. This ensures that the only economical way to buy health insurance is through an employer, which means you are not free to change plans without changing employers (or change employers without changing plans).
- mminer237 3mo ago
  The only tax incentive for employers is deducting it as a business expense. I.e., paying with pre-tax income. Individuals can also do that if self-employed. Individuals are the one with huge tax benefits under the ACA. Last year, the government paid 73% of my health insurance premiums as a tax credit.
  - ajmurmann 3mo ago
    "if self-employed" is a big if here
    - Ajedi32 2mo ago
      Yeah and to be more precise the problem isn't really that individuals don't get tax incentives for buying their own plan, it's that employers don't get tax incentives for giving individuals money to buy their own plans, only for buying a plan for them. So even if you could get a tax break for buying your own health insurance, you'd still have to give up a bunch of free money from your employer in order to take advantage of that, which isn't realistic.
ajmurmann 3mo ago

forshaper 3mo ago

There are just so many middle steps that are unnecessary, though I think the easiest policy lever is simply mandatory price transparencies, with zero exceptions.

Cyclone_ 3mo ago

So how would private healthcare happen without employer provided insurance?

therealdrag0 3mo ago
Same way you buy anything else without your employer getting in the way?
bluGill 3mo ago
Same way my auto body repairs are done. I have insurance on my car that isn't through my company. I can choose who the provider is. I'm not limited to the two plans my company offers from the same provider. There are dozens of companies who want my business.
- Cyclone_ 3mo ago
  Except your company covers a lot of the cost for your health insurance.
  - ajmurmann 3mo ago
    They can just give you that money instead. The current situation is even worse than it might seem: Employers must provide the same plan options to all employees. A high-earner might prefer a more premium plan over a barbones, catastrophic coverage-only plan while a low-earner at the same company might prefer the extra cash in their pocket. Even if some of the cost of the premium plans is forwarded to the employee the cost to the employer is still higher and they must price that case into their calculation of the overall comp package. The market is more competitive, by definition for high-earners. So the employer will offer plans that cater to them. But this cost still impacts the comp package of the low earner. For many years this dynamic has eaten up most raises to take home pay got low income earners. See: https://www.econtalk.org/mark-warshawsky-on-compensation-health-care-costs-and-inequality/ https://www.econtalk.org/mark-warshawsky-on-compensation-hea...